June 2013

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HCDCP
HELLENIC CENTER FOR
DISEASE CONTROL & PREVENTION
MINISTRY OF HEALTH
Hellenic Center for Disease Control and Prevention
Agrafon 3- 5, Maroussi, 15123, Tel: +30 210 5212000,
[email protected], http://www.keelpno.gr
June 2013
Vol. 28/ Year 3rd
ISSN 1792-9016
VOL. 2
8
Travel-related accidents and injuries
Travel-related morbidity and mortality has become as an almost
acceptable risk since people, as individuals or in groups, have
begun to travel, be it by foot, animal, carriage, ship, train,
automobile or airplane. Multiple studies have shown that, although
the majority of morbidity is the result of infectious diseases (e.g.
traveler’s diarrhea), injuries account for the most significant
part of serious morbidity and mortality. The multiple causes and
spectrum of travel-related injuries has only recently become a
subject of scientific and epidemiological studies. Almost 25% of
travel-related deaths are the result of injuries, while victims of
motor vehicle accidents account for 30-44% of air evacuations.
Unreliable road and vehicle conditions in many developing
countries, as well as several personal factors such as alcohol use,
tiredness and poor vision, contribute to motor vehicle crashes.
Other accidents that can result in injuries or death include saltand freshwater drowning, falls, burns and airplane crashes, while
injuries from violent attacks are increasingly becoming a safety
issue for travelers.
Before departure, the consulting health care provider must draw
a traveler’s attention to all the basic security measures, including
safety belt and helmet usage and avoiding driving and sea sports
when inebriated, as well ensuring he or she has an insurance for
injuries that happen abroad.
Brig General (MED) Dimitrios Hatzigeorgiou, MD
Internal Medicine and Infectious Diseases Specialist
Contents
Main article: Injuries &
safety of international
travelers
2
Surveillance data
5
Invited articles
8
Recent publications
18
Conferences and meetings
19
Interview
20
Myths and truths
23
Outbreaks around the world 24
News from HCDCP’S
administration
25
World day
27
Quiz of the month
29
MINISTRY OF HEALTH
Highlights
International travelers’ injuries and death are a recognized, serious, world-wide problem. The number of fatal
and non-fatal accidents among tourists in Greece is significant. The scope of this problem is presented and
discussed in the main feature, and useful precautionary measures presented.
More on page 2
The veteran Greek rally driver and safe driving trainer, Tasos Markouizos, widely known as ‘Iaveris’, writes in
his unique style on the scourge that is traffic accidents.
More on page 13
Professor George Saroglou, ex-president of the HCDCP’s BoD, is the subject of this month’s interview. Professor Saroglou comments on the challenges of modern travel medicine and on the presence that this field should
have in the public health system of our country.
More on page 20
http://www.keelpno.gr
[email protected]
Main article
2
Injuries & safety of international travelers
People crossing international boundaries away from their medical support systems are put at
risk by illness and injury. The risk of injury to international travelers has been recognized by
the World Health Organization (WHO) and by the Centers for Disease Control (CDC). Injuries
are the leading cause of travel-related mortality world-wide, accounting for up to 25 times
more deaths than infectious disease. Obtaining health and evacuation insurance prior to a trip
is very important, particularly for travelers with underlying medical conditions, those planning
trips to developing tropical or subtropical regions of the world, and those who are long-term
international travelers.
Injuries among people aged 5–44 years account for seven of the 15 leading causes of death
world-wide. Injuries account for approximately 5 million deaths world-wide. Travelers are 10
times more likely to die as the result of an injury than from an infectious disease. It is estimated
that injuries cause 23% of travelers’ deaths, compared with only 2% caused by infectious
diseases. Business and pleasure travelers may visit several countries and encounter regional
variations in injury risk. Studies have shown that injury is the second most common cause of
death for those away from their home country, after cardiovascular disease. The incidence of
travel-related injuries depends on the travel destination and duration, and planned activities.
Furthermore, gender may be a contributing factor to injuries among travelers: men are more
likely than women to die from injuries while traveling. Acquaintance rape and sexual assault
are more likely to be risks for women travelers.
From 2004 to 2006, 2,361 US citizens died abroad as a result of injury. Vehicle crashes and
homicides were the most common causes of injury death; 768 deaths were the result of traffic
accidents. European Union (EU) countries are among the leading tourist destinations in the
world. Despite growing consumer demands for the safety of traveling, injuries amongst tourists
remain an essentially invisible problem. The relative age distribution indicates that travelers
between 25 and 44 years of age and between 45 and 64 years of age, both predominantly
male, are specifically prone to suffer from fatal injuries during vacation, the latter group
mainly from overexertion during physical activity (swimming, skiing and mountain hiking), the
former mainly from traffic accidents.
With regard to travelers to Greece in 2000, 2% of all the injuries treated at Greek hospitals, and
3.5% of all fatal injuries in Greece, involved tourists. Compared with residents, tourists aged
between 15 and 64 years were injured more frequently and tourists aged between 25 and 44
years were more frequently fatally injured, particularly men. Transport (mainly road traffic) and
drowning accounted for more than 70% of fatal injuries among non-domestic tourists.
Motor vehicle crashes consistently emerge from the travel medicine literature as the most
common cause of injury death for tourists. Nearly 3,500 people die every day, including 1,000
children, world-wide as a result of traffic accidents involving cars, buses, motorcycles, bicycles,
trucks and pedestrians; a number likely to double by 2020. More than 85% of these casualties
(and 96% of child deaths) occur in low- and middle-income countries. Contributing factors to
traffic accidents during travel include exposure to unfamiliar and risky environments, driving
on the opposite side of the road, communication problems arising from language difficulties,
inadequate vehicle standards, unfamiliar rules and regulations, increased risk-taking behavior
as a result of a care-free vacation spirit, and over-reliance on travel and tour operators to
provide safety and security. Preventive measures with regard to road safety for travelers are
shown in Table 1.
Drowning is consistently reported as a leading cause of injury death among tourists. The death
rate among all divers, world-wide, is estimated to be about 15–20 deaths per 100,000 divers
per year. The risk factors may be related to unfamiliarity with local water currents and water
conditions, rip tides, and dangerous sea animals such as urchins, jellyfish and coral. Alcohol
also contributes to drowning and boating mishaps. Scuba diving and snorkeling have become
increasingly popular for travelers to coastal destinations. Travelers should take appropriate
preventive measures in order to reduce the risk of water-related injuries (Table 2).
Violence is a very important cause of injury and/or death for travelers. In 2000, about 1.6 million
people died from violence and one-fifth were casualties of armed conflicts. The numbers of
violent deaths in low- to middle-income countries are more than three times higher than those
http://www.keelpno.gr
in higher income countries. Travelers are viewed by many criminals as wealthy, inexperienced
and naive, unfamiliar with the culture, and therefore good targets. Visiting high-poverty areas
in unfamiliar environments, in particular at night, civil unrest, and alcohol or drug use, increase
the likelihood that a traveler will be the victim of planned or random violence. Therefore it
is advisable for travelers to avoid traveling at night, to travel with a companion, and to vary
routine travel habits. Expensive clothing and accessories should be avoided. Accommodation
should not be booked on the ground floor of hotels. If confronted, travelers should give up all
their valuables and not resist the attackers.
Other causes of injuries include natural hazards during outdoor and wilderness activities,
because of the popularity of eco-tourism and adventure travel, which is likely to increase the
number and diversity of accidents in remote locations. Other causes of injuries include falls,
burns, poisoning, drug overdoses, suicide, civil unrest and terrorism.
The burden of and regional risk variation in travel-related injury death continues to be a
challenging problem. Travelers should be aware of the regional variation in injury deaths in
foreign countries, especially from motor vehicle crashes, drowning and violence. There is a
need for more studies that describe further the regional risk to travelers, to help inform policies
and programs for corporations and individual travelers. Better knowledge of the variable risk
in infectious diseases has resulted in more informed prevention strategies based on the travel
destination. Furthermore, studies could be used to provide more focused, evidence-based
advice regarding injury. The World Tourism Organization recommends that ‘every state should
develop a national policy on tourism safety commensurate with the prevention of tourist
risk’. All destinations have a major responsibility to protect their visitors and, in turn, their
reputation. Similarly, travel medicine practitioners need to monitor the risk of injury according
to geographical location, in order to provide balanced and accurate pre-travel advice, including
recommendations for travel health and evacuation insurance and a travel health kit, which
should be customized to the anticipated itinerary and activities.
Table 1: Preventive measures for travelers regarding traffic accidents
Carry an international driving license as well as your national driving license
Have full health insurance cover for medical treatment of both illness and injuries and evacuation
Be aware of the regulations governing traffic and vehicle maintenance, and on the state of the roads,
in the country of destination
Know the informal rules of the road (e.g. sounding the horn or flashing the headlights before
overtaking)
Before renting a car, check the state of the tires, seat belts, spare wheels, lights, brakes, etc.
Be particularly vigilant in a country where the traffic drives on the opposite side of the road to that
used in your country of residence
Do not drive on unfamiliar and unlit roads
Avoid driving a moped, motorcycle, bicycle or tricycle
Avoid drinking alcohol before driving
Drive within the speed limit at all times
Always wear a seat belt if available
Beware of wandering animals.
[email protected]
Surveillance data
4
Table 2: Preventive measures for travelers regarding drowning and water-related injuries
SURVEILLANCE DATA, MAY 2013, GREECE
Supervise children in or near recreational waters
Do not drink alcohol before any water activity
Assess the depth of the water before diving, and avoid diving or jumping into murky water
Do not jump into water or jump onto others in the water
Table 1: Number of notified cases in May 2013, and median number and range of notified
cases in May for the years 2004−2012, Mandatory Notification System, Greece
Disease
Pay attention to tides and currents
References
1. World Health Organization. International Travel and Health. Available at http://www.
who.int/ith/en/index.html [accessed 9 May 2013].
2. Wilder-Smith A, Wantz C, Anderson R, et al. International Travel and Health. Chapter
4. Geneva, Switzerland: World Health Organization, 2007.
3. Wallace D, Sleet D. Non-infectious risks during travel. Chapter 6. In: Arguin PM, Kozarsky
PE, Reed C, eds. CDC Health Information for International Travel 2008. Atlanta: US
Department of Health and Human Services, 2008.
4. Hargarten SW, Gûler Gürsu K. Travel-related injuries, epidemiology, and prevention.
In: DuPont HL, Steffen R, eds. Textbook of Travel Medicine and Health. Hamilton,
Ontario: BC Decker, 1997; pp 258–261.
5. Scope and Patterns of Tourist Accidents in the European Union. Available at ec.europa.
eu/health/ph.../2001/injury/fp_injury_2001_frep_10_en.pdf‎ [accessed 1 May 2013].
6. Hargarten SW, Baker TD , Guptill K. Overseas fatalities of United States citizen travelers:
an analysis of deaths related to international travel. Ann Emerg Med 1991;20:622–626.
7. Paixao ML, Dewar RD, Cossar JH, et al. What do Scots die of when abroad? Scott Med
J 1991;36:114–116.
8. Nurthen NM, Jung P. Fatalities in the Peace Corps: a retrospective study, 1984 to 2003.
J Travel Med 2008;15:95–101.
9. McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a
review. J Travel Med 2002;9:297–307.
10. M
acPherson DW, Gushulak BD, Sandhu J. Death and international travel, the Canadian
experience: 1996 to 2004. J Travel Med 2007;14:77–84.
11. T
onellato DJ, Guse CE, Hargarten SW. Injury deaths of US citizens abroad: new data
source, old travel problem. J Travel Med 2009;16:304-301.
Dr Androula Pavli, Head of Travel Medicine Office,
Valentinos Silvestros, Travel Medicine Office,
Helena Maltezou, Head of the Department for Interventions in Health
Care Facilities, HCDCP
http://www.keelpno.gr
0
0
0
19
0
0
0
0
0
0
6
Median
number May
2004−2012
0
1
0
19
0
0
3
0
0
1
4
Minimum
number May
2004-2012
0
0
0
13
0
0
0
0
0
0
3
Maximum
number May
2004-2012
0
6
0
75
0
0
5
0
0
5
11
1
5
2
21
0
3
0
10
0
0
3
2
4
6
0
0
0
0
1
0
1
2
4
1
1
0
0
0
0
0
0
0
3
0
0
0
0
0
121
1
3
3
8
3
2
0
0
0
20
13
0
5
0
0
0
1
22
0
0
0
0
0
19
16
1
5
0
0
0
0
44
2
0
0
0
0
8
13
0
2
0
0
0
0
15
1
0
0
0
0
31
24
11
16
0
8
0
2
114
4
0
0
1
0
2
6
1
9
0
0
0
0
48
0
0
0
0
1
55
0
0
0
0
0
47
0
1
0
0
2
78
0
May
2013
Use life jackets where appropriate
Avoid outlets in spas and swimming pools.
Number of notified cases
Botulism
Chickenpox with complications
Anthrax
Brucellosis
Diphtheria
Arbo-viral infections
Malaria
Rubella
Smallpox
Echinococcosis
Hepatitis Α
Hepatitis B, acute & HBsAg(+) in infants <12
months
Hepatitis C, acute & confirmed anti-HCV
positive (1st diagnosis)
Measles
Haemorrhagic fever
Pertussis
Legionellosis
Leishmaniasis
Leptospirosis
Listeriosis
EHEC infection
Rabies
Melioidosis/glanders
Meningitis
aseptic
bacterial (except meningococcal disease)
unknown etiology
Meningococcal disease
Plague
Mumps
Poliomyelitis
Q fever
Salmonellosis (non-typhoid/paratyphoid)
Shigellosis
Severe acute respiratory syndrome
Congenital rubella
Congenital syphilis
Congenital toxoplasmosis
Cluster of foodborne/waterborne disease
cases
Τetanus/neonatal tetanus
Tularaemia
Trichinosis
Typhoid fever/paratyphoid
Tuberculosis
Cholera
[email protected]
Surveillance data
6
Table 2: Number of notified cases by place of residence (region), May 2013,
Mandatory Notification System, Greece (place of residence is defined according to
the home address of patients)
Western Macedonia
Epirus
Thessalia
Ionian islands
Western Greece
Sterea Greece
Attica
Peloponnese
Northern Aegean
Southern Aegean
Crete
Unknown
Region
2
1
0
1
0
0
0
0
6
0
0
0
1
1
3
1
4
2
1
0
0
0
1
0
0
0
1
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
1
1
1
0
0
0
0
3
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
0
2
6
2
0
3
0
1
0
5
0
0
0
1
0
2
3
0
0
1
0
2
1
3
0
0
0
0
1
1
0
1
0
0
0
0
0
0
0
0
0
2
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
Salmonellosis (non-typhoid/
paratyphoid)
2
0
0
1
1
1
2
4
7
1
1
2
0
0
Cluster of foodborne/waterborne
disease case
0
1
0
0
1
0
0
0
0
0
0
0
0
0
Tuberculosis
2
5
0
2
6
0
4
0
19
3
0
1
0
6
Brucellosis
Hepatitis Α
Hepatitis B, acute & HBsAg(+) in
infants <12 months
Pertussis
Legionellosis
Leishmaniasis
Leptospirosis
Meningitis
aseptic
b
acterial (except meningococcal
disease)
Meningococcal disease
Q fever
http://www.keelpno.gr
0
0
0
0
Disease
Number of notified cases by age group (years) and gender
<1
Central Macedonia
Number of notified cases
Eastern Macedonia and Thrace
Disease
Table 3: Number of notified cases by age group and gender, May 2013, Mandatory
Notification System, Greece (M: male; F: female)
1-4
5-14
15-24
25-34
35-44
45-54
55-64
65+
Un.
M
0
0
F
0
1
M
0
1
F
0
0
M
2
0
F
1
0
M
1
0
F
1
0
M
0
0
F
0
1
M
1
2
F
0
1
M
2
0
F
1
0
M
2
0
F
1
0
M
7
0
F M
0 0
0 0
F
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
2
1
0
0
0
0
0
0
0
1
0
0
0
0
0
2
0
1
0
0
1
1
0
0
0
0
0
0
0
0
2
0
1
0
5
1
3
1
2
0
2
2
0
0
0
0
1
0
0
0
1
2
0
0
0
0
0
0
1
0
0
2
0
0
1
1
3
1
1
0
0
0
0
0
1
3
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
Salmonellosis
(non-typhoid/
paratyphoid)
2
1
2
4
0
4
0
0
1
1
1
0
0
1
0
0
0
0
0
0
Tuberculosis
0
0
1
0
0
0
3
1
8
5
4
1
6
0
4
0
11 4
0
0
Brucellosis
Hepatitis Α
Hepatitis B, acute &
HBsAg(+) in infants
<12 months
Pertussis
Legionellosis
Leishmaniasis
Leptospirosis
Meningitis
aseptic
b
acterial (except
meningococcal
disease)
Meningococcal
disease
Q fever
The data presented are derived from the Mandatory Notification System (MNS) of the Hellenic
Center for Disease Control and Prevention (HCDCP). Forty-five infectious diseases are included
in the list of the mandatory notifiable diseases in Greece. Notification forms and case definitions
can be found on HCDCP’s website (www.keelpno.gr).
It should be noted that the data for May 2013 are provisional and could be slightly modified/
corrected in the future, and also that data interpretation should be made with caution as there
are indications of under-reporting in the system.
Department of Epidemiological Surveillance and Intervention
[email protected]
Invited articles
8
Swimming Pool Accidents
According to a modern myth, the swimming pool is a miniature version of the sea, and because
of that it is absolutely safe. Is it really though? This article aims to dispense with that belief,
to highlight the injuries that can occur in swimming pools, and to emphasize the role of those
people involved at an organizational level for preserving public health.
The Most Common Swimming Pool Accidents
The aquatic area of a swimming pool could be a pool, spa, jacuzzi, water-park or any other
facility that contains water. All of these areas can encourage numerous accidents and cause
injuries. Such injuries include drowning, limb dislocation, epileptic seizure, hypoglycemia,
heart attack, stroke, sun stroke, hypothermia, heat stroke, spinal injury as a result of a bad
dive, wounds, nose bleeding and loss of teeth after a fall on the land or being hit by a flotation
device on a waterslide.
Each year the injuries in Greece are not insignificant. Although there may only be a few
dozen fatal incidents, there can be several thousand non-fatal injuries, many of which often
go unreported. As a consequence of the under-reporting, the problem continues to be
underestimated and no safety measures are taken. Strong legislation is therefore essential
and important regarding prevention, rescue and treatment.
Prevention
Accident prevention is an equation that involves the bather, the lifeguard and the government.
The bather should follow a number of safety rules. More precisely, a bather should not swim
alone and not until 3 hours after a meal, should not partake in games with other bathers that
could be dangerous (holding the breath under water, horse riding in water, playing ball games
in water, etc.), should be protected from the sun with sunscreen, a cap and a t-shirt, and
should drink plenty of liquids. A bather should not dive head first into shallow water, and (if a
bather is a parent/guardian) he or she needs to supervise young children at a close distance
without relying on the lifeguard or the use of a flotation device for their safety.
The lifeguard should follow a series of safety rules and should maintain a working timetable.
http://www.keelpno.gr
A lifeguard should maintain a professional position by never turning his or her back on the
water and by making a professional rotation with their colleagues. The current rules, models
and protocols on drowning, other injuries and resuscitation should be maintained. Certification
should be renewed every 2 years. A lifeguard should act primarily in a preventive manner, not
by having to carry out rescues. A good team spirit should be maintained by all the lifeguards
working together. However, a lifeguard should have the ability to act individually and as a team
member depending on the situation. Finally, a lifeguard should be aware of the important
professional role he or she has in society.
The government is responsible for the legislation and enforcement of the law, as well as for
setting responsibilities for organizations that are under its umbrella. Unfortunately, so far no
strong legislation has been established to support public health by avoiding injuries in Greek
swimming pools. Government activity is currently limited to issuing some health regulations
(ΓΔΥ2 οικ. 6955306-06-2006) that need to be updated.
The Hellenic Center for Disease Control and Prevention (HCDCP) has an important
role to fulfill based on the National Action Plan for the Injuries 2008-2012 (Ministry of Health
2008), in which it is clear that one of the injuries is drowning (p. 17). Accordingly, during the
period 2009-2013, the HCDCP has undertaken specific activities to reduce injuries in water.
Specifically, it has implemented the program Hygiene, Safety and Rescue in the Water in
swimming pools, summer camps and schools, educating thousands of people. It has created a
historical documentary about lifeguarding and a public statement announcement for drowning
that were aired on Greek television with permission from the National Radio-Television
Broadcasting Council. HCDCP has participated in more than 30 television interviews (including
the program Prevention & Safety) to raise public awareness of the issues of hygiene in
swimming pools, swimming, prevention and rescue from water accidents. It has co-organized
seven workshops, daily gatherings and international congresses in Greece and abroad. It has
published 18 research papers and 41 oral/poster presentations at Greek, international and
world congresses. It has edited four conference proceedings for international congresses,
published two books and is currently writing four more books. It has collaborated, organized
and offered ‘know-how’ to a number of organizations in Greece and abroad. It has created
the educational leaflet I Love Water – I Protect Myself. HCDCP has received 15 individual
and team honors from Greek and international organizations. It offers interactive education
(e-learning) about prevention and safety for people that have had accidents in the water that
[email protected]
Invited articles
10
has been rewarded with a certificate of accomplishment (on the main page of www.keelpno.
gr, click on the letter ‘N’ and then “Water (Prevention of Accidents). Finally, as part of its role
in the protection of public health in water, HCDCP has prepared a draft of a decree law entitled
Prevention, Rescue and Treatment of Water Accidents, in which it defines criteria for the
establishment of lifeguard agencies and the operation of all aquatic bathing areas.
Rescue – Treatment
As with prevention, the occurrence of an emergency situation demands decision-making from
everyone involved in the situation.
The bathers, as soon as they realize that someone is in danger, should notify the lifeguard
immediately. If they are asked, they should provide assistance (e.g. they could be sent to call
for an ambulance, to bring the first aid kit, to show the ambulance how to get to the location
of the incident). They should attempt to rescue someone only if they are absolutely sure that
their own safety is not jeopardized.
The lifeguards are responsible for the instigation of the aquatic facility’s emergency action
plan. They should be able to make interventions on their own, or be assisted by their colleagues,
or even seek the assistance of bystanders, in order to save the person in need in the water,
and ensure rapid administration of care (first aid, admission to the hospital, etc.).
Stathis Avramidis, PhD
Associate, CLPH-HCDCP
Visiting Research Fellow, Leeds Metropolitan University
http://www.keelpno.gr
Travel Insurance and Health
Travel insurance is an important safety net for travelers and its importance should be reinforced by
travel health professionals. Travelers must consider the financial consequences of a severe illness
or injury abroad. People who have domestic health insurance policies need to determine whether
medical care abroad will be covered adequately or whether supplemental travel health insurance
policies are needed. Travelers whose domestic policies provide adequate health insurance abroad
should look for potential gaps in coverage: domestic health insurance policies may not cover
medical evacuation from a resource-poor area to a hospital where definitive care can be obtained,
or the insurance company may not have the resources to help organize such an evacuation. Travel
insurance for international travel should be taken out well before travel, and advice concerning
travel insurance should be sought early by travelers, preferably 6-8 weeks before travel, when the
traveler is seeking travel health advice for the journey.
When traveling abroad, people with any insurance coverage should always carry copies of their
insurance policy identity card and an insurance claim form. Travelers who receive medical care
in other countries will usually be required to pay in cash or with a credit card, even if they have
insurance coverage in their home country. They should also consider the fact that the existence of
a nationalized health care service in a given destination does not ensure that non-residents will be
given full coverage. Additionally, travelers should be reminded to locate medical services in areas
they plan to visit beforehand and carry this information with them, and, if they must pay out of
their pocket for care, they should obtain copies of all bills and receipts.
Those traveling with children should ensure that their travel insurance policy, usually a family
policy, covers their dependent children up to a certain age limit while they are traveling. They
should be advised to check with their travel insurance company.
Travelers should carefully examine their present coverage and planned itinerary to determine
exactly what medical services will be covered abroad and what supplemental insurance is needed.
The following is a list of things to consider:
• exclusions for treating exacerbations of pre-existing medical conditions
• the company’s policy for ‘out-of-network’ services
• coverage for complications in pregnancy
• exclusions for high-risk activities such as skydiving, scuba diving and mountain climbing
• exclusions regarding psychiatric emergencies or injuries related to terrorist attacks or acts of war
• whether pre-authorization is needed for treatment, hospital admission or other services
• whether a second opinion is required before obtaining emergency treatment
• whether there is a 24-hour physician-backed support center.
In general, travelers should purchase a policy that provides the following:
• arrangements with hospitals to guarantee payments directly
• assistance via a 24-hour physician-backed support center (critical if the traveler is going
to pay for evacuation insurance)
• emergency medical transport, including repatriation
• any specific medical services that may apply to their circumstances, such as coverage of
high-risk activities
Medical evacuation insurance may only cover the cost to the nearest destination where definitive
care can be obtained. Some policies will cover eventual repatriation to one’s home country.
Although travel health and medical evacuation insurance are considerations for all travelers,
they are particularly important for travelers who have underlying health conditions (travelers
should make certain that complications will be covered) and participate in high-risk activities.
Travelers with underlying medical conditions may want to take extra precautions in preparing
for travel. These travelers should choose a medical assistance company that allows customers
to store their medical history before departure, so that it can be accessed from anywhere in
the world, if needed. Travelers should carry a letter from their physician listing underlying
medical conditions and all current medications (including their generic names). They should
[email protected]
Invited articles
12
also pack all medications in their original bottles, checking beforehand with the appropriate
international embassy to ensure that none is considered to be an illegal narcotic in the
destination country. If possible, travelers should carry with them the name of their medical
condition and medications written in the local language of the area they plan to visit.
European Health Insurance Card
The European Health Insurance Card (EHIC) is a free card that provides access to medically
necessary, state-provided health care during a temporary stay in any of the 27 European Union
(EU) countries, Iceland, Lichtenstein, Norway and Switzerland. Using an EHIC, travelers will
receive treatment under the same conditions and at the same cost (free in some countries)
as people insured in that country. Each country’s health care system is different. Services that
cost nothing at home might not be free in another country. The EHIC is not an alternative to
travel insurance. It does not cover any private health care or costs such as a return flight to a
traveler’s home country or lost/stolen property. Nor does the EHIC cover the costs of traveling
for the express purpose of obtaining medical treatment.
Travelers can obtain a card by contacting their local health authority, as each individual country
is responsible for producing and distributing the card in its own area. To be eligible for a card,
travelers must be insured by or covered by a state social security system in any member state
of the EU, Iceland, Liechtenstein, Norway and Switzerland. Each separate member of a family
traveling should have their own card. People from non-EU countries who are legally residing in
the EU and are covered by a state social security scheme are also eligible for a card. However,
nationals from non-EU countries cannot use their EHIC for medical treatment in Denmark,
Iceland, Liechtenstein, Norway and Switzerland.
Useful links
1. Centers for Disease Control and Prevention (CDC). Johnson KJ, Sommers TE. Travel
Health Insurance & Evacuation Insurance. Available at http://wwwnc.cdc.gov/travel/
yellowbook/2012/chapter-2-the-pre-travel-consultation/travel-health-insurance-andevacuation-insurance [accessed 1 July 2013].
2. Leggat PA, Carne J, Kedjarune U. Travel insurance and health. J Travel Med 1999;6:243248.
3. European Commission. Employment, Social Affairs & Inclusion. European Health
Insurance Card. Available at http://ec.europa.eu/social/main.jsp?langId=en&catId=559
[accessed 1 July 2013].
Paraskevi Smeti, Androula Pavli, Maltezou Helena
Travel Medicine Office
Department for Interventions in Health Care Facilities
http://www.keelpno.gr
National despair
This is probably the only way that someone with true feelings and social consciousness can
characterize the genocide of Greeks on the lethal and defective asphalt.
You see, the 120,000 dead, the 160,000 quadriplegic or comatose patients, the 200,000
disabled people and the 2,000,000 wounded from the past 50 years as a result of the weapon
called a vehicle (be it two-wheeled or four-wheeled) is an ethnic cleansing as a result of a civil
war on the streets.
However, the real despair is not from the street termination of Greeks but its deeper
consequences.
More than 85% of the victims are younger than 35 years old. This means that they are our
youth, who are a productive part of the population: they carry out heavy labor, they pay taxes,
they contribute to the social insurance system so that their parents and grandparents can
receive their pension, they have ‘built’ and reformed their country, thus their loss costs more
than 25 billion euro every year!
They are reproductive! They are the men and women who would give birth to children; they
should be going to have grandchildren, descendants who in fact will not exist because our
youth are being lost or destroyed (due to disability), losing their lives in vain and foolishly as
a result of the butchery on the road network.
Two and a half million (yes 2,500,000) young Greeks will be missing from our population
in 2050 because their parents did not have the chance to give birth to them, because of the
misfortune of cars, and not simply car accidents.
We are obviously talking about a plague of unconsciousness, an epidemic of foolishness.
Nevertheless, if we do not manage to make an accurate diagnosis of the problem, we will not be
in a position to find out the real cause of this national woe, each time a parent buries a child.
Unfortunately, even today, the pathetic state system of this country and its miserable citizens
have not managed to diagnose the causes of criminal, morbid and lethal road behavior.
Almost everybody believes and claims, with absolute confidence, that the ‘reasons’ for our
losses are traffic violations. By this they mean excessive speed, violating red lights and stop
signs, drink-driving, using a cell-phone when driving, overtaking traffic in conditions with poor
visibility, etc., etc.
This is so wrong! All of the above are just the symptoms that lead to dead bodies.
The cause is stupidity, a mental disease.
It is beyond any doubt, for instance, that a red light is only violated by an idiot and pathetically
unaware stupid driver or rider, who does not think that a truck passing the green light is about
to ‘send’ him to the other world, hence his children will become orphans and his parents and
friends will kiss him goodbye at his grave. Besides, by passing a red light he could ‘meet’
his neighbor/pal instead, who is riding his own small motor, so share his misery with his
neighbor’s house.
All of you should bear in mind that the cancer of lethal streets cannot be healed with aspirins
but needs a surgical operation.
This means that a small fine of 300 euro for a stop sign violation, with a 50% discount if it is
paid within 10 days (discount for an attempted murder case?) cannot make the dangerous
and criminally idiotic driver a more careful and prudent driver.
But if instead this idiot was arrested in handcuffs and sent to an emergency hospital for
injuries, to provide social service for a while, listening to the cries of despair of the relatives
of victims, of the dead, the amputated, the crippled and kids who have been torn apart, then
he would have the chance to realize how lucky he was that the traffic policeman was waiting
for him after the red light and not (fortunately) the Charon.
Only through this type of creative thinking, as in countries with high levels of education
and social consciousness, is the criminal (not just a violator) who attempts road murder
arrested, obliged to provide social service in an emergency hospital, undergo long hours of
social training, become a blood and organ donor, have his electricity cut and pay fines that are
10 times higher than ours.
Who really believes that he would do it again, after that?
[email protected]
Invited articles
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These severe punishments, combined with public awareness and information campaigns on the
dangers of road, through television and radio shows, combined with proper driving education
and promotional lessons and lectures at schools, with continual references to road accidents
by the media, combined with the right role models (politicians, police, media heroes, stars,
etc.), with the right advise and exhortation by priests (it is a sin to take another person’s life
on the streets), and above all through proper education by the parents (idols) of their kids
through experiential methods, could lead to a decrease in road deaths and injuries, or at least
stop the increase in them. There has been a 60–90% decrease in road accidents in Europe
during the last 20 years, but a 50% increase in Greece.
Before we close on this issue of national importance, we would like to emphasize and encourage
everybody to consider: every morning, before we walk out the door of our home to go to work,
let us pause for a bit and think within our soul: ‘how many hugs will be waiting for us in the
afternoon?’
Then, with greater self-esteem regarding how important, irreplaceable and unique we are to
our families, we will enter our car, fasten our seatbelt and we will start driving, taking care of
and protecting the father/mother of our children and the child of our parents and the friend
of our friends. We will drive or ride focused, with respect, paying attention, at low speeds,
without using a cell phone, without smoking, drinking a frappe or eating, while listening to soft
music, without being distracted by beautiful ladies and gentlemen, without beers and raki,
without macho behavior, keeping our eyes and mind on the street, seeing what we are looking
at, in order to bring back home the one beloved by his beloved ones … us!
We should all be aware that on the street we do not need macho drivers but good, decent and
fair men.
Notice 1. The state of a civilization and the culture of a people are reflected on the streets
(and unfortunately we are still a mob).
Notice 2. In our country, the ‘experts’, with great ignorance of their ignorance, tend to give
answers that are unfortunately ineffective and socially useless, simply because these answers
respond to the wrong questions.
Hence, regarding traffic crimes, the answer, instead of being concerned with the socially moral
question ‘How can we have good people with emotional intelligence on the streets?’ should
respond to ‘How can we have competent, skillful drivers, not arrogant dudes?’
Iaveris,
Philip Koukouritakis
Accidents at the coastal beaches
Introduction
Every year, thousands of people visit the coasts of Greece. Most of visitors swim, others try
water sports, fishing or diving. Such physical exercise can have benefits to health, however
under certain circumstances accidents can happen to bathers.
Published data about accidents in Greece
Published data demonstrate that drowning is an important problem in Greece. Every year
about 300 deaths from drowning at sea are recorded in Greece, not only among bathers, but
also among people using boats for transportation, recreation, fishing or sports.
The following paragraphs describe data that have been reported to WHO as well as three
studies about drownings and injuries among bathers in Greece.
Drownings
In 2009 386 deaths were reported to World Health Organization (WHO) due to accidental
drowning and submersion, while from 1979 to 2009 a total of 9,490 deaths were reported in
Greece (2). In 2009, the majority of the 386 deaths occurred among people more than 55
years old. In particular, 146 occurred among persons between 55 and 74 years of age (37.8%)
and 130 deaths among persons with age of more than 75 years (33,7%). The same year, 57
deaths were reported among persons from 35 to 54 years old (14.8%), while for the following
age categories 25-34, 15-24, 5-14, 1-4 and less than one year, the number of deaths were
29 (7,5%), 14 (3,6%), 6 (1,6%) , 4 (1,0%) και 0 (0,0%) respectively. It is estimated that the
drowning mortality rate among children in Greece is 1 per 1.000.000 population (6).
In another study conducted in the Hospital in Corfu between 1990 and 2003, a total of 160
deaths from drowning were recorded. One hundred thirty one deaths occurred at sea, 12 in
wells, seven in swimming pools and one in a river (3). Additional studies showed that the
majority of deaths (76%) from drowning or almost drowning occur at sea (4, 5).
Injuries
A cohort study conducted in the summer months of 2008 collected data from 3,805 bathers
in three beaches in Larisa and from 572 non bathers (7). The study demonstrated that 200
bathers from the total 3,805 (5.3%) had an accident during their stay at the beach. Men bathers
presented higher risk of having an accident comparing to females (RR=2.51, 95%CI=1.185.36, p=0.02; OR=1.61, 95%CI=1.19-2.17 p<0.01). Accidents reported frequently among
bathers of 15 to 24 years of age (RR= 3.83, 95%CI= 2.90-5.05, p<0.001) (7).
Sports injuries
Another study recorded 22 serious accidents among windsurfers in a timeframe of 12 months
in Aegean Sea (8). Two of these accidents were fatal, others caused permanent disability and
others prolonged hospitalization. These accidents caused head injuries, spinal cord injuries,
and severe fractures of the extremities (8).
Accidents and health outcomes
WHO categorises health outcomes of accidents from recreational use of water and adjacent
areas as follows:
• drowning and near-drowning;
• major impact injuries;
• slip, trip and fall injuries;
• cuts, lesions and punctures (1).
http://www.keelpno.gr
[email protected]
Invited articles
16
Conclusions
Sever and fatal accidents occur at the beaches in Greece every year. A large number of local
population moves at coastal areas together with thousands of tourists.
Health care services infrastructure in remote areas are not always the same as in big cities
and therefore, emergency medical services can be challenged.
Strategies for the prevention of accidents at beaches need to target the local population as
well as foreign tourists.
Preventive and control measures include: public awareness and education, enforcement of
regulations based on the risk assessment results of the coastal beaches and compliance of
bathers, availability and alertness of first aid and emergency services.
Spinal cord injury
Drowning and near drowning
Table: Contributing factors and preventive actions for accidents at the beach
(WHO, 2003)
Contributing factors
Preventive actions
• Alcohol consumption
• Cold
• Current (including rip currents, river
currents, and tidal currents)
• Offshore winds (especially with
flotation devices)
• Ice cover
• Pre-existing disease
• Underwater entanglement
• Bottom surface gradient and stability
• Waves (coastal, boat, chop)
• Water transparency
• Impeded visibility (including
coastal configuration, structures and
overcrowding)
• Lack of parental supervision (infants)
• Poor or inadequate equipment (e.g.
boats or lifejackets)
• Overloading of boats
• Overestimation of skills
• Lack of local knowledge
• Public education regarding hazards and
safe behaviours
• Regulations that discourage unsafe
behaviours (e.g., exceeding recommended
boat loadings)
• Continual adult supervision (infants)
• Restriction of alcohol provision
• Provision of properly trained and
equipped lifeguards
• Provision of rescue services
• Access to emergency response (e.g.,
telephones with emergency numbers)
• Local hazard warning notices
• Availability of resuscitation skills/facilities
• Development of rescue and resuscitation
skills among general public and user groups
• Coordination with user group associations
concerning hazard awareness and safe
behaviours
• Wearing of adequate lifejackets when
boating
• Alcohol consumption
• Diving into water of unknown depth
• Bottom surface type
• Water depth
• Lack of adult supervision
• Conflicting uses in one area
• Diving into water from trees/balconies/
structures
• Poor underwater visibility
• Local hazard warnings and public
education
• General public (user) awareness of
hazards and safe behaviours, including use
of signs
• Early education in diving hazards and
safe behaviours
• Restriction of alcohol provision
• Use separation
• Lifeguard supervision
• Emergency services, access
http://www.keelpno.gr
Cuts, lesions and punctures
The majority of accidents at the beach can be avoided by recognizing of hazards and by
avoiding risky behavior, while WHO estimates that 80% of drowning can be preventable (1).
The following Table presents contributing factors to accidents and preventive measures for
each of the category as described by WHO (1). Alcohol consumption before swimming or using
boats, the lack of education of water sports and swimming and the lack or not use of lifesaving
devises can cause drownings.
Head injuries
Contributing factors and prevention
• Diving into shallow water
• Underwater objects (walls, piers)
• Poor underwater visibility
• Adjacent surface type (e.g., of water
fronts and jetties)
• Conflicting uses in one area
• General user awareness of hazards and
safe behaviours
• Appropriate surface type selection
• Adjacent fencing (e.g., of docks and
piers)
• Use separation
• Lifeguard supervision
• Warning signs
• Presence of broken glass, bottles,
cans, medical wastes
• Walking and entering water barefoot
• Beach cleaning
• Solid waste management
• Provision of litter bins
• Regulation (and enforcement) prohibiting
glass containers
• General public awareness regarding safe
behaviours (including use of footwear)
• General public awareness regarding litter
control
• Local first aid availability
References
1. World Health Organization. Guidelines for safe recreational water environments. Volume
1, Coastal and fresh waters, Geneva. 2003.
2. World Health Organization. WHO mortality database: No. of deaths - Accidental
drowning and submersion, both sexes, all ages, Greece.
3. Κ. Δ. Χαίνης Ο πνιγμός και ο παρολίγον πνιγμός. Αρθρα Πνευμονολογικά. (http://www.
pneumonologist.gr/article.php?article_id=52&lang=gr).
4. E. Γερμενή, A. Τερζίδης, E. Θ. Πετρίδου. Mήνυμα 6: «Φροντίστε για την ασφάλειά σας
όταν βρίσκεστε κοντά σε νερό». Αρχεία Ελληνικής Ιατρικής. 2008, 25(Συμπλ 1):40-45.
5. Alexe D, Dessypris N, Petridou E. Epidemiology of unintentional drowning deaths in
Greece. Book of Abstracts, World Congress on Drowning, Amsterdam, The Netherlands,
2002.
6. Petridou E, Klimentopoulou A. Risk factors of drowning. In: Bierens J ed. Handbook on
drowning. Springer, Berlin 2006: 63–69.
7. P. Papastergiou, V. Mouchtouri, G. Rachiotis, O. Pinaka, A. Katsiaflaka, C.
Hadjichristodoulou. Health hazards at coastal areas and injuries among bathers: results
from a cohort study in Greece. Unpublished data.
8. A. Kalogeromitros, H. Tsangaris, D. Bilalis, A. Karabinis. Severe accidents due to
windsurfing in the Aegean Sea. Eur J Emerg Med. 2002 Jun;9(2):149-54.
Barbara Mouchtouri
Environmental Health Officer, MSc, PhD
Peripheral Public Health Laboratory of Thessaly
[email protected]
Conferences and meetings
18
Recent publications
Can business road travel be safe? Experience of an international organization
Goldoni Laestadius J, Selod AG, Ye J, Dimberg L, Bliss AG
J Travel Med 2011;18:73-79
Globally, more than 1.2 million people die on the roads every year, and unfortunately so do
one or two operational travelers for the World Bank Group (WBG).
To investigate potentially preventable factors and improve the institution’s road safety policies
and practices, an electronic survey was designed in 2008 targeting about 16,000 WBG staff
world-wide to inquire about road crashes and near crashes over the 3-year period. Questions
were also asked about contributing circumstances. Staff members were encouraged to provide
comments on prevention. A combined index based on the number of reported crashes and
near crashes divided by person-days spent on a trip to each country was used to rank the
countries.
A total of 3,760 responses was collected. There were 341 road crashes reported, about 1 in 175
trips. Seventy per cent took place in taxis, and 40% of crash victims reported that seatbelts
were not used. Contributing factors included driver decision error, speeding and road/weather
conditions. On the basis of a combined index, a list of 36 high-risk countries is presented. A
high correlation between crashes and near crashes (r = 0.89) justifies the method. The top
high-risk countries with respect to perception of risk were India, Kenya, South Africa, Egypt,
Nigeria, Vietnam, Indonesia, Pakistan, Bangladesh and Tanzania.
In conclusion, improved corporate policies will need to be developed to address the preventable
risk factors identified in the study.
Injuries occurring in medical students during international medical rotations:
a strategy toward maximizing safety
Galvin S, Robertson R, Hargarten S
Fam Med 2012;44:404-407
Conferences and meetings
August 2013
27-29 AUGUST 2013
Title: 3rd International Public Health Conference & 20th National Public Health
Colloquium
Country: Malaysia
City: Kuching
Venue: Riverside Majestic Hotel
Contact Number: +60 (3) 9145 6041 Website: http://www.pubhealthcollo.org/pubhealthcollo.asp
28-31 AUGUST 2013
Title: A multi-disciplinary approach to infectious diseases
Country: Spain
City: Valencia
Venue: Las Arenas Resort
Contact Number (fax): +32 16 438402
Website: http://www.medical-credits.com/Valencia.html
Office for Public and International relations, HCDCP
The number of medical students traveling to nations outside the USA is steadily increasing.
The Association of American Medical Colleges graduation questionnaire notes an increase
from 2,838 students in 2001 to 3,799 students in 2009, the last year for which information is
available. The risk of having any type of illness during international travel approaches 50%.
Up to 19% of students will seek medical care for illnesses on their return to the USA. Most
illnesses are benign and self-limited. However, when deaths do occur, the leading causes are
motor vehicle crashes and drownings. If air medical evacuation occurs, the most likely cause
is an injury event.
The authors reviewed the literature to determine the risk and type of illnesses and injuries
suffered by travelers while overseas, especially medical volunteers. They describe the major
categories of illness and injury risk and propose reasonable risk reduction strategies for
prevention of injury, a relatively neglected area. It is recommended that medical schools
provide pre-travel training that includes injury prevention so that students are prepared
not only for illness prevention but also for injury prevention. A focus on injury prevention,
especially from motor vehicle crashes and drowning, is warranted given their role in causing
death and serious injury to traveling students.
Paraskevi Smeti, Androula Pavli, Travel Medicine Office
http://www.keelpno.gr
[email protected]
Interview
20
George Saroglou, Emeritus Professor of Internal
Medicine and Infectious Diseases, University of
Athens
C. It is also crucial that there is free access to the consulting room and the ability to
provide the traveler with any vaccine needed, obligatory or not. For this, the consulting
room needs to have properly trained employees as well as facilities where the traveler
can be given the relevant treatment, according the directives of the World Health
Organization (WHO) and ISTM.
You have traveled to several destinations. Would you like to share with us a little bit of your
experience as a doctor and a traveler?
A recent destination that remains strongly in my mind is Skala (Lakonia, Greece), where I was
part of group along with members of HCDCP accompanying WHO and European Center for
Disease Control (ECDC) specialists, who were visiting in order to study the conditions under
which malaria incidents have reappeared in our country. The tremendous living conditions of
the foreign workers in the orange tree fields had a great impact on me, as well as the touching
efforts of the municipal authorities, the prefecture and the HCDCP unit, in order to confront
the reappearance of malaria in Greece, a fact that has negative consequences as much for
the local population as for tourism. We most certainly need to protect two brand name areas
of local tourism, Marathonas and Sparta/Lakonia, from any impact on tourism arising from
vector-borne diseases such as malaria, West Nile virus, etc.
These days travel medicine and all incoming diseases are top priority for those working in
public health. Since you, as a doctor, have worked in the field, could you share with us what
you think is crucial?
Today, travel medicine deals with any threat to public health that concerns the whole of
the planet, given the globalization of public health issues. A typical example is that which
appeared lately in Mecca, Saudi Arabia, threatening the pilgrims from all over the world that
will be visiting in a few months, because of the appearance of a new epidemic of coronovirus
(MERS-CoV) in the Middle East. In order to achieve full surveillance of these arising diseases,
every country should create and operate a network of travel medicine clinics and another of
laboratories capable of diagnosing tropical and parasitical diseases. These networks, which
should operate within the framework of the Hellenic Center for Disease Control and Prevention
(HCDCP), need to include a section for an obligatory travel vaccine program, a service that is
now offered by the municipalities.
Furthermore, because of the geographical position of our country, we should also work on
organizing medical tourism much more, and approach the very sensitive subject of public
health regarding foreign workers and other immigrants coming from developing countries.
What would you advise a traveler right now?
The dangers that a traveler has to be aware of, in any place of the world right now, whether
we are talking developed or developing countries, always exist and sometimes they are even
unknown to public health services. So, in order for the traveler to stay informed, he or she
needs to keep updated via the websites of the official organizations in the field of public health,
such as HCDCP, the Centers for Disease Control (CDC) and the Health Protection Agency
(HPA), for any travel alert notices. For example, only a few are aware of the danger that lies
in the transmission of rabies to hunting dogs of hunters who travel to Skopje and Romania,
or even the danger presented by a pregnant woman in Poland who gets infected by measles.
This current issue of our monthly newsletter is dedicated to the accidents befalling travelers.
Would you like to say anything regarding this subject?
Travel accidents come first on the list of mortality factors during travel. While the travel
medicine agents try to inform widely on the dangers of infectious diseases, the health problems
that can arise during a flight, diseases as a result of height (mountain disease), very few are
informed about the prevention of traffic and other accidents, criminal attacks and in general
the attitude and adjustment of the traveler to the local culture, the way of life and the customs
of their destination country.
Α. To be accessible and competent in communicating with the target population,
which is the future traveler. In order to achieve this, it is necessary to have strategic
communication with all the travel agents of the city, the marine network that supports
foreign cruise ships, the travel medicine office of HCDCP, the services of the former
prefecture offices of public health and, generally, everyone involved in the industry of
tourism.
What would you advise new professionals in the field of public health who wish to work in
travel medicine?
Travel medicine is expanding world-wide rapidly, as much for doctors as for paramedics. What
our country really lacks is the special training of doctors in first-degree treatment, and the
pathologists, infectious diseases specialists, clinical microbiologists and nurses on matters
of travel medicine and health. It is necessary that we bring together a new specific subject,
as much in the medical schools in general as in the paramedic department of the medical
schools, as well as organize a postgraduate degree in travel medicine.
It is widely known that only through the right specialization and training can someone
practice effective travel medicine. We should also emphasize putting the right resources in the
vaccination offices of the prefectures, and having well-trained scientists of travel medicine, as
in the United Kingdom, Canada and Scandinavian countries, etc.
Β. The travel medicine consulting room should be able to inform the traveler by providing
information, maps and directions via the internet, thus saving the traveler having to
visiting its premises.
What do you consider to be the major challenges for public health today, as our country is
going through a difficult period?
Because our country is going through a financial crisis, and taking into consideration the
problems in public health, a major challenge is realizing how we can change the attitude
For many years you have been operating a travel medicine consulting room with the aim of
informing the traveler before his or her travel and to look for any possible disease after his
or her return. Could you tell us in a few words how such a service can operate effectively
nowadays?
The main factors for an effective travel medicine consulting room are as follows.
http://www.keelpno.gr
[email protected]
Myths and truths
22
towards our profession and become even more active functionaries of public health. What
I am trying to say is that it is not enough just to know that in the Middle East there is an
epidemic of MERS-CoV that can be easily transmitted to the staff who treat patients, as was the
case in Saudi Arabia. Our aim should be to change our attitudes in outpatient departments,
hospital rooms and intensive care units (ICUs), in order to shield all the health care services
against any new threat. The same alertness should help us with the task of confining the
biggest endemic that our country has suffered in the past few years, the diseases that derive
from multi-resistant microbes. It is no longer acceptable within the international community
that foreign visitors who are hospitalized in ICUs return to their countries cured but currying
multi-resistant microbes in their gastroenteric system, something that is often responsible for
starting epidemics in other countries.
Myths and truths
Myths
Truths
The severity
of injuries is
proportional to the
damage done to
the vehicle.
You get drunk
faster when
drinking on a plane.
Studies involving live humans have demonstrated that a motor vehicle
accident at as low as 5 mph can induce cervical (neck) injury. However,
other studies have shown that cars can often withstand crashes of 10
mph or more without sustaining damage. Most injuries occur at speeds
less than 25 km/hr.
One’s blood alcohol level does not increase in the air. So drinking alcohol
on an airplane, as opposed to on the ground, does not lead to greater
levels of alcohol in the blood. What contributes to the misconception
that one drink in the air is equal to three on land could be the onboard effects of hypoxia (less oxygenated conditions because of the
low-pressure environment and high altitude), which can lead to bodily
symptoms similar to intoxication (as less oxygen is circulated to the
brain).
The safest seat on
There’s no evidence that any one part of an aircraft is safer than
a jet during a crash another. Also, it is best to listen to the pre-take-off safety briefing on
is near the wings
each flight, as well as all in-flight announcements.
or in the rear of the
cabin.
Drowning children
People who are drowning are unable to speak. Speaking is a function
will call out.
secondary to breathing. If someone cannot breathe, they cannot
speak. There is also no time. When a child is drowning, he or she will
alternately sink below and then rise above the water’s surface. While
above the surface, a child will have to exhale and inhale before he or
she sinks again. There is not enough time to cry out.
Having trip
Some travel rewards credit cards and regular credit cards offer trip
protection with
protection as a cardholder perk. However, most do not provide the
a credit card is
full extent of coverage as a standard travel insurance package does.
sufficient.
If you are heading to a high-risk destination or traveling to airports in
remote locations, make sure your credit card travel insurance package
includes lost baggage protection, trip cancellation coverage and other
basics. In many cases, you will need to buy extended coverage to
make sure you are fully protected for the entire trip.
Travel Medicine Office
Department for Interventions in Health Care Facilities
http://www.keelpno.gr
[email protected]
News from the HCDCP’s administration
24
Outbreak news, June 2013
Middle East respiratory syndrome coronavirus (MERS-CoV) [1]
Globally, from September 2012 to the end of June 2013, the World Health Organization (WHO)
has been informed of a total of 77 laboratory-confirmed cases of infection with MERS-CoV,
including 40 deaths. Laboratory-confirmed cases have originated in the following countries
in the Middle East to date: Jordan, Qatar, Saudi Arabia and the United Arab Emirates (UAE).
France, Germany, Italy, Tunisia and the United Kingdom have also reported laboratoryconfirmed cases; patients were either transferred there for care of the disease or had returned
from the Middle East and subsequently became ill. In France, Italy, Tunisia and the United
Kingdom, there has been limited local transmission among people who had not been to the
Middle East but had been in close contact with the laboratory-confirmed or probable cases.
WHO does not advise special screening at points of entry with regard to this event, nor does
it recommend that any travel or trade restrictions be applied.
Rubella (German measles) [2]
Japan
As of 29 May 2013, more than 8,500 laboratory-confirmed rubella cases have been reported
in Japan during 2013. Numbers of rubella cases have been highest in Osaka, Tokyo Metropolis,
Kanagawa and Kagoshima prefectures. The peak period for rubella is spring to summer in
Japan. Reported cases have substantially increased over the last couple of months and are
expected to continue to increase.
Poland
As of 19 June 2013, more than 26,000 cases of rubella have been reported in Poland since
the beginning of 2013. The entire country is affected, but the western region (Malopolskie
and Wielkopolskie provinces) has the highest number of cases. Other provinces with high
numbers of cases include Lublin, Lubusz, Kuyavian-Pomeranian, Podkarpackie, Pomeranian
and Zachodniopomorskie (West Pomeranian).
EPIET/EUPHEM training courses hosted in
Greece,
June 2013
Within the context of the European training program on field epidemiology and public health
microbiology (EPIET/EUPHEM) of the European Center for Disease Prevention and Control
(ECDC), two 1-week training programs were hosted in Greece during June. These comprise
two of the seminars that members of the program have to attend during their training in order
to graduate. The seminars were organized by the National School of Public Health with the cooperation of the Hellenic Center for Disease Control and Prevention (HCDCP).
The first course, on sampling, took place from 17 to 21 June 2013. Different sampling methods
and their advantages and disadvantages were described. Examples of sampling methods that
can be used under different situations were presented.
The second course, on Rapid Assessment in Complex Emergency Situations and Mass Gatherings,
took place from 23 to 28 June 2013, with the aim of preparing members/epidemiologists
to contribute to the multi-disciplinary and international response to complex emergencies
and mass gathering events, and to apply their epidemiological skills to serve public health
interventions. The course included a 2-day training trip to Lakonia.
It is important that, apart from the EPIET and EPIET/EUPHEM members, health professionals
of KEELPNO also had the chance to participate on the courses. The organization of the seminar
was considered successful by both the ECDC representatives and the participants.
Kassiani Mellou
Local supervisor of the program EPIET/EUPHEM
on behalf of HCDCP
Yellow fever [3]
Six laboratory-confirmed cases have been reported from three health zones in the Democratic
Republic of Congo (Kinshasa): Lubao (4), Kamana (1) and Ludimbi-Lukula (1). The outbreak
investigation team has also identified 51 suspected cases, including 19 deaths, in the three
health zones.
References
1. World Health Organization. Available at http://www.who.int/csr/don/ [accessed 1 July
2013].
2. Centers for Disease Control and Prevention (CDC). Available at http://wwwnc.cdc.gov/
travel/ notices/outbreak-notices/ [accessed 1 July 2013]
Meeting between HCDCP and the USA Embassy
for Greece
On Wednesday 17 July 2013, a meeting with officials from the medical staff of the USA
Embassy in Greece was held at the premises of the Hellenic Center for Disease Control and
Prevention (HCDCP). The agenda included topics such as epidemiological data and actions for
West Nile virus, dengue virus, malaria, rabies and MERS-CoV. In addition, issues regarding
multi-resistant pathogens in Greek hospitals and infection control measures were presented.
Travel Medicine Office
Department for Interventions in Health Care Facilities
http://www.keelpno.gr
[email protected]
World day
Health Professionals and Rabies
The Office of Zoonotic disease which is part of the Department of Epidemiological Surveillance
and Intervention of the HCDCP in collaboration with the HCDCP office in Thessaloniki, organized
meetings aimed at informing and educating health professionals in the public and private
sector, especially those working in health units and the departments of Public Health, Social
Welfare and the Veterinary Directorate on the re-emergence of rabies.
The purpose of these meetings was to train and prepare all the stakeholders on the Protection
Measures, Interoperability and Collaboration of all sectors involved.
The HCDCP organized seminars in high risk areas and particularly those that have had
laboratory-confirmed cases of rabies in animals and also in the areas that have an increased
risk of finding rabid animals.
The meetings took place on the following dates (the Regional Authorities and the related
Hospitals in local language):
•
“ΠΕ ΠΕΛΛΑΣ -ΓΝ Γιαννιτσών” (04/06/2013)
•
“ΠΕ ΣΕΡΡΩΝ- ΓΝ Σερρών” (05/06/2013)
•
“ΠΕ ΒΕΡΟΙΑΣ- ΓΝ ΒΕΡΟΙΑΣ” (06/06/2013)
•
“ΠΕ ΓΡΕΒΕΝΩΝ- ΓΝ Γρεβενών” (19/06/2013)
•
“ΠΕ ΠΙΕΡΙΑΣ- ΓΝ Κατερίνης” (20/06/2013)
•
“ΠΕ ΘΕΣΣΑΛΟΝΙΚΗΣ- ΓΝ Αγ. Δημητρίου” (21/06/2013)
•
“ΠΕ ΚΟΖΑΝΗΣ- ΓΝ Κοζάνης” (11/07/2013)
•
“ΠΕ ΚΙΛΚΙΣ- ΓΝ Κιλκίς” (12/07/2013)
•
“ΠΕ ΛΑΡΙΣΑΣ- ΠΓΝ Λάρισας” (18/07/2013)
•
“ΠΕ ΚΑΡΔΙΤΣΑΣ- ΓΝ Καρδίτσας” (19/07/2013)
•
“ΠΕ ΤΡΙΚΑΛΩΝ – ΓΝ Τρικάλων” (19/07/2013)
An exact date has not yet been set for the following:
•
“ΠΕ Φλώρινας- ΓΝ Φλώρινας”
•
“ΠΕ Καστοριάς- ΓΝ Καστοριάς”
28 July: International Day of Viral Hepatitis
Viral hepatitis continues to plague hundreds of millions of people on the planet and to be a
huge public health problem. The 28th of July has been established as World Hepatitis Day. The
aim of this day is to raise public awareness about viral hepatitis, to eliminate the unreasonable
anxiety, fear and prejudice that lead to emotional and social isolation of people infected with
hepatitis B or C virus, and to inform people about the modes of transmission, prevention, early
diagnosis and treatment.
Hepatitis B is caused by the virus hepatitis B. World-wide, more than 2 billion people are
infected with hepatitis B virus, of which about 350 million people are chronic carriers. Greece
is an intermediate endemic area, although the prevalence of hepatitis B has declined in recent
years. However, mass migration into Greece from areas of high or intermediate endemicity
increases the prevalence of hepatitis in the general population in our country. Since 1982 there
has been a safe and effective vaccine against hepatitis B virus, which is the first preventive
vaccine against cancer of the liver. Hepatitis B is transmitted by infected blood items (syringes,
razors, needles, etc.), by sexual contact and from mother to child. For chronic hepatitis B
there are now drugs that act by enhancing the body’s defenses, decreasing virus replication
and slowing liver disease, and in rare cases can even eradicate the virus. The dosing can only
be made by qualified physicians and always under medical supervision.
Vaccination against hepatitis B is the only effective way to prevent the disease and
its complications.
Hepatitis C is a major public health problem world-wide because it has a broad geographic
distribution. The World Health Organization (WHO) has estimated that 3% of the world’s
population, 200 million people, are chronic carriers of the disease.
In Greece, in the general population the rate of infection is estimated to be 1.9%, i.e.
approximately 200,000 people are infected with the virus. Hepatitis C is transmitted by infected
blood items (syringes, razors, needles, etc.) and rarely by sexual contact or from mother to
child. There is no vaccine or other means of prophylaxis. The use of combination antiviral
drugs has significantly improved the treatment of hepatitis C.
Recently in the USA and Europe two new generation drugs have been approved. These are expected to
change the landscape radically in the treatment of patients with chronic hepatitis C virus infection.
The use of the new drugs should increase the response rate to treatment while reducing its duration.
The dosing of these drugs should be carried out under close medical supervision.
Hepatitis A is an acute illness, usually self-limited to a period of several weeks, that never
leads to chronic hepatitis. Hepatitis A has a world-wide distribution. Annually there are about
1.5 million new cases of hepatitis A in the world and transmission of the virus is favored by
bad living conditions. The improvement in socio-economic level of the population and the
water and sanitation conditions in our country has resulted in a reduction in the incidence of
new cases and longer for travelers to developing countries and people who came in contact
with patients. The cornerstone in the prevention of hepatitis A is the application of
hygiene rules and the maintenance of hygiene standards.
There is an effective and safe vaccine that has been included in the National Immunization
Program.
The Hellenic Center for Disease Control and Prevention (HCDCP) endeavors to prevent the
transmission of viral hepatitis, and to improve the care and quality of life and to safeguard the
rights of infected people.
In February 2013, the HCDCP issued new guidelines for therapeutic intervention for patients
infected with hepatitis B or C based on recent scientific data. You can find the guidelines on
HCDCP’s website: www.keelpno.gr.
The Office of Viral Hepatitis provides information to the public and to health professionals. You
can call us on 210 5215179 and 210 5212183 or visit our website: www.keelpno.gr
http://www.keelpno.gr
29
Useful Tips
• Comply with rules of personal hygiene (washing hands)
• Find out with a simple blood test if you are infected with viral hepatitis
• Be vaccinated against hepatitis A and B if you belong to a high-risk group or are traveling
to a country with high endemicity
• Use a condom during sexual intercourse if you do not know the virological profile of your
partner
• Do not share personal items (syringes, needles, scissors, nail clippers, toothbrushes,
razors, etc.)
• Be sure to use sterilized or single-use tools in manicure, acupuncture, tattooing, piercing,
etc.
Office of Viral Hepatitis HCDCP
Quiz of the month,
June 2013
“Which are the most common injuries experienced by travelers?”
List the following in order:
a. Outdoor and wilderness injuries
b.Motor vehicle accidents
c. Water-related injuries
Send your answer to the following e-mail: [email protected]
The answer to May’s quiz was: mammals.
For further information see:
Drew WL. Rabies. Chapter 41. In Ryan KJ, Ray CG (eds) Sherris Medical Microbiology,
4th edn. McGraw Hill, 2004; pp 597–600. ISBN 0-8385-8529-9.
36 people answered correctly.
http://www.keelpno.gr
[email protected]
Chief Editor:
Associate Editors:
Ch. Hadjichristodoulou
P. Koukouritakis
Μ. Fotinea
Scientific Board:
Editorial Board:
Ν. Vakalis
Ε. Vogiatzakis
P. Gargalianos- Kakoliris
Μ. Daimonakou- Vatopoulou
Ι. Lekakis
C. Lionis
Α. Pantazopoulou
V. Papaevagelou
G. Saroglou
Α. Tsakris
R. Vorou
E. Karatampani
P. Koukouritakis
Κ. Mellou
D. Papaventsis
Τ. Patoucheas
V. Roumelioti
V. Smeti
Ch. Tsiara
Μ. Fotinea
Ε. Hadjipashali
Editors:
Graphic Design:
Τ. Kourea- Kremastinou
HCDCP President
T. Papadimitriou
HCDCP Director
Ε. Lazana
Copy Editor:
P. Koukouritakis
HCDCP
HELLENIC CENTER FOR
DISEASE CONTROL & PREVENTION
MINISTRY OF HEALTH
http://www.keelpno.gr
MINISTRY OF HEALTH
[email protected]
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