Avoiding Mosquitoes 101

Did you know that the animal responsible for more human deaths than any other is actually an insect and it’s the mosquito? Mosquitoes transmit diseases by biting someone with a virus and then injecting that virus into the blood of the next human it bites. And so on…. It’s a very efficient way to spread the viruses that cause such diseases as encephalitis, West Nile, yellow fever, malaria, dengue fever and chikungunya.

Different mosquitoes transmit different diseases. The mosquito that spreads malaria only bites from sunset to sunrise but the mosquito that transmits dengue fever bites during the day.

Some of these diseases only occur in tropical areas but some, such as dengue fever, as now seen in Southern Florida. West Nile and other forms of encephalitis affect many different areas of the US.

Treatment for most of these diseases is supportative. Therefore it’s best to prevent them.

How to avoid mosquito bites:

1. Cover up. If it’s hot wear light weight clothing- long sleeved shirts, pants and shoes instead of sandals.

2. Treat your clothing with permetherin , which is insecticidal. You can buy pre treated clothes (expensive) or do it yourself by spraying or soaking clothes and air drying ahead of travel. Treated clothing will stay active for 6 weeks and several launderings. If using mosquito nets, treat them, too.

3. Use 30% DEET on exposed skin and reapply as needed based on locale, swimming and perspiring. Don’t forget your scalp, ears and feet. Mosquitoes are very good at finding any exposed area they can! Avoid contact with your eyes, mouth and any open areas. DEET products come as sprays and wipes.

4. Don’t use products that attract mosquitoes such as perfumes, scented products, including hair spray.

So, be aware of where mosquitoes reside and protect yourself.

My Favorite Travel Tips

Here are just a few of the things I have found so helpful when I travel.

Email yourself before you leave. Send yourself an email with your itinerary, passport number, and immunization and health records. There is almost nowhere in the world that you that you won’t be able to access your email.

Bring a hair scrunchie. You know those covered elastics. Find a bright colored one. When you travel to a country where you can’t drink the water out of the faucet – put the scrunchie on the faucet as a visual reminder not to automatically grab a toothbrush or glass and drink.

Don’t go barefoot. Bring a pair of flip flops – you can even wear them in the shower for protection and traction. They don’t take up much space. This way you avoid stepping on or in things you don’t want to and helps prevent getting cut and bitten.

Have tissues or toilet paper with you all the time. Even in the USA there are lots of places when you find yourself stranded.

Smile. It’s the most important thing I bring with me wherever I go and it has helped me in more situations than almost anything else – except when I got detained in the airport in St Petersburg, Russia a few years ago, but that’s another story….

Rabies and Traveling

Most of us in the U.S. don’t think about rabies unless we have pets and have to innoculate them. But in most parts of the world, animals are not immunized for rabies. Each year it kills 50,000 people, mostly children, as it is spread by bites and when saliva from an infected animal gets into the eyes, nose, and mouth or through broken skin. Dogs account for most cases but foxes, raccoons, monkeys and bats are also sources of infection. Rabies is almost 100% fatal in humans. So what should travelers do to protect themselves and their families from rabies?

Avoid animal bites by avoiding touching all animals, including wild animals and pets. Pets in other countries may not have been vaccinated against rabies. Supervise children closely, especially around dogs, cats, and wildlife, such as monkeys. This is important since children are more likely to be bitten by animals, may not report the bite, and may have more severe injuries from animal bites.

If you are going abroad for an extended period of time or will work around animals, or spend time in wilderness areas, consider getting pre exposure vaccination to rabies. This will not prevent you from getting rabies but will enable you more time to get treatment. Act quickly if an animal bites or scratches you.

Wash the wound thoroughly with soap and water. See a doctor right away, even if you don’t feel sick or your wound is not serious. To prevent rabies, you may need to start a series of vaccinations immediately. Be prepared to travel back to the United States or to another area for treatment adequate vaccination for exposure to rabies is not available in all parts of the world.

Before your trip, find out if your health insurance covers health care overseas and medical evacuation. If it does not, consider buying supplemental health insurance for your trip.

Why Don't We Bill Insurance?

This is probably the most frequently asked question we get. Some clinics, especially those associated with a medical center, do bill insurances. Most private travel clinics don’t. Instead clients are given forms with all the necessary information to submit to their insurers for possible, direct reimbursement.

Most insurers do not cover travel vaccines. Medicare does not cover travel vaccines at all. (They only cover flu and pneumonia and hepatitis B under very limited circumstances and herpes zoster vaccine under optional plan D). The reimbursement rate for vaccines is slightly above or below the cost of the vaccine. Vaccine prices rise faster than reimbursement rates do. To make up for this, an administrative fee for each vaccine is added. Some clinics that do not bill third parties charge administration fees, too. Most don't. The office charge for a clinic that bills in our area is about $250. Those that don't bill direct charge much less. We charge $85 per person or $100 for two people traveling together.

So, what do we tell the consumer?

We tell them to call their insurer and ask if they cover travel health office visits and travel vaccines. They have to ask specifically about travel vaccines or they may find out that they were told they were covered but that they didn’t mean yellow fever. If they cover it all, they can go to a clinic that bills direct or may still choose to go to one that doesn’t and submit the form themselves. If you do not bill insurance you still need an NPI number and need to give the clients statements with proper coding. Other factors that determine how consumers choose travel care are location, convenient hours and the reputation of the clinic.

Even though we have client's that don't come to us because we won't bill, I don't regret that business decision. It would cost us alot more to bill and collect fees that were denied by the insurer because they were not covered, had a high deductable, etc. Because we don't bill, I can spend more time providing direct client care than dealing with administraive and billing problems.

Typhoid Vaccine - Oral or Injectable?

There are many different places in the world that travelers need to protect themselves from typhoid fever. Salmonella Typhi is bacteria carried the bloodstream and intestinal tract. It is shed by persons with the infection and by carriers in their stools. Typhoid fever is contracted by eating food or drinking fluids that have been handled by a someone who is shedding the bacteria.

It can be spread by sewage contaminating the water used for drinking or washing food. Travelers from the United States to Asia, Africa, and Latin America are at risk.

Light green areas are endemic

Dark green areas are highly endemic

Symptoms range from mild to severe and include fever as high as 103° to 104° F, weakness, abdominal pains, headache, diarrhea and loss of appetite. In some cases, patients have a rash of flat, rose-colored spots. Diagnosis is made by stool culture. Treatment is with antibiotics and prevention and treatment of dehydration.


So how do you decide which vaccine to give to patients who are traveling?

The injectable vaccine is well tolerated but costs more and lasts only 2-3 years. The oral vaccine is a series of four capsules given every other day so it takes a week to complete it and then a week for it to become effective. It needs to be stored properly, refrigerated , or it loses potency. It must be taken on an empty stomach (one hour before or two hours after eating) and can’t be taken concurrently with antibiotics , alcohol or with very hot or cold beverages. To enhance patient compliance Berna, the manufacturer, has a very good informative booklet, reminder cling decals for the bathroom mirror and refrigerator and an animated video http://www.oraltyphoidvaccine.com/.

They have an absent minded patient program where they will replace a vaccine for free if you sent it back when the patient hasn’t taken it properly. So if you have a compliant patient with enough time, it makes sense to offer the oral vaccine and save your patient some money and give patient 5 years worth of protection and one less shot . If time is short, and you or your patient decides the oral regimen is too complicated, you can give the injection.

Food and water precautions are still recommended because of all the other food and water borne pathogens. Remember to counsel your patients to
Boil it. Peel it. Cook it. Or forget it!

Planning Ahead and Being Prepared

Every year in the Fall I stock up on a few essentials in anticipation of another New England winter. This year I am doing it a bit early in anticipation of H1N1 outbreak. It’s not that I am an alarmist or pessimist but I like to be prepared. I am asking my patients to think about what they would need at home if they couldn’t get out to the grocery store or pharmacy for a few weeks and suggesting that then plan ahead. Here's what I think we need to tell our patients.

Have enough nonperishable groceries on hand to last at least 2-3 weeks. Make sure you have enough of the essentials, such as toilet paper, soap, hand sanitizer, laundry detergent, and tooth paste, stocked up.

Check to see if you have enough acetaminophen and cough syrup on hand in proper doses for the entire family.

Evaluate your prescriptions. Is there anything that you couldn’t go without for a month? If so, get an extra month’s supply and set it aside in a safe place.

Keep a small amount of cash on hand in case you can’t get to the bank.

Got pets? Make sure you have enough food, litter, and pet meds for an extra month.

If you are putting off any repairs that if put off could be a big problem, just get them done.

Keep you gas tank full.

It’s easy to live week to week since banks, groceries, gas stations and pharmacies are readily available but what if supplies became scarce? What if you didn’t want to go out in public? If this Fall is uneventful then we will all be prepared for the next weather related event or public health threat. There’s no harm in being prepared.

Give a better shot.

What do most adult patient’s fear almost more than anything else? Shots. Why do patient’s come up with so many excuses not to get vaccinated? Fear of shots. Why do lots of adults (and health care providers) avoid the flu vaccine every year? Yup, afraid of shots. Why don’t more people take advantage of travel health clinics? Because they are worried about the shots.
So, how can you change this? Give a better shot. I’ve been giving shots for over 30 years and I give over 1,000 flu shots alone every year. Here’s my thought on this or what I like to call…
Nancy’s Needle Tips
Like any procedure, first learn the technique, and then perfect it. But don’t stop there. Now learn how to do it quickly and efficiently without sacrificing the quality. Speed is good.
If you don’t feel comfortable giving an injection, you will project that to the patient. If you need help, seek out a mentor, practice and perfect your skills and build your confidence.
Don’t aspirate. If you learned how to give an injection more than a few years ago, this may sound like heresy. According to the CDC, it is not necessary to aspirate when giving an injection. It makes the task harder, takes longer and hurts more.
Don’t linger. Draw up all injections at once, away from the patient’s view. Keep the needle discreetly out of view and tell the patient right before the procedure what you are going to do. Ask them to hang their arm down and make it loose and then just do it. Have the patient apply pressure or rub it.
You don’t need gloves for an injection. It takes more time to put them on.
Distract them. I call this “vocal anesthesia”. Don’t discuss how everyone hates shots. Don’t even talk about shots. Ask about work, school, their kids, and their trip.
Offer an ice pack. I keep Boo Boo Kitty, my ice pack, in my refrigerator. (Yes, for the adults). I like to keep an assortment of specialty band aids for them to choose. I think Dora the Explorer is nice for the travel clinic.
And last, but not least, I praise the patient. I tell them they did a good job and that I know how hard that was for them to get that shot/s. All of these techniques help make getting a shot a little more pleasant this time and helps set the stage for the next one.

How many of your patients are fully immunized?

Take every opportunity to update your patient’s routine immunizations. Most patients’ don’t know their immunization status and don’t have records. So how can you find out? Look at previous primary care records, emergency room records (especially for wound care), college/high school records, military records, and don’t forget Mom. I have my original pediatric immunization records that my mother saved from over 50 years ago. Check to see if your patient has a “yellow book”, an international certificate of vaccination. If no records exist, then begin updating considering the recommendations for tetanus, diphtheria, pertussis, influenza, pneumococcal disease, MMR, varicella, herpes zoster, hepatitis A and B.

Here’s a list of resources to help you increase the immunization rates for routine immunizations for adults in your practice.

2009 Immunization schedule for adults for the U.S. with footnotes
VIS-Vaccine Information Statements are required by law to be given to patients. 30 languages other than English are also available.
Needle Tips is an e newsletter all about vaccinations for adults and children.
Do I Need Any Vaccinations Today? Is a handout you can leave in your waiting area for patients to consider for themselves and other family members? Many patients ask me about this and it helps to remind me to use every opportunity I can to immunize.
Immunization Screening Questionnaire is available to photocopy or purchase a tear off pad to use as a timesaving tool to prescreen contraindications for vaccination.
Immunization records may be available free from your state’s public health department or may be purchased inexpensively from immunize.org

There are 3 types of immunizations to consider when preparing a patient for international travel.
1. Routine- what every adult in the U.S. needs
2. Recommended- what the traveler needs because of possible exposure on this trip
3. Required- what is needed for entry into a specific country (i.e. yellow fever vaccine)

If your patients have all of their routine immunizations up to date, they will need fewer shots for their upcoming trip.

Does Travel Health fit into your primary care practice?

Despite the current state of the economy, many people are traveling. Immigrants return home to visit friends and relatives. Students travel abroad to study and do humanitarian work. Church groups offer tours that combine missionary work and vacations. People, who can’t find work here, travel to find jobs. People who can’t afford certain medical procedures in the U.S. are traveling abroad for what is now called medical tourism. And of course, those who can are taking advantage of worldwide discounts in vacation travel.

As a primary care provider, you will be asked for health advice for travel. You will need to decide which patients you can advise and which you will want to refer to a travel health specialist.
So, how do you decide? First, evaluate your level of expertise in travel health. Do you understand the destinations and types of itineraries your patients are taking? Do you have the knowledge to evaluate when malaria chemoprophylaxis is warranted and which drug to choose? Do you understand all of the travel vaccines and drug and other vaccination interactions? Are you current with the latest evidence based recommendations for self treatment for traveler’s diarrhea ?

Do you have the time in your practice to devote to travel health? A typical travel health visit in my practice involves about one and half hours for the preparation, research, visit, charting and follow up. Medicare and Medicaid will not reimburse you for travel health visits or most vaccines. Medicare B covers pneumonia and flu vaccines and hepatitis B in very high risk patients only. Medicare D covers herpes zoster vaccines in varying degrees. Most private third party insurers do not cover travel visits, most vaccines or malaria medications if used for prophylaxis. Third party payers typically reimburse at cost or less than your cost for immunizations. Only certified yellow fever centers can administer yellow fever vaccine. If your patient is traveling to an area where yellow fever is required or recommended, you will need to refer to a certified yellow fever centers.

After gaining expertise in this field, I choose to set up a travel health clinic as a separate entity from my primary care practice. Travel Health of NH, PLLC is a fee for service practice that does not bill or accept any insurance. As a family nurse practitioner in the state of New Hampshire, I am able to operate my own practice and prescribe independently. You will need to check with your state's laws to determine your legal scope of practice.

So, you can refer all your travel patients or offer some travel health services within your level of expertise in your primary care practice. Or you could add to your education and start a travel health practice separate from your primary care practice. No matter what level of involvement you choose, the most important thing you can do for all your patients is make sure all their routine adult immunizations are current and documented.