How to prepare and conduct your medical missions trip safely.

1. Food and Drink Safety 4-10 Hugh J. Davis RN, MHA,MPH Betsy Christiansen BSN, RN AMLT - Honduras 1

2. In the field, remember: 1.Eat to stay healthy! 2. Follow safe water protocols. 3. Protect yourself from blood-borne disease. 4. Follow basic immunization schedules. 5. Know how to diagnose & treat travelers’ diarrhea. 6. Follow malaria protection protocols. 7. Protect yourself from TB. 4-10 AMLT - Honduras 2

3. Pathways to Infection Water Food Skin Mucous Membranes 4-10 4-10 AMLT - Honduras 3

4. 4 Universal Precautions… …what’s wrong here? AMLT - Honduras 4-10

5. Universal Precautions What’s right in this picture? 5 4-10 AMLT - Honduras

6. It’s been said,“Travel broadens the mind as it loosens the bowels!” 6 4-10 AMLT - Honduras

7. MTW Medical Team Goal: 4-10 0% incidence of diarrhea and >90% of our medical teams have achieved that goal! AMLT - Honduras 7

8. THINK Before You Eat!!! Everything that looks good may not be safe. That which looks unpalatable may be safe. 4-10 AMLT - Honduras 8

9. 4-10 AMLT - Honduras 9

10. Boil it, Cook it,Peel it, or…Forget it! Giardia trophozoites No, No 10 4-10 AMLT - Honduras

11. Only 2% of travelers are compliant! 53% use ice in drinks; 71% consume uncooked vegetables; 40-60% get diarrhea! 11 4-10 AMLT - Honduras

12. An Unwanted Part of the Missionary Experience Julie: 9 mo diarrhea 4-5 days per month 10% weight loss Laurie: 1 year Giardia 2 week hospitalization 4-10 12 AMLT - Honduras

13. 4-10 AMLT - Honduras Hepatitis Polio Typhoid fever Protozoa Bacteria Viral enteritis What does Cipro cover? 13

14. Your body is not your own; you were bought with a price. 1 Cor. 6:20 14 4-10 AMLT - Honduras

16. a translator’s time

17. a transportation unit

18. a team’s productivity… or even

19. a potential cancellation of trip. 4-10 15 AMLT - Honduras

20. Wash your hands before you eat! Water from any spigot, tube or pipe is considered contaminated! DON’T wash your dirty hands in contaminated water and with contaminated soap; don’t use a contaminated towel for drying! 16 4-10 AMLT - Honduras

21. Water Hygiene Water from spigot is considered contaminated… …you don’t know the source! 4-10 AMLT - Honduras

22. Safe Alternatives for Hand Washing Wash in disinfected “clean” water. Use antibacterial soap. Air dry or use your own “camp towel”. Use jellied alcohol. Much better 18 4-10 AMLT - Honduras

23. Are We Ready to Eat? Eat with “clean hands”! Don’t use dirty utensils, dishes or cups! What’s dirty? What’s clean? 19 4-10 AMLT - Honduras

24. The ‘Tupperware Alternative’ A sealed container with your own utensils inside;A 3-step wash using disinfectant. 4-10 AMLT - Honduras 20

25. What’s For Supper? Ascaris Giardia Amoebas Taenia Hepatitis 21 4-10 AMLT - Honduras

26. ALWAYS Unsafe… …NEVER eat! Salads (lettuce) Custards Potato salad Mayonnaise 22 4-10 AMLT - Honduras

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28. More Unsafe Foods Milk products… butter ice cream unpasteurized cheese Raw or undercooked meat & fish 24 4-10 AMLT - Honduras

29. Safe Foods MUST be well-cooked cooked to 158º & hot at serving time MUST be reheated to 158º if previously cooked Jellies & breads (covered - no flies!) AMLT - Honduras 25 4-10

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32. Dry Things are Safe… …If packaged or protected properly! 28 4-10 AMLT - Honduras

33. Staphylococcal Food Poisoning is from a heat-stable Toxin. MUST keep hot foods hot (> 140ºF)… …and cold foods cold (<40ºF). Heat Kills Germs! Yum Yum 29 4-10 AMLT - Honduras

34. Initial symptoms: Staph Toxin 1-8 hrs E Coli 0157 4 +days Giardiasis 1-2 wks Amoebiasis 2-4 wks Hepatitis A 2-6 wks Ascariasis 4-16 wks Taeniasis 2 mo 30 4-10 AMLT - Honduras

35. Thursday, Day 4 4-10 AMLT - Honduras 31

36. 4-10 32 AMLT - Honduras 4-10 32

37. What About Fruit? Is the outside of the fruit clean? Was the knife clean that cut the fruit? (2-knife method?) Were the hands clean that prepared the fruit? 33 4-10 AMLT - Honduras

38. Not all Fruit is Created Equal! Best = fruit with rind or skin that can be peeled Easy Very easy AMLT - Honduras

39. Difficult or impossible to clean Difficult Almost impossible 35 4-10 AMLT - Honduras Not all Fruit is Created Equal!

40. Raw vegetables such as lettuce, spinach, tomatoes and onions were responsible for the illness or deaths of nearly 19,000 people nationwide over a 5-year period. 36 4-10 AMLT - Honduras

41. What is Safe to Drink? Hot beverages: boiled water, tea or coffee Soda & carbonated beverages Coconut water or milk Pasteurized milk & juices 37 4-10 AMLT - Honduras

42. The Story on Bottled Water 11 of 14 randomly-selected bottles representing 8 brands in Nepal were contaminated with Coliforms! Poop! 38 4-10 AMLT - Honduras

43. Outbreaks of diarrheal illness are common from “safe” bottled water. [Wisconsin, Lima, Mexico and Peru’s “San Antonio”] 39 4-10 AMLT - Honduras The Story on Bottled Water

44. Is it safe or… Has it been rebottled? …refilled? Safety designation e.g., reverse osmosis Bottle dirty? …wet? Cap secure? …new or replaced? Do you trust your life & your team’s health with it ?! 40 4-10 AMLT - Honduras

45. Drinking-water on Airplanes A substantial number of aircraft going to / returning from developing countries serve contaminated drinking water. Travel with “Sweet Water” drops, Iodine or Chlorine Dioxide tabs, or a “Steri-Pen”. 41 4-10 AMLT - Honduras

46. Coconut Water… 42 4-10 AMLT - Honduras

47. …it’s always in good taste …& all over the world! 43 4-10 AMLT - Honduras

48. Cleaning Dishes… a Triple Process 44 4-10 AMLT - Honduras

49. Other Water Challenges Brushing teeth Showering Swimming pool Ocean 45 AMLT - Honduras

50. High Risk Behavior Bad information or ignorance Non-compliancy Eating in “dirty” restaurants Whoa! 46 4-10 AMLT - Honduras

51. Prevention… Active vs Passive Dietary Restrictions 47 4-10 AMLT - Honduras

52. Prevention Active vs Passive 48 4-10 AMLT - Honduras

53. Active verses Passive Restrictions Passive = everybody orders for themselves, then leader must tell them no! 49 4-10 AMLT - Honduras

54. Active = Eat everything that is put in front of you 50 4-10 AMLT - Honduras

55. So-o-o… what-R-U-gonna-eat? Spoon? Banana? Iced tea? Hot soup? Lettuce? Tomato? Silverware? Napkin? Hamburger? Bun? 51 4-10 AMLT - Honduras

56. What if you are served unsafe food? 52 4-10 AMLT - Honduras

57. What if you are served unsafe food? Try not to offend. Eat small portions. [risk of diarrhea linked to size of inoculum] Have a designated eater. [someone w/ indigenous bowel flora] 53 4-10 AMLT - Honduras

58. Taking 500mg Cipro after eating will NOT protect you from crypto, Hepatitis A, rotovirus, etc. 54 4-10 AMLT - Honduras

59. If you can’t live without cut fruit, salad, ice or fruit juice for 2 weeks… …stay home!!! 55 4-10 AMLT - Honduras

60. Food at luxury hotels no safer than the food in standard hotels. Flies are important vectors of disease. Watch for flies in the restaurant & on food! 4-10 AMLT - Honduras 56 Shangri-La Hotel in New Delhi

61. Food consumed on aircraft home was likely prepared in country of origin of the flight. If eating is unavoidable, limit intake [inoculum]! 57 4-10 AMLT - Honduras

62. Epilogue If you can sleep well & eat well, you can endure almost anything! 58 4-10 AMLT - Honduras

63. Let’s Eat !!! Good, Safe Food in Jungle Kitchen 59

64. You CAN stay healthy!1. Think, Think, THINK !!!2. Think as a group !3. Look out for each other !4. Choose food carefully !5. Treat water appropriately ! 4-10 60 AMLT - Honduras