Category Archives: __6. Medical

Sunburn: Protection & Treatment

(Survival manual/6. Medical/e) Skin/Sunburn protection & treatment)

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 Protective Clothing
Sunlight is strongest when it is directly above the sky.  This is why health professionals advise that a person must avoid the sun between ten o’clock in the morning to four o’clock in the afternoon.  A marathon conducted at exactly twelve noon not only plays havoc on the skin, but also causes heat stroke and dehydration.

If going out in the sun is unavoidable during such hours, a person should wear protective clothing.  Protective clothing can reduce the skin’s exposure to sunlight.  Long pants protect the legs.  Long-sleeved shirts protect the arms.  And broad-brimmed hats can protect the face, especially the eyes.  Umbrellas are also effective tools in reducing sun exposure.

Seven Tips for Treating a Sunburn at Home
A sunburn is an actual burn of your skin from the ultraviolet (UV) light from the sun or other UV light sources (ie tanning beds). A sunburn can occur from as little as 15 minutes of midday sun exposure in a very light-skinned person.
The first signs of a sunburn may not appear for a few hours after the UV exposure. Sunburns may often appear “worse” the day after being at the beach, as it can take 24 hours or longer for the full effect of the UV damage to your skin to appear.
Sunburned skin is red and tender skin that is warm to the touch. Severe sunburned skin may result in the formation of blisters. Almost all sunburned skin will result in skin peeling on the burned areas several days after the sunburn.

It is always best to PREVENT sunburns, but when the sunburn occurs use these seven tips for comfort and healing:

  1. Take anti-inflammatory medications such as ibuprophen (Advil, Motrin), naproxen (Aleve) or aspirin. Do NOT give aspirin to children. These help decrease the inflammation and reduce the amount of redness and pain. The pain from a sunburn is usually worst between 6 and 48 hours after sun exposure.
  2. If your skin is not blistering, moisturizing cream may be applied to relieve discomfort. Store the moisturizing cream in the refrigerator between applications as the coolness will aid in comfort to your skin.
  3. Apply cool compresses to the burned skin. Cold wash clothes work well.
  4. Avoid hot showers or bathes. Take a luke warm bath instead. If there is no blistering of the skin, consider adding Aveeno Collodial Oatmeal to the bath water. It will aid in anti-inflammatory relief and act as a moisturizer for your skin.
  5. Avoid any additional sun or UV light exposure while your sunburn is healing. Clothing is better than protection while healing – long sleeves, hats, etc.
  6. Avoid products that contain benzocaine and lidocaine. They may actually create more itching and inflammation by causing an allergic contact dermatitis.
  7. If your sunburned skin develops blisters, resist the urge to pop them. The blister cover is actually protecting your raw skin underneath.

Sunburn Protection
Most organizations recommend using sunscreen with an SPF between 15 and 50 (SPF ratings higher than 50 have not been proven to be more effective than SPF 50). A sunscreen with an SPF of 15 protects against about 93 percent of UVB rays, and one with an SPF of 30 protects against 97 percent of rays, according to the Mayo Clinic. No SPF can block 100% of UV rays.

Because some UV radiation still gets through the sunscreen and into your skin, the SPF number refers to roughly how long it will take for a person’s skin to turn red. Sunscreen with an SPF of 15 will prevent your skin from getting red for approximately 15 times longer than usual (so if you start to burn in 10 minutes, sunscreen with SPF 15 will prevent burning for about 150 minutes, or 2.5 hours), according to the American Academy of Dermatology.

The UV (Ultraviolet) Index
The UV Index scale used in the United States conforms with international guidelines for UVI reporting established by the World Health Organization. What follows is a description of each UV Index level and tips to help you avoid harmful exposure to UV radiation.
** You can sign up for the free, daily  EPA (Environmental Protection Agency’s UV Index alert e-mail for your zip code, at:

 2 or less: Low
A UV Index reading of 2 or less means low danger from the sun’s UV rays for the average person:
•  Wear sunglasses on bright days. In winter, reflection off snow can nearly double UV strength.
•  If you burn easily, cover up and use sunscreen.

Look Out Below:
Snow and water can reflect the sun’s rays. Skiers and swimmers should take special care. Wear sunglasses or goggles, and apply sunscreen with an SPF of at least 15. Remember to protect areas that could be exposed to UV rays by the sun’s reflection, including under the chin and nose.

3 – 5: Moderate
A UV Index reading of 3 to 5 means moderate risk of harm from unprotected sun exposure.
•  Take precautions, such as covering up, if you will be outside.
•  Stay in shade near midday when the sun is strongest.

Me and My Shadow: An easy way to tell how much UV exposure you are getting is to look for your shadow: If your shadow is taller than you are (in the early morning and late afternoon), your UV exposure is likely to be low. If your shadow is shorter than you are (around midday), you are being exposed to high levels of UV radiation. Seek shade and protect your skin and eyes.

6 – 7: High
A UV Index reading of 6 to 7 means high risk of harm from unprotected sun exposure. Apply a sunscreen with a SPF of at least 15. Wear a wide-brim hat and sunglasses to protect your eyes.
•  Protection against sunburn is needed.
•  Reduce time in the sun between 10 a.m. and 4 p.m.
•  Cover up, wear a hat and sunglasses, and use sunscreen.

Made in the Shades: Wearing sunglasses protects the lids of your eyes as well as the lens.

8 – 10: Very High
A UV Index reading of 8 to 10 means very high risk of harm from unprotected sun exposure. Minimize sun exposure during midday hours, from 10 a.m. to 4 p.m. Protect yourself by liberally applying a sunscreen with an SPF of at least 15. Wear protective clothing and sunglasses to protect the eyes.
•  Take extra precautions. Unprotected skin will be damaged and can burn quickly.
•  Minimize sun exposure between 10 a.m. and 4 p.m; seek shade, cover up, wear a hat and sunglasses, and use sunscreen.

Stay in the Game: Be careful during routine outdoor activities such as gardening or playing sports. Remember that UV exposure is especially strong if you are working or playing between the peak hours of 10 a.m. and 4 p.m. Don’t forget that spectators, as well as participants, need to wear sunscreen and eye protection to avoid too much sun.

11+: Extreme
A UV Index reading of 11 or higher means extreme risk of harm from unprotected sun exposure. Try to avoid sun exposure during midday hours, from 10 a.m. to 4 p.m. Apply sunscreen with an SPF of at least 15 liberally every 2 hours.
•  Take all precautions. Unprotected skin can burn in minutes. Beachgoers should know that white sand and other bright surfaces reflect UV and will increase UV exposure.
•  Try to avoid sun exposure between 10 a.m. and 4 p.m.
•  Seek shade, cover up, wear a hat and sunglasses, and use sunscreen.

Beat the Heat: It is possible to go outside when the UV Index is 11 or higher. Make sure you always seek shade, wear a hat, cover up, wear 99-100% UV-blocking sunglasses, and use sunscreen. Or you can opt to stay indoors and take the opportunity to relax with a good book rather than risk dangerous levels of sun exposure

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Ebola Hemorrhagic Fever

(Survival manual/6. Medical/b) Disease/Ebola Hemorragic Fever)


Introduction to Ebola hemorrhagic fever
•  Ebola [ee-BO-luh] hemorrhagic fever is a deadly disease that has occurred in outbreaks in Central Africa.
•  Ebola hemorrhagic fever is caused by several Ebola viruses. The source of these viruses in nature is not known.
•  People can get Ebola hemorrhagic fever by direct contact with virus-infected blood, body fluids, organs, or semen.
•  There is no known cure or treatment.
•  Recent outbreaks in humans have occurred in areas where medical supplies and care were inadequate. The outbreaks were controlled by using barrier nursing techniques.
•  Under normal circumstances, travelers are at low risk of getting the disease. To eliminate the risk, travelers should avoid areas where Ebola outbreaks are occurring.

 What is Ebola hemorrhagic fever?
Ebola hemorrhagic fever is one of the deadliest of a group of diseases called viral hemorrhagic fevers. They range in seriousness from relatively mild illnesses to severe and potentially fatal diseases. All forms of viral hemorrhagic fever begin with fever and muscle aches. Depending on the virus, the disease can get worse until the patient becomes very ill with breathing problems, severe bleeding (hemorrhage), kidney problems, and shock. You die, bleeding from every pore as your internal organs are liquefied and turned to mush. Ebola is the 2nd most lethal disease of the 20th Century. Untreated rabies is 100% fatal, treated Ebola is 80-90% fatal.  The virus has a very brief survival period outside its host. When anywhere around Ebola, masks and gloves are minimal requirements.

Viral hemorrhagic fevers are caused by viruses from four families: filoviruses, arenaviruses, flaviviruses, and bunyaviruses. The usual hosts for most of these viruses are rodents or arthropods (such as ticks and mosquitoes). In some cases, the natural host for the virus is not known.

What is the infectious agent that causes Ebola hemorrhagic fever?
Ebola hemorrhagic fever is caused by several Ebola viruses. Ebola viruses are members of the filovirus family; when magnified several thousand times by an electron microscope, these viruses look like threads (filaments). Ebola virus was discovered in 1976 and named for a river in Zaire, Africa, where it was first detected.

Where is Ebola hemorrhagic fever found?
Ebola viruses are found in Central Africa. The source of the viruses in nature remains unknown. Monkeys, like humans, appear to be susceptible to infection and might serve as a source of virus if infected.

How do people get Ebola hemorrhagic fever?
People get the disease by direct contact with virus-infected blood, body fluids, organs, or semen.

The disease is spread mainly by close person-to-person contact with severely ill patients. This happens most often to hospital-care workers and family members who care for an ill person infected with Ebola virus. Close personal contact with persons who are infected but show no signs of active disease is very unlikely to result in infection.

Transmission of the virus has also been linked to the re-use of hypodermic needles in the treatment of patients. Re-using needles is a common practice in developing countries, such as Zaire and Sudan, where the health-care system is underfinanced. Medical facilities in the United States do not re-use needles.

Ebola virus can be spread from person to person through sexual contact. Persons who have recuperated from an illness caused by Ebola virus can still have the virus in their genital secretions for a short time after recovery and can spread the virus through sexual activity.

What are the signs and symptoms of Ebola hemorrhagic fever?
People infected with Ebola virus have sudden fever, weakness, muscle pain, headache, and sore throat, followed by vomiting, diarrhea, rash, limited kidney and liver functions, and both internal and external bleeding. Death rates range from 50% to 90%.

How soon after exposure do symptoms appear?
Symptoms begin 2 to 21 days after infection.

How is Ebola hemorrhagic fever diagnosed?
Diagnosis requires specialized laboratory tests on blood specimens. Handling blood from a persons infected with Ebola virus is an extreme biohazard and can be done only in specially equipped laboratories. Diagnosis in patients who have died can be made by testing tissue samples.

Who is at risk for Ebola hemorrhagic fever?
•  Persons traveling to areas where Ebola hemorrhagic fever is occurring
•  Hospital staff and family members who care for patients with Ebola hemorrhagic fever
•  Central African residents of rural areas and small towns

What is the treatment for Ebola hemorrhagic fever?
There is no known cure or treatment. Severe cases need intensive supportive care.

How common is Ebola hemorrhagic fever?
Until recently, only three outbreaks of Ebola hemorrhagic fever in humans had been reported. The first two, in 1976 in Zaire and in western Sudan, were large outbreaks that resulted in more than 550 cases and 340 deaths. The third outbreak, in 1979 in Sudan, was smaller, with 34 cases and 22 deaths. In each of these outbreaks, most cases occurred in hospitals where medical supplies were inadequate and where needles and syringes were re-used. The outbreaks were quickly controlled by isolating sick patients in a place requiring the wearing of mask, gown, and gloves; sterilizing needles and syringes; and disposing of wastes and corpses in a sanitary way.

In 1995, an outbreak in Kikwit and surrounding areas in Bandundu Province, Zaire, caused 316 deaths. The outbreak was amplified in a hospital by staff who became infected through poor nursing techniques. At the request of health officials in Zaire, medical teams from CDC and the World Health Organization, and from Belgium, France, and South Africa, collaborated to investigate and control the outbreak.

Two isolated cases of Ebola hemorrhagic fever were identified in Cote d’Ivoire in 1994-1995. The most recent outbreaks were in rural Gabon in 1994 and in 1996. A patient from the 1996 Gabon outbreak traveled to Johannesburg, South Africa, and fatally infected a health-worker there as well.

How can Ebola hemorrhagic fever be prevented?
Under normal circumstances, travelers are at low risk of getting the disease. To eliminate the risk, travelers should avoid areas where Ebola outbreaks are occurring.

Ebola virus
      A notoriously deadly virus that causes fearsome symptoms, the most prominent being high fever and massive internal bleeding. Ebola virus kills as many as 90% of the people it infects. It is one of the viruses that is capable of causing hemorrhagic (bloody) fever.

Epidemics of Ebola virus have occurred mainly in African countries including Zaire (now the Democratic Republic of Congo), Gabon, Uganda, the Ivory Coast, and Sudan. Ebola virus is a hazard to laboratory workers and, for that matter, anyone who is exposed to it.

Infection with Ebola virus in humans is incidental — humans do not “carry” the virus. The way in which the virus first appears in a human at the start of an outbreak has not been determined. However, it has been hypothesized that the first patient (the index case) becomes infected through contact with an infected animal.

Ebola virus is transmitted by contact with blood, feces or body fluids from an infected person or by direct contact with the virus, as in a laboratory. People can be exposed to Ebola virus from direct contact with the blood or secretions of an infected person. This is why the virus has often been spread through the families and friends of infected persons: in the course of feeding, holding, or otherwise caring for them, family members and friends would come into close contact with such secretions. People can also be exposed to Ebola virus through contact with objects, such as needles, that have been contaminated with infected secretions.

The incubation period –the period between contact with the virus and the appearance of symptoms — ranges from 2 to 21 days.

The initial symptoms are usually high fever, headache, muscle aches, stomach pain, and diarrhea. There may also be sore throat, hiccups, and red and itchy eyes. The symptoms that tend to follow include vomiting and rash and bleeding problems with bloody nose (epistaxis), spitting up blood from the lungs (hemoptysis) and vomiting it up from the stomach (hematemesis), and bloody eyes (conjunctival hemorrhages). Then finally come chest pain, shock, and death.

A protein on the surface of the virus has been discovered that is responsible for the severe internal bleeding (the death-dealing feature of the disease). The protein attacks and destroys the endothelial cells lining blood vessels, causing the vessels to leak and bleed.

There is no specific treatment for the disease. Currently, patients receive supportive therapy. This consists of balancing the patient’s fluids and electrolytes, maintaining their oxygen level and blood pressure, and treating them for any complicating infections. Death can occur within 10 days of the onset of symptoms.

The prevention of the spread of Ebola fever involves practical viral hemorrhagic fever isolation precautions, or barrier nursing techniques. These techniques include the wearing of protective clothing, such as masks, gloves, gowns, and goggles; the use of infection-control measures, including complete equipment sterilization; and the isolation of Ebola fever patients from contact with unprotected persons. The aim of all of these techniques is to avoid any person’s contact with the blood or secretions of any patient. If a patient with Ebola fever dies, it is equally important that direct contact with the body of the deceased patient be prevented.

Bioterrorism — There has been concern about Ebola virus as a possible weapon for bioterrorism. However, the General Accounting Office, the investigative arm of the US Congress, in a 1999 report considered Ebola virus to be an “unlikely” biologic threat for terrorism, because the virus is very difficult to obtain and process, unsafe to handle, and relatively unstable.

Table: Cases of Ebola Hemorrhagic Fever in Africa, 1976 – 2008

Country Town Cases Deaths Species Year
Dem. Rep. of Congo Yambuku 318 280 Ezaire 1976
Sudan Nzara 151 151 Esudan 1976
Dem. Rep. of Congo Tandala 1 1 Ezaire 1977
Sudan Nzara 34 22 Esudan 1979
Gabon Mekouka 52 31 Ezaire 1994
Ivory Coast Tai Forest 1 0 EIvoryCoast 1994
Dem. Rep. of Congo Kikwit 315 250 Ezaire 1995
Gabon Mayibout 37 21 Ezaire 1996
Gabon Booue 60 45 Ezaire 1996
South Africa Johannesburg 2 1 Ezaire 1996
Uganda Gulu 425 224 Esudan 2000
Gabon Libreville 65 53 Ezaire 2001
Republic of Congo Not specified 57 43 Ezaire 2001
Republic of Congo Mbomo 143 128 Ezaire 2002
Republic of Congo Mbomo 35 29 Ezaire 2003
Sudan Yambio 17 7 Esudan 2004
Dem. Rep. of Congo Luebo 264 187 Ezaire 2007
Uganda Bundibugyo 149 37 Ebundi 2007
Dem. Rep. of Congo Luebo 32 15 Ezaire 2008

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(Survival manual/6. Medical/ b) Disease/Typhus)

It has been estimated that epidemic typhus has caused more deaths than all the wars in history.

Epidemic typhus is found most frequently during times of war and deprivation. (also called camp fever, jail fever, hospital fever, ship fever, famine fever, Epidemic louse-borne typhus,and louse-borne typhus) is a form of typhus so named because the disease often causes epidemics following wars and natural disasters.

Typhus was the most common waterborne disease according to Thomas Sydenham, England’s first great physician of the 17th century. A disease caused by contamination from human feces.

Epidemic Typhus is carried by the body louse and is excreted in the feces. The human scratches the bite and rubs the feces into the wound and contracts the disease, which incubates 1-2 weeks. Epidemics occurred throughout Europe from the 17th-19th century. Known as “Gaol Fever” in prisons, it was very common. Widespread epidemics occurred during the Napoleonic Wars and during the Potato Famine 1846-1849.

Throughout the middle ages and into the early part of the 20th century, periodic epidemics of typhus infection killed millions of people. As an example, during the eight-year period from 1917 to 1925, over 25 million cases of epidemic typhus occurred in Russia, causing an estimated three million deaths.

Epidemic typhus is now a rare disease, but two recent developments illustrate that an understanding of it is still important to clinicians:
•  A new cycle of infection involving flying squirrels and their ectoparasites with secondary transmission to humans has been recognized in the United States.
•  More than 45,000 cases of epidemic typhus occurred in Burundi in association with civil war during the 1990s; body louse infestation preceded outbreaks of both epidemic typhus and trench fever.

The outbreaks of typhus in Africa illustrate that the words of Hans Zinsser are still applicable today: “Typhus is not dead. It will live on for centuries and it will continue to break into the open whenever human stupidity and brutality give it a chance as most likely they occasionally will”.

The four main types of typhus are:
•  epidemic typhus (global, in areas with cold weather, poverty, war  and/or disaster)
•  Brill-Zinsser disease (a reinfection of epidemic typhus)
•  endemic or murine typhus (southeast and south USA)
•  scrub typhus (not in North America)
These diseases are all somewhat similar, although they vary in terms of severity. The specific type of Rickettsia that causes the disease also varies, as does the specific insect that can pass the bacteria along.

Epidemic typhus is caused by Rickettsia prowazekii, which is carried by body lice. When the lice feed on a human, they may simultaneously defecate. When the person scratches the bite, the feces (which carries the bacteria) are scratched into the wound. Body lice are common in areas in which people live in overcrowded, dirty conditions, with few opportunities to wash themselves or their clothing. Because of this fact, this form of typhus occurs simultaneously in large numbers of individuals living within the same community; that is, in epidemics. This type of typhus occurs when cold weather, poverty, war, and other disasters result in close living conditions that encourage the maintenance of a population of lice living among humans. Epidemic typhus is now found in the mountainous regions of Africa, South America, and Asia. [Its not enough to plan for food, water storage, personal protection in the eventuality of a long term disaster. Its as vitally important to protect yourself from bacteria, viral and insect infectionss. Maintain heat, warmth, relatively low density living arrangements, personal hygiene, make sure you have clean-sanitary clothing, and maintain sanitary cooking and eating utensils, only drink water that has been sanitized. Mr. Larry]

Epidemic typhus symptoms:
•  fever,
•  headache,
•  weakness, and muscle aches,
•  a rash composed of both spots and bumps. The rash starts on the back, chest, and abdomen, then spreads to the arms and legs.

The worst types of complications involve swelling in the heart muscle or brain (encephalitis). Without treatment, this type of typhus can be fatal.
While children usually recover well from epidemic typhus, older adults may have as much as a 60% death rate without treatment.

Brill-Zinsser disease is a reactivation of an earlier infection with epidemic typhus. It affects people years after they have completely recovered from epidemic typhus. When something causes a weakening of their immune system (like aging, surgery, illness), the bacteria can gain hold again, causing illness. This illness tends to be extremely mild.
•  Brill-Zinsser disease is quite mild, resulting in about a week-long fever, and a light rash similar to that of the original illness.
•  Brill-Zinsser, on the other hand, carries no threat of death.

Murine typhus occurs in the southeastern and southern United States, often during the summer and fall. It is rarely deadly. Risk factors for murine typhus include:
•  Exposure to rat fleas or rat feces
•  Exposure to other animals (such as cats, opossums, raccoons, skunks, and rats)

Symptoms of murine typhus may include:
•  Abdominal pain
•  Backache
•  Dull red rash that begins on the middle of the body and spreads
•  Extremely high fever (105 – 106 degrees Fahrenheit), which may last up to 2 weeks
•  Hacking, dry cough
•  Headache
•  Joint pain
•  Nausea
•  Vomiting
•  The early rash is a light rose color and fades when you press on it. Later, the rash becomes dull and red and does not fade. People with severe typhus may also develop small areas of bleeding into the skin

Treatment includes antibiotics such as:
•  Doxycycline
•  Tetracycline
•  Zithromax

Patients with epidemic typhus may need intravenous fluids and oxygen.

•  Clean drinking water and personal sanitation are a must.
•  Avoid areas where you might encounter rat fleas or lice.
•  Good sanitation and public health measures reduce the rat population.

Measures to get rid of lice when an infection has been found include:
•  Bathing;
•  boiling clothes or avoiding infested clothing for at least 5 days (lice will die without feeding on blood);
•  using insecticides (10% DDT, 1% malathion, or 1% permethrin)

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(Survival manual/6. Medical/b) Disease/Plague)

Plague was known as the Black Death during medieval times, when it killed up to a third of the population of Europe. Currently, plague occurs in fewer than 3,000 people per year worldwide. It can be deadly if not treated promptly with antibiotics.

The organism that causes plague, Yersinia pestis, lives in a variety of small rodents on every continent except Australia. The organism is transmitted to humans when they are bitten by fleas that have previously fed on infected rodents.

The most common form of plague results in swollen and tender lymph nodes — called buboes — in the groin, armpits or neck. The rarest and deadliest form of plague affects the lungs, and it can be spread from person to person.

Plague is divided into three main types — bubonic, septicemic and pneumonic — depending on which part of your body is involved. Signs and symptoms vary depending on the type of plague.

1.  Bubonic plague
Bubonic plague is the most common variety of the disease. It’s named after the buboes — swollen lymph nodes — which typically develop within a week after an infected flea bites you. Buboes may be:
•  Located in the groin, armpit or neck
•  About the size of a chicken egg
•  Tender and warm to the touch

Other signs and symptoms may include:
•  Sudden onset of fever and chills
•  Headache
•  Fatigue or malaise
•  Muscle aches

2.  Septicemic plague
Septicemic plague occurs when plague bacteria multiply in your bloodstream. Signs and symptoms include:
•  Fever and chills
•  Abdominal pain, diarrhea and vomiting
•  Bleeding from your mouth, nose or rectum, or under your skin
•  Shock
•  Blackening and death of tissue (gangrene) in your extremities, most commonly your fingers, toes and nose

3.  Pneumonic plague
Pneumonic plague affects the lungs. It’s the least common variety of plague but the most dangerous, because it can be spread from person to person via cough droplets. Signs and symptoms can begin within a few hours after infection, and may include:
•  Cough, with bloody sputum
•  Difficulty breathing
•  High fever
•  Nausea and vomiting
•  Weakness

Pneumonic plague progresses rapidly and may cause respiratory failure and shock within two days of infection. If antibiotic treatment isn’t initiated within a day after signs and symptoms first appear, the infection is likely to be fatal.

 When to see a doctor
Seek immediate medical attention if you begin to feel ill and have been in an area where plague has been known to occur. Thisincludes parts of several states in the western portion of the United States — primarily New Mexico, Arizona and Colorado.

The plague bacteria, Yersinia pestis, is transmitted to humans when they are bitten by fleas that have previously fed on infected animals, such as:
•  Rats
•  Squirrels
•  Rabbits
•  Prairie dogs
•  Chipmunks

The bacteria can also enter your body if you have a break in your skin that comes into contact with an infected animal’s blood. Domestic cats can become infected with plague from flea bites or from eating infected rodents.
Pneumonic plague, which affects the lungs, is spread by inhaling infectious droplets coughed into the air by a sick animal or person.

Risk factors
The risk of developing plaque is very low. Worldwide, only a few thousand people develop plague each year. However, your risk of plague can be increased by where you live and travel, your occupation, and even by some of your hobbies.
When traveling in areas where plague is prevalent, use generous amounts of insecticide on your clothes, stay out of areas likely to be infested by rats and have a speedily administer antibiotics in the event of a sudden fever, chills or headache.

Plague outbreaks are most common in rural areas and in urban areas characterized by overcrowding, poor sanitation and a high rat population.
The greatest number of human plague infections occurs in Africa. But the largest concentration of infected animals is in the United States — particularly in New Mexico, Arizona and Colorado — and in the former Soviet Union.

Veterinarians and their assistants have a higher risk of coming into contact with domestic cats that may have become infected with plague. Also at higher risk are people who work outdoors in areas where plague-infested animals are common.

Camping, hunting or hiking in areas where plague-infected animals reside can increase your risk of being bitten by an infected flea.

Complications of plague may include:
•  Death. Most people who receive prompt antibiotic treatment survive plague. Untreated plague has a fatality rate over 50 percent.
•  Gangrene. Blood clots in the tiny blood vessels of your fingers and toes can disrupt the flow of blood and cause that tissue to die. The portions of your fingers and toes that have died may need to be amputated.
•  Meningitis. Rarely, plague may cause meningitis, an inflammation of the membranes surrounding your brain and spinal cord.

Tests and diagnosis
If your doctor suspects plague, he or she may look for the Yersinia pestis bacteria in samples taken from your
•  Buboes. If you have the swollen lymph nodes (buboes) characteristic of bubonic plague, a fluid sample can be taken from them with a needle.
•  Blood. Yersinia pestis bacteria generally are present in your bloodstream only if you have septicemic plague.
•  Lungs. To check for pneumonic plague, fluid is extracted from your airways using endoscopy — a thin, flexible tube inserted through your nose or mouth and down your throat.

As soon as a diagnosis of suspected plague is made, the patient should be isolated, and local and state health departments should be notified. Confirmatory laboratory work should be initiated, including blood cultures and examination of lymph node specimens if possible. Drug therapy should begin as soon as possible after the laboratory specimens are taken.

The drugs of choice are streptomycin or gentamycin, but a number of other antibiotics are also effective.

Those individuals closely associated with the patient, particularly in cases with pneumonia, should be traced, identified, and evaluated. Contacts of pneumonic plague patients should be placed under observation or given preventive antibiotic therapy, depending on the degree and timing of contact.

Source : CDC’s home page on Plague

Treatments and drugs
As soon as your doctor suspects that you have plague, you’ll need to be admitted to an isolation room in a hospital. There, you’ll receive powerful antibiotics, such as:
•  Streptomycin
•  Gentamicin
•  Doxycycline (Vibramycin)
•  Ciprofloxacin (Cipro)
•  Chloramphenicol

Streptomycin is the most effective antibiotic against Y. pestis and the drug of choice for treatment of plague, particularly the pneumonic form. Therapeutic effect may be expected with 30 mg/kg/day (up to a total of 2 g/day) in divided doses given intramuscularly, to be continued for a full course of 10 days of therapy or until 3 days after the temperature has returned to normal. Gentamicin has been found to be effective in animal studies, and is used to treat human plague patients.

Chloramphenicol is a suitable alternative to aminoglycosides in the treatment of bubonic or septicaemic plague and is the drug of choice for treatment of patients with Y. pestis invasion of tissue spaces into which other drugs pass poorly or not at all (such as plague meningitis, pleuritis, or endophthalmitis). Dosage should be 50 mg/kg/day administered in divided doses either parenterally or, if tolerated, orally for 10 days. Chloramphenicol may be used adjunctively with aminoglycosides.

Different modalities of treatment are used:
•  Aminoglycosides
•  Chloramphenicol
•  Tetracyclines
•  Sulfonamides
•  Fluoroquinolones
•  Aminoglycosides: streptomycin and gentamicin

Tetracyclines:  This group of antibiotics is bacteriostatic but effective in the primary treatment of patients with uncomplicated plague. An oral loading dose of 15 mg/kg tetracycline (not to exceed 1 g total) should be followed by 25-50 mg/kg/day (up to a total of 2 g/day) for 10 days. Tetracyclines may also be used adjunctively with other antibiotics.

Sulfonamides: Sulfonamides have been used extensively in plague treatment and prevention; however, some studies have shown higher mortality, increased complications, and longer duration of fever as compared with the use of streptomycin, chloramphenicol or tetracycline antibiotics. Sulfadiazine is given as a loading dose of 2-4 g followed by a dose of 1 g every 4-6 hours for a period of 10 days. In children, the oral loading dose is 75 mg/kg, followed by 150 mg/kg/day orally in six divided doses. The combination drug trimethoprim-sulfamethoxazole has been used both in treatment and prevention of plague.

Fluoroquinolones: Fluoroquinolones, such as ciprofloxacin, have been shown to have good effect against Y. pestis in both in vitro and animal studies. Ciprofloxacin is bacteriocidal and has broad spectrum activity against most Gram-negative aerobic bacteria, including Enterobacteriaceae and Pseudomonas aeruginosa, as well as against many Gram-positive bacteria. Although it has been used successfully to treat humans with Francisella tularensis infection, no studies have been published on its use in treating human plague.

Other classes of antibiotics (penicillins, cephalosporins, macrolides):  These classes of antibiotics have been shown to be ineffective or of variable effect in treatment of plague and they should not be used for this purpose.

Supportive therapy
 The clinician must prepare for intense supportive management of plague complications, utilizing the latest developments for dealing with Gram-negative sepsis. Aggressive monitoring and management of possible septic shock, multiple organ failure, adult respiratory distresssyndrome (ARDS) and disseminated intravascular coagulopathy should be instituted.

Treatment of plague during pregnancy and in children
With correct and early therapy, complications of plague in pregnancy can be prevented. The choice of antibiotics during pregnancy is confounded by the potential adverse effects of three of the most effective drugs.
•  Streptomycin may be ototoxic and nephrotoxic to the foetus. Tetracycline has an adverse effect on developing teeth and bones of the foetus.
•  Chloramphenicol carries a low risk of “grey baby” syndrome or bone-marrow suppression.
•  Experience has shown that an aminoglycoside judiciously administered is effective and safe for both mother and foetus, and in children.
•  Because of its safety, intravenous or intramuscular administration, and ability to have blood concentrations monitored, gentamicin is the preferred antibiotic for treating plague in pregnancy.

Prophylactic therapy
Persons in close contact with pneumonic plague patients, or persons likely to have been exposed to Y. pestis-infected fleas, to have had direct contact with body fluids or tissues of a Y. pestis-infected mammal, or exposed during a laboratory accident to known infectious materials should receive antibiotic preventive therapy, if the exposure was in the previous six days.

The preferred antimicrobials for preventive or abortive therapy are the tetracyclines, chloramphenicol, or one of the effective

Although no effective vaccine is available, antibiotics can help prevent infection if you’re at risk of or have been exposed to plague. Take the following precautions if you live or spend time in regions where plague outbreaks occur:
•  Rodent-proof your home. Remove potential nesting areas, such as piles of brush, rock, firewood and junk. Don’t leave pet food in areas that rodents can easily access.
•  Keep your pets free of fleas. Ask your veterinarian which flea-control products will work best.
•  Use insect repellent. Closely supervise your children and pets when spending time outside in areas with large rodent populations. Use insect repellent.

Additional sources:

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Hantavirus pulmonary syndrome

(Survival manual/6. Medical/b) Disease/Hantavirus)

Hantavirus pulmonary syndrome is an infectious disease characterized by flu-like symptoms that can progress rapidly to potentially life-threatening breathing problems.
Several types of hantavirus can cause hantavirus pulmonary syndrome. They are carried by several types of rodents, particularly the deer mouse. You become infected primarily by breathing air infected with hantaviruses that are shed in rodent urine and droppings. Because treatment options are limited, the best protection against hantavirus pulmonary syndrome is to avoid rodents and their habitats.

Hantavirus occurs almost exclusively in healthy young adults who are living ‘close to nature’. Starting with acute lethargy, following by a raging fever, then degenerates into a deep resonating cough, accompanied by a rapid increase in heart rate often exceeding 100 beats per minute. Victims often gasp for air as their lungs begin to fill, shock and death result as the victims capillaries leak blood disrupting other vital organs. The death rate from the deadliest forms of hantavirus is 50-60%. The virus is carried by the Striped Field Mouse and is primarily located in the Four Corner region of AZ, NM, CO and UT.

Shacks/trailers infiltrated by the Striped Field Mouse leave droppings and  urine throughout the home., The disease is not contagious, and does not pass from person to person. Only direct contact or breathing  the  dried particles of the mouse urine and feces allow the disease into the body.

If you live in a remote area or cabin, you must be scrupulous about not harboring disease bearing critters.


[Map updated to 29 June 2012]

Hantavirus advances through two distinct stages. In the first stage, you may experience flu-like signs and symptoms that may include:

  • Fever and chills
  • Headaches and muscle aches
  • Vomiting, diarrhea or abdominal pain

In its early stages, hantavirus infection is difficult to distinguish from influenza, pneumonia or other viral conditions. After three to seven days, more-serious signs and symptoms begin. They typically include:

  • A cough that produces secretions
  • Shortness of breath
  • Fluid accumulating within the lungs
  • Low blood pressure
  • Reduced heart efficiency

 When to see a doctor
The signs and symptoms of hantavirus pulmonary syndrome can worsen suddenly and may quickly become life-threatening. If you’ve been around rodents or rodent droppings and have signs and symptoms of fever, chills, muscle aches or any difficulties breathing, seek immediate medical attention.

Each type of hantavirus has a preferred rodent carrier. The deer mouse is the primary carrier of the virus responsible for most cases of hantavirus pulmonary syndrome in North America. Other hantavirus carriers include the white-tailed mouse, cotton rat and rice rat.

Inhalation: Main route of transmission
Hantaviruses are transmitted to people primarily through the “aerosolization” of viruses shed in infected rodents’ droppings, urine or saliva. Aerosolization occurs when a virus is kicked up into the air, making it easy for you to inhale. For example, a broom used to clean up mouse droppings in an attic may nudge into the air tiny particles of feces containing hantaviruses, which you can then easily inhale.

After you inhale hantaviruses, they reach your lungs and begin to invade tiny blood vessels called capillaries, eventually causing them to leak. Your lungs then flood with fluid, which can trigger any of the respiratory problems associated with hantavirus pulmonary syndrome.

Person-to-person transmission
People who have the North American version of hantavirus pulmonary syndrome aren’t contagious to other people. However, the milder South American variety of the disease can be transmitted from person to person.

Risk factors
Hantavirus pulmonary syndrome is most common in rural areas of the western United States during the spring and summer months. Hantavirus pulmonary syndrome also occurs in South America and Canada. Other hantaviruses occur in Asia, where they cause kidney disorders rather than lung problems.

The chance of developing hantavirus pulmonary syndrome is greater for people who work, live or play in spaces where rodents live. Factors and activities that increase the risk include:

  • Opening and cleaning long unused buildings or sheds
  • Housecleaning, particularly in attics or other low-traffic areas
  • Having a home or work space infested with rodents
  • Having a job that involves exposure to rodents, such as construction, utility work and pest control
  • Camping, hiking or hunting

Hantavirus pulmonary syndrome can quickly become life-threatening. As the lungs fill with fluid, it becomes more and more difficult to breathe. Blood pressure drops and organs begin to fail, particularly the heart. The mortality rate for the North American variety of hantavirus pulmonary syndrome is more than 30 percent.

Tests and diagnosis
Blood tests can reveal if your body has made antibodies to a hantavirus. Your doctor may order other laboratory tests to rule out other conditions with similar symptoms.

Treatments and drugs
Specific treatment options for hantavirus pulmonary syndrome are limited. But the prognosis improves with early recognition, immediate hospitalization and adequate support for breathing.

 Supportive therapy
People with severe cases need immediate treatment in an intensive care unit. Assisted respiration, whether through intubation or mechanical ventilation, can help with breathing and ward off pulmonary edema. Intubation involves placing a breathing tube through your nose, mouth or trachea to help keep your airways open and functioning.

Blood oxygenation
In extremely severe cases of pulmonary distress, you’ll need a method called extracorporeal membrane oxygenation to help ensure you retain a sufficient supply of oxygen. This involves continuously pumping your blood through a machine that removes carbon dioxide and adds oxygen. The oxygenated blood is then returned to your body.

Prognosis (Outlook)
Hantavirus is a serious infection. Even with aggressive treatment, more than half of the cases are fatal.

Keeping rodents out of your home and workplace can help reduce your risk of hantavirus infection. Try these tips:

  • Block access. Mice can squeeze through holes as small as a quarter-inch (6 millimeters) wide. Seal holes with wire screening, metal flashing or cement.
  • Close the food buffet. Wash dishes promptly, clean counters and floors, and store your food — including pet food — in rodent-proof containers. Use tight fitting lids on garbage cans.
  • Reduce nesting material. Clear brush, grass and junk away from the building’s foundation.
  • Set traps. Spring-loaded traps should be set along baseboards. Exercise caution while using poison-bait traps, as the poison also can harm people and pets.

 Safe cleanup procedures
Wet down dead rodents and areas where rodents have been with alcohol, household disinfectants or bleach. This kills the virus and helps prevent infected dust from being stirred up into the air. Once everything is wet, use a damp towel to pick up the contaminated material. Then mop or sponge the area with disinfectant.
Take special precautions, such as wearing a respirator, when cleaning buildings with heavy rodent infestations.

For further information see: <>

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West Nile Virus

(Survival manual/ 6. Medical/c) Disease/West Nile Virus)

West Nile virus is an infection transmitted by mosquitoes. If you become infected with West Nile virus, you may not experience any signs or symptoms or you may experience only minor ones, such as fever and mild headache. However, some people who become infected with West Nile virus develop a life-threatening illness that includes inflammation of the brain.
Mild signs and symptoms of a West Nile virus infection generally go away on their own. But severe signs and symptoms — such as a severe headache, disorientation or sudden weakness — require immediate attention.
Exposure to mosquitoes where West Nile virus exists increases your risk of getting West Nile virus. Protect yourself from mosquitoes by using mosquito repellent and wearing clothing that covers your skin to reduce your risk.

Pasted from <>
1. Most have no symptoms:
About 80% of people infected with the West Nile virus have no signs or symptoms.

2. Mild infection signs and symptoms
About 20% of people develop a mild infection called West Nile fever. Common signs and symptoms of West Nile fever include:

  • Fever
  • Headache
  • Body aches
  • Fatigue
  • Skin rash (occasionally)
  • Swollen lymph glands (occasionally)
  • Eye pain (occasionally)

3. Serious infection signs and symptoms
In less than 1% of infected people, the virus causes a serious neurological infection. Such infection may include inflammation of the brain (encephalitis) or of the brain and surrounding membranes (meningoencephalitis). Serious infection may also include infection and inflammation of the membranes surrounding the brain and spinal cord (meningitis), inflammation of the spinal cord (West Nile poliomyelitis) and acute flaccid paralysis — a sudden weakness in your arms, legs or breathing muscles. Signs and symptoms of these diseases include:

  • High fever
  • Severe headache
  • Stiff neck
  • Disorientation or confusion
  • Stupor or coma
  • Tremors or muscle jerking
  • Lack of coordination
  • Convulsions
  • Pain
  • Partial paralysis or sudden weakness

Signs and symptoms of West Nile fever usually last a few days, but sign and symptoms of encephalitis or meningitis can linger for weeks, and certain neurological effects, such as muscle weakness, may be permanent.

 When to see a doctor
Mild symptoms of West Nile fever usually resolve on their own. If you experience signs or symptoms of serious infection, such as severe headaches, a stiff neck or an altered mental state, seek medical attention right away. A serious West Nile virus infection generally requires hospitalization.

1. Infection transmitted by mosquitoes
Typically, West Nile virus spreads to humans and animals via infected mosquitoes. Mosquitoes become infected when they feed on infected birds. You can’t get infected by touching or kissing a person with the virus.

Most West Nile virus infections occur during warm weather, when mosquito populations are active. The incubation period — the period between when you’re bitten by an infected mosquito and the appearance of signs and symptoms of the illness — ranges from three to 14 days.

West Nile virus is present in areas such as Africa, parts of Asia and the Middle East. It first appeared in the United States in the summer of 1999 and since then has been found in all 48 contiguous states.

2. Other possible routes of transmission
In a few cases, West Nile virus may have been spread through other routes, including organ transplantation and blood transfusion. However, blood donors are screened for the virus, substantially reducing the risk of infection from blood transfusions.

There have also been reports of possible transmission of the virus from mother to child during pregnancy or breast-feeding, but these have been rare and not conclusively confirmed.

Risk factors
Your overall risk of getting West Nile virus depends on these factors:

  • Time of year. The majority of cases in the United States have occurred between the months of July and September.
  • Geographic region. West Nile virus has been reported in most of the United States, but the Western and Midwestern states have had the highest incidence rates.
  • Time spent outside. If you work or spend time outdoors, you have a greater chance of being bitten by an infected mosquito.

Risk of serious infection
Even if you are infected, your risk of developing a serious West Nile virus-related illness is extremely small — less than 1 percent of people who are bitten become severely ill. And most people who do become sick recover fully. You’re more likely to develop a severe or fatal infection based on:

  • Age. Adults over the age of 50 are at higher risk of infection.
  • Health. Those who have a weakened immune system, such as from receiving an organ transplant, are at greater risk of infection.

Tests and diagnosis [for that less than 1%]
Your doctor can confirm the presence of West Nile virus in your body by analyzing a sample of your blood or the fluid surrounding your spinal cord (cerebrospinal fluid). If your doctor suspects a serious, West Nile virus-related illness such as meningitis or encephalitis, you may undergo a lumbar puncture or brain-imaging tests.

  • Laboratory tests. If you are infected, a blood test may show a rising level of antibodies to the West Nile virus. Antibodies are immune system proteins that attack foreign substances, such as viruses. A positive ribonucleic acid (RNA) test for the West Nile virus also is an indicator that you have the virus.
  • Lumbar puncture (spinal tap). The most common way to diagnose meningitis is to analyze the cerebrospinal fluid surrounding your brain and spinal cord. A needle inserted between the lower vertebrae of your spine is used to extract a sample of fluid for laboratory analysis. The fluid sample may show an elevated white cell count — a signal that your immune system is fighting an infection — and antibodies to the West Nile virus.

Treatments and drugs
Most people recover from West Nile virus without treatment. Over-the-counter pain relievers can help ease mild headaches and muscle aches.
There’s no direct cure for encephalitis or meningitis, but you may need supportive therapy in a hospital with intravenous fluids and medicines to prevent other types of infections.

West Nile Virus, Treatment
If you become ill with West Nile fever, treatment is seldom necessary. The only treatment currently available is supportive for the flu-like symptoms you may experience.
Many who become mildly ill with West Nile fever do not need to seek medical care and may not even know they were infected with West Nile virus.
Supportive care may include relieving symptoms of fever and muscle aches with over-the-counter medicines, rest, and fluids.

Prevention [these ares good general pest reduction strategies. lp]
Your best bet for preventing West Nile virus and other mosquito-borne illnesses is to avoid exposure to mosquitoes and eliminate mosquito-breeding sites. To help control West Nile virus:

  • Eliminate standing water in your yard. Mosquitoes breed in pools of standing water.
  • Unclog roof gutters.
  • Empty unused swimming pools.
  • Change water in birdbaths at least weekly.
  • Remove old tires or any unused containers that might hold water and serve as a breeding place for mosquitoes.

To reduce your own exposure to mosquitoes:

  • Avoid unnecessary outdoor activity when mosquitoes are most prevalent, such as at dawn, dusk and early evening.
  • Wear long-sleeved shirts and long pants when you go into mosquito-infested areas.
  • Apply mosquito repellent with DEET to your skin and clothing. Choose the concentration based on the hours of protection you need — the higher the percentage (concentration) of the active ingredient, the longer the repellent will work. Avoid using DEET on the hands of young children, in case they put their hands in their mouths, or on infants under 2 months of age. When outside, cover your infant’s stroller or playpen with mosquito netting.

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Suture techniques

(Survival manual/6. Medical/e) Skin/Suture techniques

 A.   Introduction
Pasted from <>
As a method for closing cutaneous wounds, the technique of suturing is thousands of years old. Although suture materials and aspects of the technique have changed, the goals remain the same: closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result, and minimizing the risks of bleeding and infection.

Proper suturing technique is needed to ensure good results in dermatologic surgery. The postoperative appearance of a beautifully designed closure or flap can be compromised if an incorrect suture technique is chosen or if the execution is poor. Conversely, meticulous suturing technique cannot fully compensate for improper surgical technique. Poor incision placement with respect to relaxed skin tension lines, excessive removal of tissue, or inadequate undermining may limit the surgeon’s options in wound closure and suture placement. Gentle handling of the tissue is also important to optimize wound healing.

The choice of suture technique depends on the type and anatomic location of the wound, the thickness of the skin, the degree of tension, and the desired cosmetic result. The proper placement of sutures enhances the precise approximation of the wound edges, which helps minimize and redistribute skin tension. Wound eversion is essential to maximize the likelihood of good epidermal approximation. Eversion is desirable to minimize the risk of scar depression secondary to tissue contraction during healing. Usually, inversion is not desirable, and it probably does not decrease the risk of hypertrophic scarring in an individual with a propensity for hypertrophic scars. The elimination of dead space, the restoration of natural anatomic contours, and the minimization of suture marks are also important to optimize the cosmetic and functional results.

In this article, the suture techniques used in cutaneous surgery are reviewed. The techniques of suture placement for each type of stitch are described, the rationale for choosing one suture technique over another are reviewed, and the advantages and disadvantages of each suture technique are discussed. Frequently, more than one suture technique is needed for optimal closure of a wound. After reading this article, the reader should have an understanding of how and why particular sutures are chosen and an appreciation of the basic methods of placing each type of suture.1,2

B.  Basic suturing principles
Many varieties of suture material and needles are available to the cutaneous surgeon. The choice of sutures and needles is determined by the location of the lesion, the thickness of the skin in that location, and the amount of tension exerted on the wound. Regardless of the specific suture and needle chosen, the basic techniques of needle holding, needle driving, and knot placement remain the same.

1.  Needle construction
•  The needle has 3 sections. The point is the sharpest portion and is used to penetrate the tissue. The body represents the mid portion of the needle. The swage is the thickest portion of the needle and the portion to which the suture material is attached.
•  In cutaneous surgery, 2 main types of needles are used: cutting and reverse cutting. Both needles have a triangular body. A cutting needle has a sharp edge on the inner curve of the needle that is directed toward the wound edge. A reverse cutting needle has a sharp edge on the outer curve of the needle that is directed away from the wound edge, which reduces the risk of the suture pulling through the tissue. For this reason, the reverse cutting needle is used more often than the cutting needle in cutaneous surgery.

2.  Suture placement
•  A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon’s preference. The needle holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened excessively because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder.

[Left: The needle holder is held through the loops between the thumb and the fourth finger, and the index finger rests on the fulcrum of the instrument.]

•  Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, and/or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle holder to provide stability (see first image below). Alternatively, the needle holder may be held in the palm to increase dexterity (see second image below).

•  The tissue must be stabilized to allow suture placement. Depending on the surgeon’s preference, toothed or untoothed forceps or skin hooks may be used to gently grasp the tissue. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis. Forceps are necessary for grasping the needle as it exits the tissue after a pass. Prior to removing the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.
[Above: Using forceps to stabilize the tissue while the suture is placed.]

•  The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the 2 sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.

3.  Knot tying
•  Once the suture is satisfactorily placed, it must be secured with a knot. The instrument tie is used most commonly in cutaneous surgery. The square knot is traditionally used. First, the tip of the needle holder is rotated clockwise around the long end of the suture material for 2 complete turns. The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, such that the 2 ends of the suture material are situated on opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of the suture. The short end is grasped with the needle holder tip, and the short end is pulled through the loop again.

•  The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound edema. Depending on the surgeon’s preference, 1-2 additional throws may be added.

•  Properly squaring successive ties is important. That is, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is inherently weaker than a properly squared knot. When the desired number of throws is completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be placed (see image below).

 4.  Placement
Sutures are placed by mounting a needle with attached suture into a needle holder. The needle point is pressed into the flesh, advanced along the trajectory of the needle’s curve until it emerges, and pulled through. The trailing thread is then tied into a knot, usually a square knot or surgeon’s knot. Sutures should bring together the wound edges, but should not cause indenting or blanching of the skin, since the blood supply may be impeded and thus increase infection and scarring. Sutured skin should roll slightly outward from the wound (eversion), and the depth and width of the sutured flesh should be roughly equal. Placement varies based on the location, but the distance between each suture generally should be equal to the distance from the suture to the wound edge.

Many different techniques exist. The most common is the simple interrupted stitch; it is indeed the simplest to perform and is called “interrupted” because the suture thread is cut between each individual stitch. The vertical and horizontal mattress stitch are also interrupted but are more complex and specialized for everting the skin and distributing tension. The running or continuous stitch is quicker but risks failing if the suture is cut in just one place; the continuous locking stitch is in some ways a more secure version. The chest drain stitch and corner stitch are variations of the horizontal mattress. Other stitches include the Figure 8 stitch and subcuticular stitch.

 5.  Removal
•  While some sutures are intended to be permanent, and others in specialized cases may be kept in place for an extended period of many weeks, as a rule sutures are a short term device to allow healing of a trauma or wound.
•  “Different parts of the body heal at different speed. Common time to remove stitches will vary: facial wounds 3–5 days; scalp wound 7–10 days; limbs 10–14 days; joints 14 days; trunk of the body 7–10 days.
•  “Not all stitches must be removed. If a small area remains unhealed, notify the health care practitioner. Then if ordered, remove sutures from the healed area only.”


C.  Tissue adhesives
Pasted from <>
In recent years, topical cyanoacrylate adhesives (“liquid stitches”), a.k.a super glue, have been used in combination with, or as an alternative to, sutures in wound closure. The adhesive remains liquid until exposed to water or water-containing substances/tissue, after which it cures (polymerizes) and forms a flexible film that bonds to the underlying surface. The tissue adhesive has been shown to act as a barrier to microbial penetration as long as the adhesive film remains intact. Limitations of tissue adhesives include contraindications to use near the eyes and a mild learning curve on correct usage.

Cyanoacrylate is the generic name for cyanoacrylate based fast-acting glues such as methyl-2-cyanoacrylate, ethyl-2-cyanoacrylate (commonly sold under trade names like Superglue and Krazy Glue) and n-butyl-cyanoacrylate. Skin glues like Indermil and Histoacryl were the first medical grade tissue adhesives to be used, and these are composed of n-butyl cyanoacrylate. These worked well but had the disadvantage of having to be stored in the refrigerator, were exothermic so they stung the patient, and the bond was brittle. Nowadays, the longer chain polymer, 2-octyl cyanoacrylate, is the preferred medical grade glue. It is available under various trade names, such as LiquiBand, SurgiSeal, FloraSeal, and Dermabond. These have the advantages of being more flexible, making a stronger bond, and being easier to use. The longer side chain types, for example octyl and butyl forms, also reduce tissue reaction.


 D.  Adventure Medical Kits Suture/Syringe Kit, ~$64.99
Product Features
•  Also used for injecting medications or anesthetics
•  And for starting or delivering IV’s
VA hospital quality field surgical kit for closing wounds

 Suture/Syringe Kit:
Suture/Syringe Supplies, 1 – Angiocatheter, 18G x11/4, 1 – Bandage, Conforming Gauze, Sterile, 3, 1 – Catheter, 18 Gauge, Plastic Tip, 1 – Gloves, Surgical Sterile, Size7.5 (pair), 1 – Gloves, Surgical Sterile, Size8 (pair), 1 – IV Start Kit, Sterile, 1 – Mayo Heger Needle Holder, 5, 1 – Packaging, Suture/Syringe Medic, 1 – Povidone Iodine Solution, 3/4 oz, 1 – Scalpel, Sterile, Disposable, with #11 Blade, 1 – Scissors, Stainless Steel, 5, 1 – Suture, Nylon, 3-0, 1 – Suture, Nylon, 5-0, 1 – Syringe, Irrigation, 20 cc with18 Gauge Tip, 1 – Syringe, Luer Lok, Sterile, 5 ml, 1 – Tape, 1/2 x10 Yards, Box/24, 1 – Thumb Tissue Forceps, Mouse-Tooth, 4.5, 1 – Towel Drape, Sterile, 1 – Wound Closure Strips, 1/4 x4, Pkg./10, 2 – Dressing, Gauze, Sterile, 4 x4, Pkg./2, 2 – Dressing, Non-Adherent, Sterile, 3 x4, 2 – Needle, Disposable, Sterile, 18G x11/2, 2 – Needle, Disposable, Sterile, 21G x11/2, 2 – Needle, Disposable, Sterile, 25G x5/8, 2 – Syringe, Luer Lok, Sterile, 3 ml, 2 – Tincture of Benzoin Topical Skin Adhesive, Swab, 2 – Trauma Pad, 5 x9, 4 – Triple Antibiotic Ointment, Net Wt. 0.9 g, , 5 – After Cuts & Scrapes Anesthetic/Antiseptic Wipe,

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Lassa fever

(Survival manual/6. Medical/b) Disease/Lassa fever)

What is Lassa fever?
Lassa is a Category A disease, according to the U.S., meaning it has the potential, like anthrax and botulism, to be used a biological weapon.
Lassa fever is an acute viral illness that occurs naturally in West Africa. The illness was discovered in 1969 when two missionary nurses died in Nigeria, West Africa. The cause of the illness was found to be Lassa virus, named after the town in Nigeria where the first cases originated. The virus, a member of the virus family Arenaviridae, is a single-stranded RNA virus and is zoonotic, or animal-borne.
In areas of Africa where the disease is endemic (that is, constantly present), Lassa fever is a significant cause of morbidity and mortality. While Lassa fever is mild or has no observable symptoms in about 80% of people infected with the virus, the remaining 20% have a severe multisystem disease. Lassa fever is also associated with occasional epidemics, during which the case-fatality rate can reach 50%.

Where is Lassa fever found?
Lassa fever is an endemic disease in portions of West Africa. It is recognized in Guinea, Liberia, Sierra Leone, as well as Nigeria. However, because the rodent species which carry the virus are found throughout West Africa, the actual geographic range of the disease may extend to other countries in the region.

How many people become infected?
The number of Lassa virus infections per year in West Africa is estimated at 100,000 to 300,000, with approximately 5,000 deaths. Unfortunately, such estimates are crude, because surveillance for cases of the disease is not uniformly performed. In some areas of Sierra Leone and Liberia, it is known that 10%-16% of people admitted to hospitals have Lassa fever, which indicates the serious impact of the disease on the population of this region. [Note: Lassa fever was discovered in 1969, now 40 years later, there have been outbreaks over much of the western side of the African continent]
At least two cases of Lassa fever have occurred in the United States, the first in Chicago, the second in New Jersey. Both individuals who had recently been traveling in endemic areas of Africa, one in Nigeria, the other in Liberia, and succumbed to the fever after returning to the United States. Several incidences of infection in the lab have occurred with Lassa virus, as in the case of well-known virologist Dr. Jordi Casals, who became infected with the virus after studying samples from the original Nigerian case.

In what animal host is Lassa virus maintained?
Mastomys rodent, also known as the “multimammate rat”.  Note the hairless tail.
The reservoir, or host, of Lassa virus is a rodent known as the “multimammate rat” of the genus Mastomys. It is not certain which species of Mastomys are associated with Lassa; however, at least two species carry the virus in Sierra Leone. Mastomys rodents breed very frequently, produce large numbers of offspring, and are numerous in the savannas and forests of West, Central, and East Africa. In addition, Mastomys generally readily colonize human homes. All these factors together contribute to the relatively efficient spread of Lassa virus from infected rodents to humans.

How do humans get Lassa fever?
There are a number of ways in which the virus may be transmitted, or spread, to humans. The Mastomys rodents shed the virus in urine and droppings. Therefore, the virus can be transmitted through direct contact with these materials, through touching objects or eating food contaminated with these materials, or through cuts or sores. Because Mastomys rodents often live in and around homes and scavenge on human food remains or poorly stored food, transmission of this sort is common. Contact with the virus also may occur when a person inhales tiny particles in the air contaminated with rodent excretions. This is called aerosol or airborne transmission. Finally, because Mastomys rodents are sometimes consumed as a food source, infection may occur via direct contact when they are caught and prepared for food.

Lassa fever may also spread through person-to-person contact. This type of transmission occurs when a person comes into contact with virus in the blood, tissue, secretions, or excretions of an individual infected with the Lassa virus. The virus cannot be spread through casual contact (including skin-to-skin contact without exchange of body fluids). Person-to-person transmission is common in both village and health care settings, where, along with the above-mentioned modes of transmission, the virus also may be spread in contaminated medical equipment, such as reused needles (this is called nosocomial transmission).

What are the symptoms of Lassa fever?
Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with the virus. These include fever, retrosternal pain (pain behind the chest wall), sore throat, back pain, cough, abdominal pain, vomiting, diarrhea, conjunctivitis, facial swelling, proteinuria (protein in the urine), and mucosal bleeding. Neurological problems have also been described, including hearing loss, tremors, and encephalitis. Because the symptoms of Lassa fever are so varied and nonspecific, clinical diagnosis is often difficult.

 How is the disease diagnosed in the laboratory?
Lassa fever is most often diagnosed by using enzyme-linked immunosorbent serologic assays (ELISA), which detect IgM and IgG antibodies as well as Lassa antigen. The virus itself may be cultured in 7 to 10 days. Immunohistochemistry performed on tissue specimens can be used to make a post-mortem diagnosis. The virus can also be detected by reverse transcription-polymerase chain reaction (RT-PCR); however, this method is primarily a research tool.

 Are there complications after recovery?
The most common complication of Lassa fever is deafness. Various degrees of deafness occur in approximately one-third of cases, and in many cases hearing loss is permanent. As far as is known, severity of the disease does not affect this complication: deafness may develop in mild as well as in severe cases.  Spontaneous abortion is another serious complication.

 What proportion of people die from the illness?
Approximately 15%-20% of patients hospitalized for Lassa fever die from the illness. However, overall only about 1% of infections with Lassa virus result in death. The death rates are particularly high for women in the third trimester of pregnancy, and for fetuses, about 95% of which die in the uterus of infected pregnant mothers.

 How is Lassa fever treated?
Ribavirin, an antiviral drug, has been used with success in Lassa fever patients. It has been shown to be most effective when given early in the course of the illness. Patients should also receive supportive care consisting of maintenance of appropriate fluid and electrolyte balance, oxygenation and blood pressure, as well as treatment of any other complicating infections. Ribavirin should be given intravenously for ten days.

What groups are at risk for getting the illness?
Individuals at risk are those who live or visit areas with a high population of Mastomys rodents infected with Lassa virus or are exposed to infected humans. Hospital staff are not at great risk for infection as long as protective measures are taken.

 How is Lassa fever prevented?
Wearing protective clothing — an important part of practicing barrier nursing methods.
Primary transmission of the Lassa virus from its host to humans can be prevented by avoiding contact with Mastomys rodents, especially in the geographic regions where outbreaks occur. Putting food away in rodent-proof containers and keeping the home clean help to discourage rodents from entering homes. Using these rodents as a food source is not recommended. Trapping in and around homes can help reduce rodent populations. However, the wide distribution of Mastomys in Africa makes complete control of this rodent reservoir impractical.

When caring for patients with Lassa fever, further transmission of the disease through person-to-person contact or nosocomial routes can be avoided by taking preventive precautions against contact with patient secretions (together called VHF isolation precautions or barrier nursing methods). Such precautions include wearing protective clothing, such as masks, gloves, gowns, and goggles; using infection control measures, such as complete equipment sterilization; and isolating infected patients from contact with unprotected persons until the disease has run its course.

What needs to be done to address the threat of Lassa fever?
Further educating people in high-risk areas about ways to decrease rodent populations in their homes will aid in the control and prevention of Lassa fever. Other challenges include developing more rapid diagnostic tests and increasing the availability of the only known drug treatment, ribavirin. Research is presently under way to develop a vaccine for Lassa fever.


Is There a Real Biological Warfare Threat?
Current unclassified information reveals that, despite the 1972 Geneva Biological Weapons Convention, at least seventeen countries are known or suspected of having offensive biological weapons programs.
Clearly, BW is a credible threat to our military, as it was during Desert Shield/Storm. Terrorist use of BW agents could kill many people to create an unparalleled medical, political, and social crisis. Despite the fact the biological weapons have never been used against the United States, we must prepare for a new age of terrorism. Civilian health-care workers must know how to recognize a BW attack in the event of terrorist use of BW agents on civilian populations.

Lassa fever may be spread as an aerosol or with dust-powder.

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Yellow Fever

 (Survival manual/6. Medical/b) Disease/Yellow Fever)

  A.  Background
From 1793-1822, yellow fever was one of the most dreaded diseases in US port cities. Yellow fever outbreaks in the United States shaped American history and influenced important national decisions. In the 1780s, yellow fever outbreaks in Philadelphia were responsible for killing one tenth of the city’s population. Benjamin Rush described the epidemic and, based on the science of the time, sought to contain the devastating illness. Yellow fever did not discriminate by gender, race, occupation, or socioeconomic status. Yellow fever may have played a part in shaping the decision to move the nation’s capital out of Philadelphia.1 The disease had such an impact on the local economies that, in 1803, Napoleon, with his troops decimated by yellow fever, had few reservations about selling the affected Louisiana and western territories to the US government.

Yellow fever is a hemorrhagic fever caused by a virus spread by a particular species of mosquito. It’s most common in areas of Africa and South America, affecting travelers to and residents of those areas.
In mild cases, yellow fever causes fever, headache, nausea and vomiting. But yellow fever can become more serious, causing bleeding (hemorrhaging), heart, liver and kidney problems. Up to 50 percent of people with the more severe form of yellow fever die of the disease.
There’s no specific treatment for yellow fever. But getting a yellow fever vaccine before traveling to an area in which the virus is known to exist can protect you from the disease.

During the first three to six days after you’ve contracted yellow fever — the incubation period — you won’t experience any signs or symptoms. After this, the virus enters an acute phase and then, in some cases, a toxic phase that can be life-threatening.

Acute phase
Once the yellow fever virus enters the acute phase, you may experience signs and symptoms including:

  • Fever
  • Headache
  • Muscle aches, particularly in your back and knees
  • Nausea, vomiting or both
  • Loss of appetite
  • Dizziness
  • Red eyes, face or tongue

These signs and symptoms usually improve and are gone within several days.

Toxic phase
Although signs and symptoms may disappear for a day or two following the acute phase, some people with acute yellow fever then enter a toxic phase. During the toxic phase, acute signs and symptoms return and more-severe and life-threatening ones also appear. These can include:

  • Yellowing of your skin and the whites of your eyes (jaundice)
  • Abdominal pain and vomiting, sometimes blood
  • Decreased urination
  • Bleeding from your nose, mouth and eyes
  • Heart dysfunction (arrhythmias)
  • Liver and kidney failure
  • Brain dysfunction, including delirium, seizures and coma

The toxic phase of yellow fever can be fatal.

 When to see a doctor
Make an appointment to see your doctor four to six weeks before traveling to an area in which yellow fever is known to occur. If you don’t have that much time to prepare, call your doctor anyway. Your doctor will help you determine whether you need vaccinations and can provide general guidance on protecting your health while abroad.
Seek emergency medical care if you’ve recently traveled to a region where yellow fever is known to occur and you develop severe signs or symptoms of the disease. If you develop mild symptoms, call your doctor.

Yellow fever is caused by a virus that is spread by the Aedes aegypti mosquito. These mosquitoes thrive in and near human habitations where they breed in even the cleanest water. Most cases of yellow fever occur in sub-Saharan Africa and tropical South America.
Humans and monkeys are most commonly infected with the yellow fever virus. Mosquitoes transmit the virus back and forth between monkeys, humans or both. When a mosquito bites a human or monkey infected with yellow fever, the virus enters the mosquito’s bloodstream and circulates before settling in the salivary glands. When the infected mosquito then bites another monkey or human, the virus then enters the host’s bloodstream, where it may cause illness.

Risk factors: Traveling to Africa or South America
Traveling to an area in which the yellow fever virus is known to be present puts you at risk of the disease. These areas include sub-Saharan Africa and tropical South America.
Even if there aren’t current reports of infected humans in these areas, it doesn’t mean you’re risk-free. It’s possible that local populations have been vaccinated and are protected from the disease, or that cases of yellow fever just haven’t been detected and officially reported.

If you’re planning on traveling to these areas, you can protect yourself by getting a yellow fever vaccine at least 10 to 14 days prior to traveling.
Anyone can be infected with the yellow fever virus, but older adults are at greater risk of getting seriously ill.

Yellow fever results in death for 20 to 50 percent of those who develop severe disease. This usually occurs within two weeks from the start of infection. Complications during the toxic phase of a yellow fever infection include kidney and liver failure, jaundice, delirium and coma.

People who survive the infection recover gradually over a period of several weeks to months, usually without significant organ damage. During this time a person may experience fatigue and jaundice. Other complications include secondary bacterial infections, such as pneumonia, or blood infections.

Tests and diagnosis
Diagnosing yellow fever based on signs and symptoms can be difficult because its early signs and symptoms can be easily confused with those of other diseases, such as malaria, typhoid, dengue fever and other viral hemorrhagic fevers. To diagnose your condition, your doctor will likely ask about your medical and travel history and order blood tests.

If you have yellow fever, your blood may reveal the virus itself. If not, blood tests known as enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) also can detect antigens and antibodies specific to the virus. Results for these tests may take several days.

Treatments and drugs
No antiviral medications have proved helpful in treating yellow fever. As a result, treatment consists primarily of supportive care in a hospital. This includes providing fluids and oxygen, maintaining adequate blood pressure, replacing blood loss, providing dialysis for kidney failure, and treating any other infections that develop. Some people receive transfusions of plasma to replace blood proteins that improve clotting.

If you have yellow fever, you may also be kept away from mosquitoes, to avoid transmitting the disease to others.

Yellow Fever Treatment in Mild Cases
People who experience mild yellow fever symptoms usually have symptoms for a couple of days. During this time, treatment to relieve symptoms can include:

•  Resting in bed
•  Drinking plenty of fluids
•  Taking common medication such as acetaminophen (not aspirin) to relieve fever and discomfort.

Common medications used at home for pain and fever in children with yellow fever include:
•  Acetaminophen
•  Ibuprofen
•  Naproxen

Aspirin and most of the other nonsteroidal anti-inflammatory drugs (NSAIDS) are not used in children except under a doctor’s care.

_Acetaminophen (Tylenol and others)
•  Acetaminophen decreases fever and pain, but does not help inflammation.
•  Dosing is 10-15 mg per kilogram (5-7 mg per pound) of body weight every 4-6 hours, up to the adult dose.
•  Do not exceed the maximum daily dose.
•  Acetaminophen products come in various strengths. Always follow the package instructions.
•  Avoid this drug in children with liver disease or an allergy to acetaminophen.
•  Common acetaminophen products include Tylenol, Panadol and many others.

•  Ibuprofen decreases pain, fever and inflammation.
•  It is a nonsteroidal anti-inflammatory medication (NSAID).
•  Dosing for children over 6 months of age is 7-10 mg per kilogram (4-5 mg per pound) of body weight every 6 hours, up to the adult dose.
•  Do not exceed the maximum daily dose.
•  Always follow the package instructions.
•  Avoid this drug in children with liver, kidney, stomach or bleeding problems.
•  Brand names include Advil, Motrin and Nuprin.

•  Naproxen decreases pain, fever and inflammation.
•  It is a nonsteroidal anti-inflammatory medication (NSAID).
•  Dosing for 13 and older is 200 mg twice a day with food.
•  Do not exceed 500 mg per day.
•  Always follow the package instructions.
•  Avoid this drug in children with liver, kidney, stomach or bleeding problems.
•  The brand name for naproxen is Aleve.

The case-fatality rate of yellow fever has been reported at 5%-70%.
•  In recent outbreaks, the fatality rate was approximately 20% among patients with jaundice.
•  Up to 50% of patients who progress to the toxic phase die.


B.  Prevention
1.  Vaccine
A safe and highly effective vaccine prevents yellow fever. Yellow fever is known to be present in sub-Saharan Africa and parts of South America. Talk to your doctor about whether you need the yellow fever vaccine at least 10 to 14 days before traveling to these areas or if you are a resident of one of them. Some of these countries require a valid certificate of immunization in order to enter the country.

A single dose of the vaccine provides protection for at least 10 years. Side effects of the yellow fever vaccine are usually mild, lasting five to 10 days, and may include headaches, low-grade fevers, muscle pain, fatigue and soreness at the site of injection. More-significant reactions — such as developing a syndrome similar to actual yellow fever, inflammation of the brain (encephalitis) or death — can occur, most often in infants and older adults. The vaccine is considered safest for those between the ages of 9 months and 60 years. Talk to your doctor about whether the vaccine is appropriate if your child is younger than 9 months or you’re older than 60 years.

2.  Mosquito protection
In addition to getting the vaccine, you can help protect yourself against yellow fever by protecting yourself against mosquitoes.

To reduce your exposure to mosquitoes:

  • Avoid unnecessary outdoor activity when mosquitoes are most prevalent, such as at dawn, dusk and early evening.
  • Wear long-sleeved shirts and long pants when you go into mosquito-infested areas.
  • Stay in air-conditioned or well-screened housing.

To ward off mosquitoes with repellent, use both of the following:

  • Nonskin repellent. Apply permethrin-containing mosquito repellent to your clothing, shoes, and camping gear and bed netting. Some products pre-treated with permethrin are available to buy. Permethrin is not intended for use on your skin.
  • Skin repellent. Products with the active ingredients DEET or picaridin provide the longest lasting skin protection. Choose the concentration based on the hours of protection you need. In general, higher concentrations last longer. Keep in mind that chemical repellents can be toxic, and use only the amount needed for the time you’ll be outdoors. Don’t use DEET on the hands of young children or on infants under 2 months of age. Instead, cover your infant’s stroller or playpen with mosquito netting when outside.

According to the Centers for Disease Control and Prevention, oil of lemon eucalyptus, a more natural product, offers the same protection as DEET when used in similar concentrations. However, these products should not be used on children younger than age 3.

_United States
Reports of yellow fever in the United States are exceedingly rare, with the last outbreak reported in New Orleans in 1905. It is a rare cause of illness in returning travelers. In 1999, the Centers for Disease Control and Prevention (CDC) reported a case of fatal yellow fever in a previously healthy California man who had returned from a 10-day trip to Venezuela. A second case of fatal yellow fever was reported in 1996 in a US resident returning from South America. Prior to these reports, the last case was reported in 1924. Neither patient had received a yellow fever vaccine prior to travel.
•  World Health Organization (WHO) data suggest that the rate of yellow fever transmission is increasing, especially in sub-Saharan Africa. In addition, the number of US residents traveling to South America and Africa is also increasing. The WHO estimates that travelers from the United States to endemic areas has doubled since 1988.  Without proper precautions, including vaccination, these travelers are at risk of contracting yellow fever.
•  A aegypti mosquitoes are present in the southeastern United States, making the outbreak of yellow fever in that region a potential risk.

•  After adjustment for underreporting, an estimated 200,000 cases of yellow fever occur annually, with 30,000 deaths per year.
•  Thirty-three countries in Africa are at risk. Transmission in Africa is facilitated by the close proximity of vector mosquito populations to unvaccinated human populations.The case-fatality rate of yellow fever in Africa approximates 20%. Infants and children are at highest risk.
•  Yellow fever is endemic in 9 South American countries and several Caribbean islands. Bolivia, Brazil, Ecuador, and Peru are considered at highest risk.The incidence of yellow fever in South America is lower than in Africa because the infected monkeys in the rain forest canopy do not often come in contact with human populations. Indigenous human populations have immunity as a part of mass immunization campaigns.  Yellow fever occurs most frequently in young men through occupational exposure in forested areas.
•  Outbreaks of yellow fever have not been reported in Asia, but this region remains at risk because of the presence of competent vector mosquitoes and nonhuman primates.  

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Cut, scrape & wound

(Survival manual/6. Medical/e) Skin)
From< >

How to treat Minor Cuts
1.  Stop the bleeding
2.  Clean the wound

3.  Home care for scrapes and cuts
4. Options for closing wounds
5.  Prevent infection
6.  Promote healing
7.  Identifying secondary infection
8.  Typical (Secondary) skin infections

1.  Stop the bleeding
The first priority is to stop the wound bleeding. Follow these simple steps:
•  Try to calm and reassure the injured person.
•  Apply firm pressure directly to the wound, ideally using a clean cloth or towel. You can also use a finger if nothing else is available.
•  If the blood seeps through the cloth or towel, add more pressure.
•  Remove pressure when the bleeding stops, usually in five to ten minutes.

 When to seek medical help
You may need to seek medical help to stop the bleeding. You should seek immediate medical attention if:
•  The bleeding does not stop in ten minutes. [I’ve had this happen a couple of times, the cut needed stitching.]
•  You see bright red and spurting blood (this means that an artery has been severed).

 2.  Clean the wound
It’s very important to carefully clean a wound. Proper cleaning removes any foreign material, reduces the risk of secondary infection and minimizes any potential scarring.
To clean the wound:
•  Rinse the wound with clear water. Running tap water can be used.
•  Remove any foreign material in the wound (such as dirt, gravel or glass) by using tweezers if necessary.
•  Ideally, clean the wound with a sterile gauze.
•  Avoid using cotton wool.
•  If the bleeding restarts, apply firm pressure.
•  Most first aid kits include sterile or antiseptic wipes which can be used to clean the wound.

 When to seek medical help
If you are unable to remove all foreign objects, you should seek medical help in thoroughly cleaning the wound.

 3.  Home care for scrapes and cuts
Most scrapes and cuts can be cared for at home.
Scrapes often cover large areas, but they are superficial. When caring for a scrape, make sure to remove any embedded grit or dirt.
Small cuts can be cared for at home if the edges of the cut are close together. Make sure to remove any foreign material from the cut, stop the bleeding and cover the cut with a bandage or dressing.

When to seek medical help
You may need to seek medical attention for a cut or scrape. Call your doctor if:
•  The wound needs sutures. A wound needs sutures if it is deep, if fat protrudes from it, if the wound is over half an inch long or if it is a gaping wound.
•  You are unable to remove dirt, debris or dead tissue.
•  You can’t stop the bleeding.
•  The wound is a puncture.
•  The wound occurs on the face, eyelids, lips, or neck.
•  The edges of the wound are badly torn
•  A tetanus shot is required.
•  You are uncomfortable or unable to deal with the situation.

 4.  Options for closing wounds
There are many ways to close wounds, and the best option will depend on the type and severity of the wound itself.
•  Skinstrips are tape-like strips that hold the skin together. These are appropriate for small cuts that occur on parts of the body where there is very little tension or movement that could pull the wound apart (e.g. torso, thigh).
•  For deeper cuts, sutures (or stitches) are used to sew the edges of the cut together. They are very useful for closing wounds that have occurred on parts of the body where there is a lot of movement (e.g. hands).
•  Steri-strips or butterfly strips are used to close wounds on the face in those instances where stitches may leave a scar. Steri-strips are thin and sticky, and usually fall off after a few days.
•  Skin glue is a special adhesive that sticks together the edges of the wound and seals the skin for protection. Skin glue is not as effective on areas where there is a significant amount of skin movement.

5.  Prevent infection
Once you have stopped the bleeding and cleaned the wound, you will want to prevent infections from developing. The most effective strategy is to apply a topical antibiotic to the wound and cover it with a dressing.

You can help prevent infection by:
•  Applying a topical antibiotic, such as Neobiotic ointment to the wound. Topical antibiotics should be applied with each dressing change, or two to three times a day if the wound is left uncovered.
•  Cover the wound to keep it moist and to protect the topical antibiotic.
Studies show that applying a topical antibiotic can promote healing in 8 days, as opposed to 13 days for wounds left untreated. The use of mercurochrome and tincture of iodine was not as effective. These products resulted in healing over 13 and 15 days respectively. 

6.  Promote healing
You can promote healing and minimize the potential for scarring by covering the wound. Scientific studies show that keeping an injured area moist:
•  promotes the growth of new tissue,
•  lessens the potential for infection,
•  minimizes scarring, and
•  lessens the chance of further injury to the cut or scrape.
Many different sizes and types of wound dressings are available. Dressings should be changed daily or when they become wet or dirty.

Although covering a wound is generally the best choice, there are times when it’s appropriate to leave a wound uncovered. A scrape on a knee or elbow, for example, can often be left to heal uncovered after cleaning and applying a topical antibiotic.

 7.  Identifying secondary infection
You should examine the wound carefully to ensure that secondary infection has not developed. Signs of infection generally emerge a few days after the injury and include:
•  red, swollen or warm skin surrounding the wound
•  discharge and pus from the cut or scrape
•  a red line moving up the limb from the wound
•  fever.
If you suspect secondary infection, seek medical help.

 Staph infections are the most common Bacterial Skin Infections, and can lead to impetigo (see below) elsewhere on the skin. Prescription and over-the-counter topical antibiotics have been shown to be as effective at treating localized infections as oral antibiotics – and they have fewer side effects.

Strep infections are often indicated by a red line (lymphangitis) leading from the wound. Strep infections can also produce cellulitis (see below), which is a tender swollen redness on the skin. Oral antibiotics provide an effective treatment.

8. Typical (Secondary) skin infections
See also, (Survival manual/6. Medical/c)Disease/streptococcal infections)

Cellulitis is an infection that involves the outer layers of the skin. It is commonly caused by bacteria known as beta-hemolytic streptococcus or Staphylococcus aureus. You may experience pain, swelling, tenderness, warmth, and redness in the infected area. If you have a severe case of cellulitis, you may experience fever, tiredness, and a lowering of blood pressure. If left untreated, pus may form and cells may die in the infected skin area. Cellulitis can involve any part of the body but most often affects the leg. It typically results from an injury to the skin, such as scratches or animal bites—these allow bacteria to enter the body and cause an infection. An additional cause of cellulitis is skin breakdown around the anal area, typically seen in children. This can lead to redness, swelling, and painful bowel movements.

Oral antibiotics are used to treat mild cellulitis; more severe cases must be treated with intravenous antibiotics in a hospital. Antibiotics that may be used include cephalosporins, dicloxacillin, clindamycin, or vancomycin. Swelling can be lessened by elevating the affected area, such as the legs or arms. To stop cellulitis from occurring again, it is important to keep applying lotion to the skin and to maintain good skin cleanliness.

Impetigo is a contagious skin infection commonly caused by Staphylococcus aureus. Although this infection may occur in adults, it is most often seen in children aged 2 to 5 years and is usually spread through direct contact with another person who has the infection. You may experience tenderness, itching, sores, or blisters that can rupture and form honey-colored crusts. It can affect different parts of the body such as the face, arms, or legs. It also can affect moist parts of the body, such as the armpits, neck folds, and diaper areas.

Impetigo can be treated with a topical ointment or oral antibiotic. Mupirocin is a typical ointment that may be prescribed by your doctor. Oral antibiotics such as penicillins or cephalosporins are used for more severe infections. To prevent the spread of the infection to other parts of the body, avoid scratching the blisters or sores. Because impetigo is commonly seen in children, it may be helpful to cut the fingernails and cover the affected areas of the body with bandages or gauze. It also is important to prevent the spread of infection to other individuals in close contact by not sharing things such as blankets, linens, toys, or clothing.

Folliculitis is a general term used to describe an infection of the hair follicles commonly caused by Staphylococcus aureus, resulting in red pimples. You may experience redness, tenderness, or swelling of the affected area. It also can spread to the deeper parts of the hair follicles and pus can form, also known as furuncles or boils. Carbuncles is a term used to describe a group of infected hair follicles. Folliculitis, furuncles, and carbuncles can be seen on any part of the body with hair, such as the face, scalp, thighs, underarms, and groin area. This includes areas that are bearded or shaved.

Mild folliculitis can be treated with topical antibiotics, such as erythromycin, clindamycin, or mupirocin. More severe infections, such as carbuncles and larger furuncles, may require a surgical cut and drainage of the affected area. After drainage, it is important to clean the area with antibacterial soap; then you should apply the antibiotic ointment to the affected area of the skin. If needed, your doctor may prescribe oral antibiotics such as cephalosporins or dicloxacillin. Keep in mind that your doctor may recommend monthly treatments with mupirocin ointment if you have folliculitis that occurs repeatedly.

General Management of Skin Infections
With antibiotic treatment, signs and symptoms of skin infections begin to improve after approximately 2 to 3 days. If your skin infection does not improve or gets worse (especially if you develop a fever or the infection spreads), notify your doctor right away. If you are prescribed topical or oral antibiotics, be sure to finish the full course of antibiotics unless otherwise directed. Keep in mind that the length of treatment will differ depending on the type and severity of the infection. Lastly, as is true among all skin infections, you should keep the affected area or wound clean with good skin hygiene.

For further information on Cuts and Scrapes see:
Mayo Clinic:  <>, and
WebMD:  <>

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