-- Reply
Dear Dr Parikh, The Winter 2002 issue was dedicated to Pediatrics but, with your comments in mind, it is perhaps time for us to consider looking at this topic again.
Thank you for your praise, your suggestion, and your offer.

Editor

Dr Jacobs,
Thank you for your article (Disaster relief: What can I do to help? Winter 2005: p 99)--I found it to be complete and well written. I just returned from a trip to Banda Aceh, and your article really hit on a number of important points, including footwear (I had only brought boots and found myself pulling them on and off quite a bit when visiting in people's homes--on the other hand, it made a rather dramatic impression on the local people of the lengths I would go toward showing respect).

I used an Extream water bottle and was pleased with its performance (at least so far--I'll be more certain after the incubation period passes).

Regarding prophylaxis--I had one member of another team have a psychotic break that was probably induced by mefloquine and triggered by the stressful conditions in Banda Aceh. It ate up a lot of time and resources and was frightening for many of the people involved. Thankfully, it resolved well for the man afflicted. However, many of the long-term relief workers gave anecdotal reports of similar problems linked to mefloquine. KP Travel Service prescribed Malarone, which many of us took without incident.

One point I would add is in regard to clothing: Most of the team were in scrubs, but I wore "technical" clothing designed for hot weather, and I was much more comfortable and less limited than they were. It is tempting to wear scrubs in a hot climate, but they actually tend to be a bit heavy and don't provide enough protection from sun and insects. Long sleeves and pants were better suited to the terrain as well as the culture.

Record keeping was another matter that would have been better to work out ahead of time--paper was in short supply, and there had been the expectation that a record-keeping system was already in place. The nonmedical Field Coordinator didn't have a comprehensive understanding of the needs of medical caregivers. Printing up new forms was not impossible two months after the tsunami, but it wasn't a simple matter either.

Your article will help all involved in such missions be better prepared for what will actually happen. Can I get a copy in digital format so that I can share this information with future medical teams going out through my church?

Thanks again,

Tom Leighton, MD
Chief of Emergency Medicine
South Bay Medical Center
Harbor City, CA

--Reply
Dr Leighton: Thank you for your letter. You have provided some excellent embellishments to my paper. Your comments on the best clothing in hot climates were especially helpful.

Thank you for commenting on the Extream water filter. Such water filters are invaluable. I'm always amazed how many travelers trust the bottled water in the field, and I am never too surprised when they incur significant waterborne infections.

Malaria prophylaxis is always a challenge. Very necessary, but never without the risk of bothersome side effects. While most people actually tolerate Lariam (mefloquine), many do get significant gastrointestinal and psychotic problems. Although daily Malarone (atovaquone/proguanil) is promoted as a better-tolerated option, I have not found the incidence of side effects to be much less than with weekly Lariam. The recommendation for Banda Aceh is daily doxycycline--100 mg daily. However, I have heard from a few individuals who took doxycycline for prophylaxis in Banda Aceh that they developed persistent light-headedness, and one got severe vertigo. Again, no real easy answer, but when you see how rapidly falciparum malaria kills, as we did in Banda Aceh, there is no doubt that the value of prophylaxis far outweighs the risks of side effects. I have found the CDC Malaria Web page to be the best reference (www.cdc.gov/malaria/).

Lee D Jacobs, MD
Health Systems Editor