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Keeping our Traveling Keeping our Traveling Students Safe and Students Safe and
HealthyHealthy
Jean Haulman MDJean Haulman MDMarch 6, 2009March 6, 2009
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www.kidsforsavingearth.org
RisksRisks
Loss of Loss of inhibitionsinhibitions
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0
50
100
150
200
250
300
350
400
1850 1900 1950 2000
days
050100150200250300350400450500
mill
ions
days to circlethe globe
internationalarrivals
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Your favorite Your favorite “exotic” disease“exotic” disease
is only anis only an airplane ride airplane ride
awayaway
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Transportation hazardsTransportation hazards
http://www.blueskyaviation.mn/medevac.html
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Injury: Land & WaterInjury: Land & Water
Leading cause of death in Leading cause of death in travelers is Motor Vehicle travelers is Motor Vehicle
Accidents (<55 y/o)Accidents (<55 y/o)
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Auto accidentsAuto accidents According to the Association for Safe According to the Association for Safe
International Road Travel, the risk is International Road Travel, the risk is 20-80 times higher in developing 20-80 times higher in developing countries than in the U.S. countries than in the U.S.
Approximately 750 Americans die Approximately 750 Americans die annually in auto accidents abroad, and annually in auto accidents abroad, and approximately 25,000 are injured. approximately 25,000 are injured.
Why does this occur?Why does this occur?
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Modes of Transportation are Modes of Transportation are UniqueUnique
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Conditions leading to MVAsConditions leading to MVAsPoor road conditions Poor road conditions Poor vehicle Poor vehicle
maintenancemaintenanceLack of seatbeltsLack of seatbelts33rdrd world countries do world countries do
not always have the not always have the same rules of the roadsame rules of the road
http://www.explorenorth.com/blog/deathroad.jpg
http://www.autocult.com.au/img/gallery/full/nickop196.jpg
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Road signsRoad signs
Road signs may be Road signs may be confusingconfusing
Advice for drivers in Advice for drivers in IndiaIndia
http://2.bp.blogspot.com/...qHw5g5ewdM/s400/2Indianroadsignsmall.jpg
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http://www.infoforhealth.org/pr/m15/p6a.jpg
Traffic in CairoTraffic in Cairo
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Donor-mobileDonor-mobile
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AAA Abroad:AAA Abroad:Roadside service variesRoadside service varies
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Rule: Pedestrians do not always Rule: Pedestrians do not always have the right of wayhave the right of way
http://www.cartoonstock.com/newscartoons/cartoonists/aia/lowres/aian23l.jpg
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RisksRisksDrowning is second leading Drowning is second leading
cause of mortality for cause of mortality for travelerstravelers
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What is the common What is the common denominator for MVA and denominator for MVA and
drowning?drowning?
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RisksRisks
Illness – Destination SpecificIllness – Destination Specific
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What are the options for What are the options for prevention and prevention and
treatment?treatment?First step: Pack your common First step: Pack your common
sensesenseSecond Step: Schedule a pre Second Step: Schedule a pre travel consultation. Novice travel consultation. Novice
students need in person students need in person consultation.consultation.
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Pre-Travel Counseling Pre-Travel Counseling VisitVisit
Focus is preventionFocus is prevention Advice given regarding ways to Advice given regarding ways to
minimize destination specific risks minimize destination specific risks • Disease and environment educationDisease and environment education
Traffic risks, drowning risksTraffic risks, drowning risks Insect precautionsInsect precautions Food and water Food and water
• VaccinesVaccines• Medications for travelers’ diarrhea (TD), Medications for travelers’ diarrhea (TD),
malaria prophylaxis, altitude sickness, HIV malaria prophylaxis, altitude sickness, HIV PEP for traveling health care studentsPEP for traveling health care students
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Travel Clinic ConsultationTravel Clinic Consultation ItineraryItinerary Reason for travelReason for travel AccommodationsAccommodations Duration of travelDuration of travel Modified byModified by
• Medical and immunization historyMedical and immunization history• AllergiesAllergies• Special needsSpecial needs
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Itinerary and Reasons for Itinerary and Reasons for TravelTravel ItineraryItinerary
• Country and regionCountry and region• City vs. ruralCity vs. rural
Reason for travel: Reason for travel: backpacking, trekking, backpacking, trekking, spelunking, business, study spelunking, business, study abroadabroad
Accommodations: Hotel, Accommodations: Hotel, tent, hostel, cave, host tent, hostel, cave, host familyfamily
http://www.arr-the-kraken.com/images/oz_02.jpg
http://ritz-carlton-boston-commons.visit-boston-massachusetts.com/boston-ritz-carlton-suite.jpg
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AccommodationsAccommodations Host familiesHost families
• Hepatitis A, TyphoidHepatitis A, Typhoid• Local waterLocal water• Well waterWell water
Crowded living conditions, group Crowded living conditions, group travel, exposure to ill persons:travel, exposure to ill persons:• Meningococcal diseaseMeningococcal disease• InfluenzaInfluenza• TuberculosisTuberculosis
Rule: There is so such thing as safe drinking water in a 3rd world country unless it comes from a sealed bottle.
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Travel location(s) and Travel location(s) and duration of stayduration of stay
Diseases follow geographic patterns Diseases follow geographic patterns and seasonal variationsand seasonal variations
The longer the stay the greater the risk The longer the stay the greater the risk of travel related illnessof travel related illness
Short stays are considered <2-3 weeksShort stays are considered <2-3 weeks Long stays are > 1 monthLong stays are > 1 month
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Pre-travel Pre-travel Consultation Consultation VACCINES: Routine, VACCINES: Routine,
Recommended and RequiredRecommended and Required
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Why insure completion and Why insure completion and update of routine vaccines? update of routine vaccines?
WorldWorld vs vs USUS Diphtheria: 9,235Diphtheria: 9,235 Measles: 30-40 mMeasles: 30-40 m Pertussis 20-40 mPertussis 20-40 m Polio: >35,000Polio: >35,000 Mumps: UnknownMumps: Unknown TetanusTetanus
>300,000>300,000(most neonatal)(most neonatal)
0 cases in 20050 cases in 2005 64 cases: 2008 *64 cases: 2008 * 25,827 in 200425,827 in 2004 Last wild case 1979Last wild case 1979 5,783 cases in 20065,783 cases in 2006 @ 40 cases in 2006@ 40 cases in 2006
86% imported
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RecommendedRecommended Hepatitis AHepatitis A TyphoidTyphoid Hepatitis BHepatitis B RabiesRabies PolioPolio MeningococcalMeningococcal JEVJEV (HPV)(HPV)
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Recommended VaccinesRecommended Vaccines Hepatitis A vaccine: Hepatitis A vaccine:
• 11stst dose can be given on the way to the airport dose can be given on the way to the airport• Most common vaccine-preventable illness in Most common vaccine-preventable illness in
returned travelers, next to influenzareturned travelers, next to influenza Typhoid vaccine: recommended for all 3Typhoid vaccine: recommended for all 3rdrd
world travel unless staying in 4-5 star world travel unless staying in 4-5 star accommodations and never eating from accommodations and never eating from the streetthe street• 1140 US cases reported 1999-2003, 74% 1140 US cases reported 1999-2003, 74%
importedimported
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VaccinesVaccines Hepatitis AHepatitis A
• 2 brand of vaccines 2 brand of vaccines available, equally effectiveavailable, equally effective
• Given 6 months apartGiven 6 months apart• Expected lifetime Expected lifetime
immunityimmunity
TyphoidTyphoid• 2 types of vaccines available2 types of vaccines available• Injectable: good for 2 yearsInjectable: good for 2 years
Can cause sore armCan cause sore arm May feel run down for 1 dayMay feel run down for 1 day Students and insurances Students and insurances
preferprefer• Oral: good for 5 yearsOral: good for 5 years
Live attenuatedLive attenuated Can cause nauseaCan cause nausea Cannot take concurrent Cannot take concurrent
antibioticsantibiotics 1 pill qod x 4 doses1 pill qod x 4 doses Should complete 4 dose Should complete 4 dose
schedule at least 10 days schedule at least 10 days prior to departureprior to departure
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Hepatitis B vaccineHepatitis B vaccine Encouraged for all Encouraged for all
travelers at risk for travelers at risk for MVA while travelingMVA while traveling
Recommended for Recommended for sexual partner seeking sexual partner seeking travelerstravelers
Recommended for Recommended for travelers seeking travelers seeking medical procedures, medical procedures, tattoos, and/or tattoos, and/or piercingspiercings
3 dose vaccine given 3 dose vaccine given at 0, 1, and 6 monthsat 0, 1, and 6 months
First cancer First cancer preventing vaccinepreventing vaccine Courtesy of Patricia Walker MD
Ramsey Clinical Assts St. Paul, MN
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Hepatitis A/B VaccineHepatitis A/B Vaccine Given as series of 3Given as series of 3 Standard schedule 0, 1, 6 monthsStandard schedule 0, 1, 6 months
• 3 doses of standard hepatitis B3 doses of standard hepatitis B• 3 doses of ½ standard dose for hepatitis A3 doses of ½ standard dose for hepatitis A
New FDA approved accelerated dosingNew FDA approved accelerated dosing• Advantage for travelersAdvantage for travelers• Given at day 0, 7, 21-28 days, booster at 1 Given at day 0, 7, 21-28 days, booster at 1
yearyear• Can fit in complete series prior to travelCan fit in complete series prior to travel
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Polio 2003:
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Polio Travel as a risk factor: 2003 and 2005, 25
previously polio-free countries were re-infected due to imports of the virus
As of March 2008, only four countries in the world (Afghanistan, India, Nigeria, Pakistan,) are still considered to be endemic for Polio
However new case reports appear monthly in most sub Saharan countries
Recent imported case from Indonesia to Australia
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Rule: If it has fur and teeth do not touch it.
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Vaccines in short supply Rabies vaccine: current shortage, not
available for pre travel use Disease is 100% fatal Only post exposure vaccination is available HRIG (expensive) + 5 doses of vaccine on
days 0,3,7,14,28
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Vaccines for specific destinationsVaccines for specific destinations
JEV: SE AsiaJEV: SE Asia Short supplyShort supply MosquitoMosquito Dusk to dawnDusk to dawn Rainy seasonRainy season 30% mortality30% mortality Given as a 3 dose Given as a 3 dose
series 0,7,21 daysseries 0,7,21 days Can cause allergic Can cause allergic
reactionreaction New 2 dose vaccine New 2 dose vaccine
close to FDA approvalclose to FDA approval
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Yellow Fever: Required Required vaccine Can be obtained only
at a yellow fever certified center
Must be documented on the official CDC or WHO yellow card
50% mortality from disease
Vaccine has rare serious side effects
1 vaccine q 10 years
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Meningococcal InfectionsMeningococcal Infections For travelers going to For travelers going to
Africa during the dry Africa during the dry seasonseason
Required for travelers Required for travelers going to the Hajj in going to the Hajj in Saudi ArabiaSaudi Arabia
Sporadic outbreaks in Sporadic outbreaks in other African countriesother African countries
2 vaccines2 vaccines• Meningococcal Meningococcal
Conjugate vaccine: age Conjugate vaccine: age 2-55 yrs2-55 yrs
• Meningococcal Meningococcal Polysaccharide: Polysaccharide: Approved for age 3 Approved for age 3 months and oldermonths and older
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MedicationsMedications
DIARRHEA PreventionDIARRHEA PreventionA.K.A.A.K.A.
Montezuma’s revengeMontezuma’s revengeAztec two-stepAztec two-step
The trotsThe trotsTurkey TrotsTurkey Trots
TuristaTurista
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Distribution of TDDistribution of TD
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Why is diarrhea more Why is diarrhea more common in the developing common in the developing
world?world?
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Travelers’ diarrheaTravelers’ diarrhea Incidence highest for Incidence highest for
travelers going to a travelers going to a 33rdrd world country world country
Food is the vector for Food is the vector for travelers’ diarrhea travelers’ diarrhea more often than more often than waterwater
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Travelers’ diarrheaTravelers’ diarrhea
Acute, self-limiting illness; resolves Acute, self-limiting illness; resolves within about 5 days. within about 5 days.
3-10% of pts with TD will have 3-10% of pts with TD will have symptoms lasting longer than 2 weeks.symptoms lasting longer than 2 weeks.
Up to 3% of travelers have TD lasting Up to 3% of travelers have TD lasting over 30 days. over 30 days.
Most symptoms occur while abroad and Most symptoms occur while abroad and are never reportedare never reported
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Treatment for Travelers’ Treatment for Travelers’ Diarrhea (short term travelers)Diarrhea (short term travelers)
Ciprofloxacin 500mg up to q 12 hours for Ciprofloxacin 500mg up to q 12 hours for 3 days (adults)3 days (adults) OROR
Azithromycin 10mg/kg up to 500mg q 24 Azithromycin 10mg/kg up to 500mg q 24 hrs for up to 3 days (peds and adults) ORhrs for up to 3 days (peds and adults) OR
Azithromycin 1000mg all at once (adults)Azithromycin 1000mg all at once (adults)
Newer option: Rifaximin 200mg tid for 3 Newer option: Rifaximin 200mg tid for 3 days days
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Travelers prefer to sit hereTravelers prefer to sit here
http://www.advillas.com/images/newImages/AdvillasBeachSunset.jpg
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--not here----not here--
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Malaria preventionMalaria preventionFever is malaria until proven otherwiseFever is malaria until proven otherwise
ANDANDMany developing countries treat every Many developing countries treat every
fever with malaria medicationfever with malaria medication
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Malaria ChemoprophylaxisMalaria Chemoprophylaxis Chloroquine: weekly medicine, most of the Chloroquine: weekly medicine, most of the
world has resistant parasites – world has resistant parasites – @$0.61-3.94/pill/week@$0.61-3.94/pill/week
Mefloquine (Larium): weekly medicine - Mefloquine (Larium): weekly medicine - @$11.33/pill/week, spotty resistance, can @$11.33/pill/week, spotty resistance, can cause psychosiscause psychosis
Doxycycline: daily, cheap - @ $0.26/pill, no Doxycycline: daily, cheap - @ $0.26/pill, no world resistance known, can cause stomach world resistance known, can cause stomach upset and vaginal yeast infection.upset and vaginal yeast infection.
Atovaquone-Proguanil (Malarone): daily - @ Atovaquone-Proguanil (Malarone): daily - @ $7.33/pill$7.33/pill
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Altitude: Acute Mountain Altitude: Acute Mountain SicknessSickness
May lead to headache, May lead to headache, insomnia, fatigue, insomnia, fatigue, nauseanausea
Occurs in @ 40-50% of Occurs in @ 40-50% of lowland persons lowland persons moving quickly to moving quickly to 14,000 ft (4250m) 14,000 ft (4250m)
PreventionPrevention• Ascend slowlyAscend slowly• AcetazolamideAcetazolamide
125 mg bid125 mg bid 250 mg qhs250 mg qhs
http://terrigick.typepad.com/.a/6a00e551f461c38833010536b4bd95970b-500wi
http://farm1.static.flickr.com/8/7741477_a1c3f15619_b.jpg
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What to expect when What to expect when illness happens during illness happens during
traveltravel
Medical Care may be DifferentMedical Care may be Different
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Medical careMedical care The standards of health care delivery The standards of health care delivery
differ in poorer countriesdiffer in poorer countries
The modernization of buildings and The modernization of buildings and number of sky scrapers doesn’t number of sky scrapers doesn’t always correlate with modern health always correlate with modern health care deliverycare delivery
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Modern & Shanty are often Modern & Shanty are often neighborsneighbors
http://lifegoesonintehran.com/images/03_2008/9b-building.jpg
http://images.google.com/imgres?imgurl=http://www.tr-ac-net.org/DBimages/
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http://3.bp.blogspot.com/
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Clean and modern on the outsideClean and modern on the outside
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doesn’t necessarily mean clean doesn’t necessarily mean clean and modern on the insideand modern on the inside
http://www.secretchina.com/news/up2007/allimg/0706/9_21174418.jpg
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Standards of Medical CareStandards of Medical Care May reuse syringes, needlesMay reuse syringes, needles May have primitive sterilization May have primitive sterilization
techniques (alcohol and a match)techniques (alcohol and a match) Medications and vaccines may be Medications and vaccines may be
counterfeitcounterfeit Overnight stay usually requires Overnight stay usually requires
assistance (bedding, food, etc)assistance (bedding, food, etc) May be dirty, may see rodents, flies May be dirty, may see rodents, flies
and mosquitoesand mosquitoes
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http://www.sos-arsenic.net/images/hospital2.jpg
http://www.bnp.org.uk/wp-content/uploads/ghana-hospital.jpg
Conditions may be crowdedConditions may be crowded
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Hospital wards varyHospital wards vary
http://www.medisend.org/images/pr86-1-lg.jpg
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http://www.globalpas.org/gpasblog/uploaded_images/ward-761111.jpg
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Tanzania: Surgical gown Tanzania: Surgical gown sterilizationsterilization
http://images.google.com/imgres?imgurl=http://movetcd.com/images/DSCF3188.JPG&imgrefurl=http://movetcd.com/MOVE2.html
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Medical care while travelingMedical care while traveling Advise small medical kitAdvise small medical kit Syringe kits for high risk destinationsSyringe kits for high risk destinations Have medical/evacuation insurance:Have medical/evacuation insurance:
• Access America (Word Access): 1-800-284-Access America (Word Access): 1-800-284-83008300
• International SOS: 1-800-468-5232International SOS: 1-800-468-5232• ASA, Inc.: 1-888-ASA-8288ASA, Inc.: 1-888-ASA-8288• Gateway:1-800-282-4495Gateway:1-800-282-4495• Travel Assistance: 1-800-821-2828Travel Assistance: 1-800-821-2828• Medjet assistance: 1-800-9MEDJETMedjet assistance: 1-800-9MEDJET• Divers Alert Network Divers Alert Network
Have health insurance on returnHave health insurance on return
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Medicine KitMedicine Kit Sunscreen Sunscreen NSAIDsNSAIDs MoleskinMoleskin Non Neomycin-containing antibiotic, band-Non Neomycin-containing antibiotic, band-
aidsaids Antifungal cream (wear white cotton socks)Antifungal cream (wear white cotton socks) Hydrocortisone creamHydrocortisone cream Stool softeners, loperamideStool softeners, loperamide AntihistaminesAntihistamines Flashlight, copy of passportFlashlight, copy of passport
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What happens when travelers What happens when travelers return home illreturn home ill
Unexplained fever is an emergency Unexplained fever is an emergency and is malaria until proven otherwiseand is malaria until proven otherwise
Also seek consultation forAlso seek consultation for• Unusual rashesUnusual rashes• Persistent diarrheaPersistent diarrhea• Persistent coughPersistent cough• Unusual weight loss or fatigueUnusual weight loss or fatigue
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CreditsCredits http://www.istm.org/ International Society of Travel International Society of Travel
Medicine (ISTM) teaching slide setMedicine (ISTM) teaching slide set www.cdc/gov www.immunize.org http://www.who.int/en/ http://www.shoreland.com/http://www.shoreland.com/ http://www.promedmail.org/
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Many ThanksMany ThanksJean Haulman MDJean Haulman MD