Outdoor: hazards preventive measures.

Along with the joys of working and playing outdoors in the beauty of nature come the nuisances that plague campers and camp staff -- the ubiquitous poison ivy plants that sometimes seem invisible to the unwary hiker and, of course, those elusive mosquitoes and ticks. With fears from last year's outbreaks of West Nile Virus and the risks of Lyme disease fresh in our minds, what's a counselor or camper to do? The following articles shed some light on this dilemma -- from expert advice presented by board members of the Association of Camp Nurses to guidelines offered by an author of a book about poison ivy -- you will want to share this information with your camp staff.

West Nile Virus

A Clinical Commentary for the Camp Health Care Community

Ellen Reynolds, M.S.N., C.P.N.P.

Holly Bauer, R.N.

Ah, summertime ... camp ... outdoor activities ... water sports ... jokes about the mosquito being the "camp bird" ... phone calls from parents concerned about West Nile Virus ...

The appearance of West Nile Virus in recent years is perhaps the most well-documented introduction of a new, vector-borne human pathogen into the U.S. in this century. Because of the spread of the virus via mosquitoes, the virus is of particular concern for camps located in rural, wooded, or wilderness areas. While the virus causes encephalitis and meningitis in serious cases, most cases are mild and require only symptomatic care. Education and prevention measures can help to place concerns about the disease in proper perspective.

Incidence and Spread

West Nile Virus was first isolated from an infected person and identified in Uganda in 1937. Until 1999, the virus was found only in the Eastern Hemisphere. Infrequent human outbreaks, mostly associated with mild illnesses in which fever was the main symptom, had been reported mostly in groups of soldiers, children, and otherwise healthy adults in Israel and Africa. Since the mid-1990s, the frequency and severity of West Nile Virus outbreaks have increased (1). United States public health surveillance has tracked disease caused by West Nile Virus each year since 1999, when it first appeared in New York City. These cases have been identified over an expanding geographic area (one state in 1999, three in 2000, and ten in 2001) (1). From January 1 to October 10, 2002, there were 2946 cases of West Nile Virus identified in 35 states and the District of Columbia, including 1 60 deaths (2). Importantly, the increase in reported cases is due in part to heightened awareness, surveillance, and testing for the illness, and not simply out-of-control spread.

West Nile Virus is thought to be maintained in a cycle involving infected birds and mosquitoes, which in turn pass the virus on to humans. Many of the "bridge vectors -- mosquitoes that bite both birds and humans -- likely become infected in late summer and then pose an infection threat to humans. West Nile Virus cannot be spread from human to human or from animal to humans. The peak of reported cases between 1999 and 2001 has occurred in August and September (1). In warm or tropical climates, year-round transmission is possible.

Clinical Features of West Nile Virus Illness

The incubation period of West Nile Virus is estimated to range from three to fourteen days. Most human infections are not clinically recognized, simply because those affected may never feel very sick. A survey of serology in residents of New York City during the 1999 outbreak indicated that only approximately 20 percent of persons infected with West Nile Virus had developed fever, and only half of these had visited a physician for this illness (3).Thus, the cases that are reported are those few that result in serious disease.

Mild disease is characterized as an illness of sudden onset consisting of mild to moderate fever with varied symptoms that may include headache, muscle aches, pains, weakness, nausea, vomiting, rash, and/or swollen lymph nodes. The symptoms generally last three to six days. It is not necessary for people with these general, mild, symptoms to be tested for West Nile Virus; in fact, it would be no more helpful in treating the person than knowing which specific virus is causing someone's common cold. There is no specific antibiotic treatment for West Nile fever; comfort measures are usually all that is needed.

People with more serious West NileVirus infections are likely to be very ill. In contrast to the above noted signs and symptoms, they are likely to have very high fever, neck stiffness, disorientation, lack of muscle coordination, tremors, and/or convulsions and paralysis. In these severe cases, physician evaluation and care should be sought immediately. Blood testing would be done in order to identify the virus and be certain of the diagnosis. Again, there is no specific antibiotic treatment. Hospital care would focus on supporting the body systems as needed.

In fatal cases, advanced age has been found to be the most important risk factor. Encephalitis (brain involvement), severe muscle weakness, and change in level of consciousness are also clinical factors associated with increased risk of death. Immunosuppressed people, such as those undergoing chemotherapy those taking long-term steroids, and those taking anti-rejection transplant drugs, are likely to be at additional risk. West Nile Virus encephalitis has recently been added to the list of designated reportable illnesses. Local public health departments should be notified of any confirmed cases. Recommended clinical and laboratory case definitions for West Nile Virus are available at www.cdc.gov/ncidod/dvbid/westnile/resources/wnv-guidelines-apr-2001.p df

Prevention

Currently, prevention of West Nile Virus infection rests on two strategies: (1) reducing the number of mosquitoes that could transmit the virus; and (2) preventing those "vector" mosquitoes from biting humans. Many mosquitoes breed in small pools of standing water and have a limited flight range, so reducing mosquito populations in the immediate vicinity of human habitat and activity is useful. Property owners and municipalities can drain water from potential breeding sites, and coordinate plans for use of insecticides. Biological products (which consist chiefly of larva-killing bacteria) as well as pesticide chemicals, may be used. More detailed information about pesticides and other mosquito control measures can be obtained from the US National Pesticide Information Center at www.ace.orst.edu/info/npic/wnv/.

DEET (N,N-diethyl-meta-toluamide) is the most effective mosquito repellent currently available. It is available in many formulations and has an excellent safety profile. Products containing 10-50 percent DEBT are considered sufficient, with concentrations greater than 50 percent demonstrating little additional efficacy. Manufacturer's recommendations should be followed for periodic re-application of the repellent. The AmericanAcademy of Pediatrics recommends that repellents containing no more than 30 percent DEBT be used in children, and that DEBT not be used on infants under the age of two months (4). DEET can be applied to skin, pets, clothing, tents, bedrolls, and screens. While other products such as Skin-so-Soft [R], citronella, etc., have mild repellent properties, the use of DEET should be promoted in order to prevent infections such as West Nile Virus that spread via mosquitoes (see sidebar on page 14).

Implications and Recommendations for Camps

West Nile Virus is presumed to be spreading in a pattern that will distribute it across North America at some point. Camps frequently are located in lake or woodland areas where mosquito populations flourish, and camps generally place emphasis on doing activities outdoors. Yet, camps do have a responsibility to provide the safest possible environment and program guidelines for their staff and campers. These guidelines should focus both on prevention strategies that minimize the potential for West Nile Virus exposure and surveillance that identifies a potential outbreak. In addition, camps should be prepared to provide information and resources for concerned parents and participants. Because this challenge is newly emerging, staying linked with reliable information will be key.

Protect Staff and Campers

* Encourage body cover (long pants, shirts, socks, hats) as appropriate for the weather and activity. Shirts should be tucked in at the waist; socks should be pulled over pant legs.

* Apply an insect repellent containing 10 percent to 30 percent (recommended for children) to 50 percent DEET. Reapply per package directions throughout the duration of the activity. Recommend spraying the repellent on clothing rather than skin when feasible. It does not need to be applied under clothing. Avoid eye and mouth areas, as well as cuts, wounds, and irritated skin. Avoid using sprays in enclosed areas. Do not use DEBT near food. Consider creating related policies to ensure safe and consistent use of repellents, such as supervision or application of repellents by counseling staff Wash repellent off skin when returning indoors, especially if repeated applications are used.

* Educate staff -- especially those who live with campers or who accompany groups of campers from activity to activity -- to notice children who are getting bitten by mosquitoes. Assess those campers for appropriate use of their repellent. Be prepared to try a different repellent if the camper's formulation is ineffective at repelling mosquitoes.

* Avoid mosquito-borne habitats (wooded areas and marshes) during the dusk and dawn periods -- a mosquito's peak biting time. Avoid campouts near marshes and other wet areas.

* Monitor activity areas--are campers or staff commenting that mosquitoes are typically bad in certain areas?

Minimize the Mosquito Population

* Alert maintenance staff to eliminate areas of standing water (gutters, old barrels, boats, buckets) and keep window screens in good repair.

* Reduce exposure to mosquitoes' long grass habitat by mowing paths of hiking trails; consider widening trails to further limit exposure.

* Be aware of measures being taken or recommended by local municipalities to decrease the mosquito population, such as pesticide spraying.

* Review and adapt the camp schedule as necessary to avoid use of outdoor activity areas when mosquitoes are heaviest.

Recognize Clinically Significant Oases

* Be aware of local guidelines for West Nile Virus testing. Ensure that access to reliable, up-to-date information (see sidebar on page 13) is available to health-care providers. In addition, work with the camp's nurse and supervising physician to determine a case profile under which potential for West Nile Virus infection should be considered, and educate camp administrative staff to this directive. Currently, only persons with signs and symptoms of neurological disease should be tested for West Nile Virus. Patients with milder illnesses (e.g., fever and rash, fever and headache, lymphadenopathy) DO NOT need to be tested for West Nile Virus (5). Bear in mind that West Nile is only one in the family of viruses that cause illness affecting the central nervous system, which also includes California, Eastern equine, Powassan, St Louis, Venezuelan equine, and Western equine encephalitis (4).

* Any camper or staff with persistent high fever, altered mental status, focal neurological signs, significant muscle weakness, or other signs/ symptoms suggestive of meningitis or encephalitis should be referred for physician evaluation.

* Campers or staff with fever, general malaise, headache, body aches, and/or swollen lymph nodes should be monitored and treated symptomatically per the individual' camp's health-care guidelines.

Partner with Parents

* Include a few sentences in precamp mailings regarding the measures your camp is taking to minimize risks from West Nile Virus.

* Make sure your packing list recommends an insect repellent containing adequate amounts of DEET.

* Have staff model appropriate repellent use and dress on opening day

While West Nile Virus may cause serious illness in children and adults, the actual likelihood of infection is low A combination of education and prevention strategies can have a significant impact on the perceived and actual risk of the virus to campers and staff

References

(1.) Petersen, L.R., & Marfin, A.A. (2002). West Nile varus: A primer for the clinician. Annals of Internal Medicine, 137(3), E173-E178.

(2.) Centers for Disease Control (2002).Web site, www.cdc.gov.

(3.) Mostashari F., Bunning M.L., Kitsutani P.T., Singer D.A., Nash D., Cooper M.J., et al. (1999). Epidemic West Nile encephalitis, New York, 1999: Results of a household-based seroepidemiological survey Lancet. 2001;358:261-4.

(4.) Kennedy, K. (2002). Calming West Nile fears. AAP Web site, www.aap.org/family/wnvsept02.htm. American Academy of Pediatrics.

(5.) Zimmerman, R.S. (2002). PA Dept. of Health: Health Alert # 31.

Reviewers

Mary Marugg, R.N., Sonlight Christian Camp, Pagosa Springs, Colorado 

Susan Van Clove, M.S.N., R.N., C.P.N.P., P.N.P., program director, University of Pittsburgh, Pennsylvania

John J. LaBella, M.D., pediatrician, Children's Community Pediatrics, Pittsburgh, Pennsylvania

Stay Informed

Develop and implement a system to stay informed of developments regarding West Nile Virus.

Suggested Online Resources

* Center for Disease Control: www.cdc.gov or call 1 -888-246-2675.

* US Food and Drug Administration: www.fda.gov or call 1-888-463-0667.

* National Institute of Health: www.naid.nih.gov.

* US Environmental Protection Agency: www.epa.gov.

* American Mosquito Control Association: www.mosquito.org or call 1-732-932-0667.

* National Pesticide Information Center: www.npic.orst.edu, or call 1-800-858-7378

* Your state's Department of Health: Check with the state in which your camp is located.

* Your camp's supervising physician.

Camp-specific Resources

* Association of Camp Nurses (ACN): www.acn.org and CompassPoint.

* American Camping Association (ACA): www.ACAcamps.org and CampLine.

DEET Recommendations

The advent of West Nile Virus has made everyone look for appropriate preventive measures. An effective insect repellent -- something that prevents mosquito bites and, thus, interrupts the chain of infection -- is a desired option. This desire triggered a re-examination of DEET, an insect repellent known chemically as N,N-diethyl-meta-toluamide, by the American Academy of Pediatrics (AAP). A pesticides chapter in AAP's 1999 Handbook of Pediatric Environmental Health stated that no definitive studies existed in literature that addressed the safety of DEET for children, While reports of ill effects from DEET are rare, its use has been associated with skin rashes, respiratory irritation, and seizures.

As a result and at that time, AAP recommended a cautious approach, using a 10 percent or less concentration of DEET on children. That recommendation has been amended. An AAP news release dated August 2001 cited information from the Environmental Protection Agency and contained the statements: "It would seem appropriate, therefore, to use products with concentrations around 30 percent for adults and children. Products with lower concentrations (10 percent to 15 percent) can be used for children if families are concerned about the potential risks of DEET and there is little or no concern about the transmission of malaria, encephalitis, or other major vector-borne diseases" (www.aap.org/family/wnv%2Daug01.htm as cited on December 6, 2002).

In planning next summer's camp response to the West Nile Virus challenge, it would be beneficial to have both this information and the AAP Web site reference available to parents and staff. Accurate and up-to-date information is important so people can make the best decision for their situation.

Ellen Reynolds, M.S.N., C.P.N.P., is a pediatric nurse practitioner with Children's Community Pediatrics in Pittsburgh, Pennsylvania, She is also a comp nurse, with many years of affiliation with Concordia Language Villages in Minnesota. Ellen is serving her second term with the Association of Camp Nurse's (CAN) Board of Directors, currently in the role of clinical chair.

Holly Bauer, R.N., is the health-care supervisor at the Lions Camp in Rosholt, Wisconsin. She is a regional facilitator and board member-at-large for ACN.

Photo: page 12, Cheley Colorado Camps, Estes Park, Colorado.

Poison Ivy

A Primer for Prevention

Heidi Ratner-Connolly

Camp staff, through sheer goodwill and the love of kids, manage to make it through entire summers of homesickness, bed-shorting, kitchen raiding ... yes, and poison ivy! Many seasons of suffering from poison ivy as a camper in Maine, with the resultant fear of repeating the torture, two children with a high sensitivity to it, and a husband who almost died from inhaling its smoke, have all contributed to my developed ability for staying poison ivy free and for helping others do the same.

What Would You Do to Prevent Poison Ivy?

As camp experts, you are very familiar with this ghoulish greenery and already know the basics about how to deal with its effects. But when it comes to poison ivy it is a jungle out there, and the more you know, the better. Take the "Poison Ivy Prevention" Quiz on page 19 to test your knowledge. Unfortunately, poison ivy is nearly impossible to get rid of, because it doesn't glow neon like our campers' sweatshirts to let you know where it is so you can avoid it. The more time we spend outdoors, the more chance we have to get it from or give it to someone we're with.

Education is the Solution

How do you ensure your campers, counselors, and the rest of your camp staff are well informed about poison ivy? This really is a case in which education is the only helpful solution -- half the battle toward a poison-ivy free summer is to provide enough information to your staff. If they are fully versed in poison ivy facts, they will be able to avoid it themselves and help the campers avoid it also. Hang up charts with photos and have warning signs prominently placed. The more reminders, the more aware your staff will be.

Prevent It, Treat It, and Get Rid of It -- Once and for All!

The amount of poison ivy oil that would fit on the head of a pin can infect more than 500 people. Only one nanogram -- a billionth of a gram -- of oil is needed to cause a rash. Armed with this information, it's important that everyone knows how to stop poison ivy from spreading -- before it starts! If your camp's location is typically woodsy -- if you have campfires, hikes, adventure trails, and all the other expected great outdoor activities, you may never be able to prevent everyone from getting poison ivy -- but every bit of information helps to ensure a more pleasant summer for your campers and staff.

The "Poison Ivy Prevention" Quiz

True or False?

1. Poison ivy is poisonous.

2. Poison ivy is contagious.

3. Poison ivy spreads when you scratch it.

4. Animals get poison ivy and share it with humans.

5. Poison ivy always has three leaves.

Answers

1. False. Technically, poison ivy plants are coated and filled with a sap-like oil called urushiol which, though NOT poisonous, does cause a fierce allergic reaction in most people.

2. False. Once a person has the symptoms of a poison ivy reaction, usually twenty-four- to forty-eight hours after contact (such as a rash, blisters, itching, etc.), it is usually well past the contagious point -- assuming the oil has already been removed from the person's skin! As long as the oil remains, however, the toxins are still present and can spread from human to baseball to dog or book.

3. False. Since the faster you remove the oil the better off you'll be, the best thing is to wash (a lot and with cold water) even if you think there's a slight chance of your having come near the plant, its vines, leaves, or berries -- or anything else it may have touched. If you are scratching and you have washed well previously, then you will not be spreading the poison ivy.

4. True and False. Animals do share poison ivy, not only with humans but with anything they touch. That means the car seat, your clothes, bedding, furniture, etc. However, though our furry friends rub up against the plant, put their noses in the plants, and carry it around, they do not get poison ivy themselves. This means that they will have absolutely no symptoms from the contact.

5. True. Here's one thing you can count on. As Ben Franklin so wisely said many years ago, "Leaves of three... let them be!" There is a vast array of plant variations, though, so it's wise to bone up on identification skills.

Scoring

1-2 If you got one or two right, you and your campers may be in for a rough time this summer!

3-4 If you got three or four right, you probably know more than most, but not enough to prevent or control an outbreak -- or keep it from recurring.

5-6 If you got five or six right, you have a good base of knowledge!

Poison Ivy Identification, Treatment, and Complications

The Association of Camp Nurses provides the following recommendations for treating campers and staff contaminated with poison ivy, along with suggestions for identifying the poison ivy plant at camp and dealing with potential complications from a poison ivy outbreak.

Identifying the poison ivy (PI) plant can be tricky since the plant often changes physical characteristics as the growing season progresses. The bright, shiny leaves of spring give way to flatter green color in later summer. For this reason, consider putting a fence around a patch of PI that's growing in camp and placing an identifying sign so campers and staff can see how the plant looks as the camp season goes on. This is especially helpful to folks who come from other geographic areas.

Speaking of PI plants, the PI root system can also give one a great rash. Have a healthy respect for this plant -- the whole thing and all year long!

Treatment

* The best way to detoxify the urushiol (the oil-like toxin from the plant, which causes the allergic reaction) seems to be common rubbing alcohol. This needs to be rubbed onto exposed skin fairly soon after exposure and followed by a soap and water scrub.

* Be cautious of simply scrubbing with soap and water, even with the old standby, Fels Naptha. It is correct that soap will emulsify the P1 oil but that's all it does. The urushiol is broken into small particles; it isn't destroyed (detoxified). As a result, the soapy urushiol must be rinsed off the skin. Many folks treated for poison ivy talk about washing their hands and forearms only to have [PI] appear around their elbows because they allowed the soapy water to drip in that direction and did not thoroughly rinse -- everywhere.

* There are some barrier creams on today's market that claim to prevent poison ivy outbreaks. Most are applied as a cream and rubbed onto the skin prior to anticipated exposure. These products often lay a polymer film on the skin that prevents urushiol from permeating to the dermal (skin) layer and, in so doing, function as a barrier. Removal is via soap and water scrub (again, a thorough scrub with a good rinse). The creams have been used with good results for camp maintenance staff who must sometimes go into PI infested areas to complete a maintenance job.

* Once the PI rash breaks out, its itchiness can be relieved by soaking the affected body part for 10-15 minutes in an Epsom salt or Domoboro[R] solution every four hours.

* Keep an eye on the blistered areas. Once the blisters rupture, there's potential for a secondary infection. Here's where maintaining cleanliness is important but also challenging given the nature of some camp activities. Some camp nurses will cover the rash at this point just to give that blistered area time to heal sufficiently.

* The liquid that's in the blisters of a poison ivy rash does NOT pass the rash to others nor to other parts of one's body.

Complications

* Some areas of our bodies appear to be more sensitive to urushiol's invasion than other areas. For example, the tender inside of one's forearms tend to break out with the characteristic rash more quickly than lower legs. It is postulated that the skin's "toughness" influences this.

* Some people are more sensitive to PI than others. Aerosolizing the urushiol -- such as burning campfire wood that the PI plant touched and aerosolizing the urushiol via smoke--can be a problem for some people. These are the folks who should think about sitting upwind in the campfire circle.

* Poison ivy can be quite debilitating for some people. Getting it on one's feet or hands, for example, gets in the way of job performance, activity participation, and doing basic things like dressing one's self. Another complication occurs when the urushiol systemically affects a person rather than maintaining a localized outbreak site. Here's where a visit to the camp doctor for more definitive treatment comes in handy.

Consider labeling poison ivy a "preventable injury" at camp. There's a lot one can do to minimize -- if not eliminate -- the potential for campers and/or staff to get PI. Join the growing number of camps that monitor their number of PI cases and use that number to benchmark their risk reduction efforts. Strategies like this also help staff buy into risk management while eliminating a factor that can negatively influence a person's perception of their camp experience.

Linda Ebner Erceg, R.N., M.S., P.H.N., health and safety coordinator, Concordia Language Villages, and executive director, Association of Camp Nurses.

Heidi Ratner-Connolly writes and edits for 2Lakes Publishing, which she co-owns with her husband, Randy Connolly. She is the author of the book, Poison Ivy: It's A Jungle Out There. She can be contacted bye-mail at [e-mail]. You can also visit the Web site, www.10thingstoknow.biz.

Lyme Disease

Prevention and Control

Lyme disease is the leading cause of tick-borne infectious illness in the U.S. with about 16,000 cases reported annually. In the United States, Lyme disease is mostly localized to states in the northeastern, mid-Atlantic, and upper north-central regions and to several counties in northwestern California. In 1999, 16,273 cases of Lyme disease were reported to the Centers for Disease Control and Prevention (CDC). Ninety-two percent of these were from the states of Connecticut, Rhode Island, New York, Pennsylvania, Delaware, New Jersey, Maryland, Massachusetts, and Wisconsin.

Signs and Symptoms

* Within days to weeks following an infected tick's bite, 80 percent of patients will have a red, slowly expanding "bull's-eye" rash (called erythema migrans), accompanied by general tiredness, fever, headache, stiff neck, muscle aches, and joint pain.

* If untreated, some patients may develop arthritis, including intermittent episodes of swelling and pain in the large joints; neurologic abnormalities, such as aseptic meningitis, facial palsy, motor and sensory nerve inflammation, and inflammation of the brain; and rarely, cardiac problems.

Tips to Protect Campers and Staff

* Wear light-colored clothing so that ticks can be spotted more easily and removed before becoming attached.

* Wear long-sleeved shirts and tuck pants into socks or boots, which may help keep ticks from reaching skin.

* Apply insect repellents containing DEET to clothes and exposed skin, and apply permethrin (which kill ticks on contact) to clothes. DEET can be used safely on children and adults but should be applied according to Environmental Protection Agency (EPA) guidelines to reduce the possibility of toxicity (See DEET Recommendations on page 14.)

The American Lyme Disease Foundation recommends:

* scanning clothes and any exposed skin frequently for ticks while outdoors;

* staying on cleared, well-traveled trails;

* avoiding sitting directly on ground or on stone walls (havens for ticks and their hosts); and

* doing a final, full-body tick check at the end of the day.

Steps for Tick Removal

The American Lyme Disease Foundation reports that infected ticks begin transmitting Lyme disease an average of thirty-six- to forty-eight hours after attachment. Chances of contracting Lyme disease are greatly reduced if the tick is removed within the first twenty-four hours. The majority of early Lyme disease cases are easily treated and cured.

To remove a tick, follow these steps:

1. Using a pair of pointed precision* tweezers, grasp the tick by the head or mouthparts right where they enter the skin. Do not grasp the tick by the body.

2. Without jerking, pull firmly and steadily directly outward. Do not twist the tick out or apply petroleum jelly, a hot match, alcohol, or any other irritant to the tick in an attempt to get it to back out. These methods can backfire and even increase the chances of the tick transmitting the disease.

3. Place the tick in a vial or jar of alcohol to kill it.

4. Clean the bite wound with disinfectant.

* Keep in mind that certain types of fine-pointed tweezers, especially those that are etched, or rasped, at the tips, may not be effective in removing nymphal deer ticks. Choose unrasped fine-pointed tweezers whose tips align tightly when pressed firmly together.

Information adopted from the Centers for Disease Control and Prevention, www.cdc,gov, and the American Lyme Disease Foundation, www.aldf.com.