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Am Fam Physician. 2002;65(12):2592-2598

Preventing Infectious Disease in International Travelers

With the significant increase in international travel in recent years, the risk of exposure to infectious diseases has also increased. In response, the U.S. Occupational Safety and Health Administration (OSHA) has issued a bulletin warning international business travelers of the risks of exposure to infectious diseases.

According to OSHA, the most common vaccine-preventable diseases in travelers are hepatitis A and B. These diseases are highly contagious and can cause serious, prolonged illness and lethargy, chronic liver disease, and liver cancer. Travelers who visit endemic areas, such as Africa, Asia (except for Japan), the Caribbean, South America, Central America, the Middle East, and eastern and southern Europe, are most at risk.

OSHA also reports that malaria is the most important infectious disease threat to travelers. This serious, sometimes fatal, disease is transmitted to humans by infected mosquitoes. By taking precautions against insect bites and completing a prescribed dosing regimen of antimalarial medication, travelers can prevent infection.

To protect the health of international business travelers, OSHA makes the following recommendations:

  • Employers should urge their employees to seek medical advice before taking an international trip.

  • Travelers should take necessary preventive measures to avoid diseases. This should include vaccinations against diseases such as hepatitis A and B and medication to prevent malaria.

  • Travelers should learn about the various health risks relevant to their destinations by using available resources on travel health. These include the Yellow Book of the Centers for Disease Control and Prevention (CDC) and the CDC Web site (

Management of Pregnant Women Exposed to Anthrax

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion paper on the management of asymptomatic pregnant or lactating women who have been exposed to anthrax. ACOG Committee Opinion No. 268 appears in the February 2002 issue of Obstetrics and Gynecology.

According to the ACOG committee, anthrax infection is caused by Bacillus anthracis and has three clinical manifestations: cutaneous, inhalational, and gastrointestinal. Cutaneous is the most common presentation with mortality rates of 20 percent in untreated persons and less than 1 percent in persons on antibiotic therapy. Inhalational anthrax is the most serious presentation; case-fatality estimates are extremely high, even with supportive care and appropriate antibiotic therapy. Gastrointestinal anthrax infection is relatively rare, with fatality estimates of 25 to 60 percent. The effect of early antibiotic therapy on this form of infection is unknown.

The ACOG committee makes the following recommendations for the management of exposed asymptomatic pregnant and lactating women:

  • Prophylaxis in these women should be limited to those who have been exposed to a confirmed environmental contamination or who are exposed to a high-risk source as determined by the local Department of Health.

  • Prophylaxis for asymptomatic pregnant or lactating women should be 500 mg of ciprofloxacin orally every 12 hours for 60 days.

  • Women who are taking ciprofloxacin when they discover that they are pregnant should continue the course of antibiotics for the full 60 days. However, if the bacteria are penicillin-sensitive, the patient should be switched to amoxicillin, 500 mg orally three times a day for 60 days.

  • If a woman is allergic to penicillin and ciprofloxacin, she should be treated with doxycycline. Penicillin desensitization should be considered if the organism is proved sensitive. In such cases, the risks of anthrax would far outweigh the risks of doxycycline to the fetus.

Updates on the prophylactic treatment of anthrax are available online

ACOG Opinion Paper on Analgesia and Cesarean Delivery

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion paper on analgesia and the rate of cesarean deliveries. ACOG Committee Opinion No. 269 appears in the February 2002 issue of Obstetrics and Gynecology.

While epidural analgesia is commonly used for women in labor, researchers question whether it is associated with an increased risk of cesarean delivery. In a previous report by the ACOG Task Force on Cesarean Delivery, various studies produced conflicting data on the risk of cesarean delivery in women who received epidural analgesia before 5 cm of dilatation. Based on the conflicting data, the Task Force recommended that, when feasible, physicians should delay the administration of epidural analgesia until cervical dilatation reaches 4 to 5 cm, using other forms of analgesia until that time. However, the Task Force specifically stated that there is no desire to limit the use of epidural analgesia by women in labor.

ACOG has learned that some institutions now require women in labor to reach 4 to 5 cm of cervical dilatation before they can receive epidural analgesia. Because there is some concern about whether these institutions have developed local protocols that are sensitive to patients' needs, ACOG has reaffirmed the following opinion, which was published jointly with the American Society of Anesthesiologists:

“Labor results in severe pain for many women. There is no other circumstance where it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician's care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor.”

ACOG also states that decisions regarding analgesia during labor should be coordinated among the physician, anesthesiologist, patient, and support personnel.

Safety Rules Activity Booklet for Elementary School Children

The Council on Family Health, in collaboration with the National Association of School Nurses, has created an activity booklet on rules of safety for younger elementary school children. The “Safety Rules” booklet includes a colorful cover, a tear-out ruler, games, and several pages for coloring.

The safety booklet includes easy-to-understand messages on bicycle, pedestrian, and school bus safety; information on safety in the home; and personal health recommendations such as frequent hand-washing to avoid illness and proper brushing and flossing to prevent cavities. General guidelines are provided for children who need to bring medicines to school. An 11 × 17-in companion poster to reinforce some of the core safety messages is also included for display in schools and nurses' offices.

For a free copy of the “Safety Rules” activity booklet, send a self-addressed, stamped, 6 × 9-in envelope to the Council on Family Health, “Safety Rules,” 1150 Connecticut Ave., NW, Suite 1200-B, Washington, DC 20036. Schools who send a request on school letterhead may receive up to 200 booklets free of charge, along with a complimentary companion poster.

NIAAA Report on Prevention of College Drinking

According to a study supported by the Task Force on College Drinking of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the consequences of drinking among college students are larger and more destructive than commonly thought. The Task Force found that among college students 18 to 24 years of age, drinking contributes to an estimated 1,400 deaths, 500,000 injuries, and 70,000 cases of sexual assault or date rape each year. More than 25 percent of college students have driven a motor vehicle while under the influence of alcohol, the researchers estimate.

While most students appear to drink moderately or abstain from drinking, about 40 percent of students binge drink, which is defined as five or more drinks in a row for men and four or more drinks in a row for women. According to a recent survey, about 20 percent of students had participated in binge drinking more than three times in the past two weeks. The Task Force reports that this group of frequent binge drinkers accounts for almost 70 percent of all alcohol consumption by college students.

Drinking rates tend to be highest among incoming freshmen, male students, members of fraternities and sororities, and athletes, according to the Task Force. Students who attend two-year schools, religious schools, commuter schools, or predominantly or historically black colleges and universities drink the least.

Research on alcohol prevention among college students is relatively new and the data are incomplete. However, the Task Force found that prevention strategies that simultaneously target the student population as a whole, the college and its surrounding environment, and the individual at-risk or alcohol-dependent drinker are most effective.

The study appears in the March 2002 issue of the Journal of Studies on Alcohol. This report and other Task Force materials (e.g., handbook for college planners on implementing alcohol prevention programs; brochures for school presidents, student peer educators, parents, and community leaders) are available online and may also be ordered by calling the NIAAA at 301-443-3860.

FDA Approval of Needle Disposal System

The U.S. Food and Drug Administration (FDA) recently approved a new needle disposal system for the 2 million to 5 million persons in the United States with type 1 diabetes. The Disintegrator is a portable, user-friendly device that safely destroys insulin pen and syringe needles in less than three seconds. A unique plasma arc melts the needle at a temperature higher than 2,500°C, reducing the needle to a small ball that no longer requires a special container or expensive disposal procedure.

The Disintegrator disposal system complies with safety standards of the U.S. Occupational Safety and Health Administration. The system was developed in response to the growing concern from nurses about the 600,000 to 800,000 accidental needle sticks each year. Needles contaminated with blood or body fluids pose a serious risk of transmission of blood-borne diseases such as hepatitis and human immunodeficiency virus.

Each day in the United States, persons with type 1 diabetes dispose of an average of five used hypodermic syringes, according to the American Diabetes Association. This adds up to 9 billion used insulin needles that must be properly disposed of each year. More information on the Disintegrator is available online or by calling the manufacturer toll free at 877-797-4277.

New Standard Classification System for Rosacea

A consensus committee of the National Rosacea Society recently developed the first standard classification system for the diagnosis and study of rosacea. The report appears in the April 2002 issue of the Journal of the American Academy of Dermatology.

According to the committee, the primary features of rosacea are flushing, nontransient erythema, papules and pustules, and telangiectases, all in the central part of the face. Secondary features include burning or stinging, plaque, dry appearance, edema, ocular manifestations, peripheral location, and thickening of the skin.

The new standard classification system for the diagnosis and study of rosacea divides the disorder into the following subtypes:

  • Subtype 1—Erythematotelangiectatic Rosacea. Patients with subtype 1 have flushing and persistent erythema on the central portion of the face. Telangiectases are common, but not essential. Swelling, stinging or burning, roughness or scaling, and history of flushing may be seen in these patients.

  • Subtype 2—Papulopustular Rosacea. Patients with subtype 2 have persistent central facial erythema with transient papules or pustules. This subtype resembles acne vulgaris, but with the absence of comedones. Burning and stinging may also occur. This subtype often follows or occurs in combination with subtype 1, including the presence of telangiectases.

  • Subtype 3—Phymatous Rosacea. Patients with subtype 3 have thickening skin, irregular nodularities, and enlargement. While rhinophyma is especially common, this type of rosacea may also occur on the chin, forehead, cheeks, and ears. Telangiectases or large follicles in the affected area may occur. This subtype is often observed following or in combination with subtypes 1 or 2.

  • Subtype 4—Ocular Rosacea. Patients with subtype 4 may have one or more of the following symptoms: watery or bloodshot eyes, the sensation of a foreign body, burning or stinging, dryness, itching, light sensitivity, blurred vision, telangiectases, and conjunctivitis. Styes are common with ocular rosacea, as are corneal complications leading to decreased visual acuity. Loss of vision is a serious risk of this subtype. About 50 percent of patients have skin lesions first, while in a few patients the skin and eyes are affected simultaneously.

Reprints of the published standard classification system are available by writing to the National Rosacea Society, 800 S. Northwest Highway, Suite 200, Barrington, IL 60010; calling 888-662-5874; or sending an e-mail request

Potential Liver Injury with Use of Kava Supplements

The U.S. Food and Drug Administration (FDA) has issued a consumer advisory about the possible risk of severe liver injury associated with the use of dietary supplements containing kava. Kava supplements are commonly promoted for relaxation and for the relief of sleeplessness and menopausal symptoms. However, the FDA has not determined the ability of kava to provide these benefits.

Regulatory agencies in countries such as Germany, Switzerland, France, Canada, and Great Britain have already issued warnings to consumers about the potential risks of kava, and some have ordered the removal of kava-containing products from the marketplace. These countries have reported more than 25 cases of adverse events such as hepatitis, cirrhosis, and liver failure associated with kava-containing products. Four of these patients required liver transplantation. In the United States, there have been several reports of liver injuries related to the use of kava supplements and one report of a previously healthy young woman who required liver transplantation after using kava supplements.

Based on this information, the FDA urges persons with liver disease or liver problems, and those who are taking medications that can affect the liver, to consult their physician before using kava supplements. Persons using kava supplements should also talk with their physician if they experience any of the following symptoms: jaundice, brown urine, nausea, vomiting, light-colored stools, unusual tiredness, weakness, abdominal pain, and loss of appetite.

The FDA asks that patients and physicians report any cases of liver problems or other injuries that may be related to the use of dietary supplements containing kava. Adverse events associated with dietary supplements should be reported immediately to the FDA MedWatch program by calling 800-332-1088 or online

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Copyright © 2002 by the American Academy of Family Physicians.

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