Sunburn and Lyme disease: two preventable injuries.

Nancy, the new lifeguard you hired four weeks into camp tried to catch up to other waterfront staff in the tanning department. The first day out, she wore an SPF 4 tanning gel and burned to a crisp. She spent the next two days in the health center under cool packs, moaning.

Cabin Three's 12-year-old boys had an overcast day for their afternoon hike. The campers applied their own sunscreen, some in the shape of funny faces, others missed key areas like ears, knees, and cheekbones. The lack of sunshine made sunscreen seem less important - until they tossed and turned at lights-out with irritable, itchy sunburned blotches.

"Sunburn is a preventable injury," says Linda Erceg, RN, Concordia Language Villages, Minn., who holds her staff as accountable for sunburns as other injuries.

Why is sunburn a big deal?

Sunburn indicates a person has been overexposed to the sun. Overexposure is dangerous for a number of reasons. The immediate concerns might be dehydration, sun/heat stroke, and scarring depending on the severity of the burn. An even greater concern is the long-term effect of a severe sunburn, namely skin cancer.

Malignant melanoma is a life-threatening, relatively rare form of skin cancer. According to the Environmental Protection Agency, it takes only two severe sunburns for a child's chances of developing melanoma later in life to double. In 1994, approximately 32,000 new cases of melanoma were detected, 6,900 people died from this skin cancer.

More common forms of skin cancer are basal-cell carcinoma (BCC), which usually does not spread to other organs but can extend below the skin to the bone. Squamous-cell carcinoma (SCC) is the second most common and tends to spread more often. The cure rate for both BCC and SCC is 95 percent or better with early detection.

Most people associate skin cancer with "lying out in the sun" for hours each day. While sunbathing is certainly not a healthy activity, skin cancer is actually more associated with recreational and sporadic sun exposure.

According to the Skin Cancer Foundation, 50 to 80 percent of lifetime sun exposure occurs before age 18. Regular use of Sun Protection Factor (SPF) 15 sunscreen during childhood can reduce by 78 percent the incidence of the most common types of skin cancer.

Protection and prevention

The first step to protecting staff and campers from sunburn (or any injury) is to educate them. Nancy should have applied an SPF 15 sunscreen or a sunblock several times that day. Was sunscreen available? Is there a camp-wide policy (not just waterfront) concerning sunscreen? Does Nancy understand why it's important?

Who supervised the application of sunscreen to campers in Cabin Three before the hike? How long was the hike? Should sunscreen or sunblock have been reapplied?

Getting in the habit of using sunscreen or sunblock, no matter what the outdoor activity or how sunny the day, is crucial to preventing sunburn at camp. If campers are too young (or irresponsible) to apply it themselves, have staff apply it for them. Staff should apply it to their own hands first then rub it on the campers' skin. Don't forget the following extra sensitive areas:

* scalp (swab sunscreen along the part in the hair)

* areas around the eyes (special products are made for the eye area)

* nose and cheek bones

* ears

* lips

* hands

* back of neck and shoulders

* knees and feet.

Safe sun recommendations from the American Academy of Pediatrics:

* Use a sunscreen with an SPF of 15. Apply the sunscreen liberally and often during hours of exposure.

* For nose and shoulders, use zinc oxide for a complete physical block. (It comes in bright colors campers love.)

* Schedule outdoor activities before 10 a.m. and after 3 p.m.

* Use protection on cloudy days too. Nearly 80 percent of the sun's radiation can reach campers under an overcast sky.

* Use extra caution around reflective surfaces, such as water, sand or cement.

Other things to think about:

* Are campers taking medications that make them more sensitive to the sun?

* Radiation increases by 4 to 5 percent with every 1,000 feet above sea level.

* The closer you are to the equator, the stronger the sun's rays.

Does your camp offer family programs such as infant swim? Remember:

* Keep babies under 1 year of age out of the sun as much as possible.

* Don't use a sunscreen with an SPF of 4 or more on babies under 6 months old.

Products

The level and ingredients of sunscreen or sunblock are as important as using it.

The purpose of any sun product is to protect the skin against the harmful ultraviolet (UVB and UVA) rays of the sun. Sunburn is primarily caused by UVB rays, which are most intense during peak sunlight hours (10 a.m. to 3 p.m.). UVA rays also contribute to skin damage and are constant throughout the day and seasons.

The Sun Protection Factor (SPF) number on sunscreen tells you how much protection you get against sunburn. When you check labels, look for oxybenzone, which protects against UVB plus short UVA rays, and avobenzone which shields against long and short UVA rays.

Chemical sunscreens absorb UV radiation well but may cause allergic reactions. Physical sun blockers (products with titanium dioxide) stop and reflect rays like a mirror and are generally nonirritating.

Another product to consider is a Sun Alert Ultraviolet Warning Badge. The single-use, waterproof sticker is applied after sunscreen to skin or to clothing, and changes color to signal when to reapply sunscreen or stop exposure.

How long is too long?

The EPA, the National Weather Service and the National Oceanic and Atmospheric Administration have developed a UV index. The index predicts the level of IN radiation in each of 58 cities around the country and gauges it on a scale of 1 to 15 for the peak hours of sun. The lower the index number, the longer the allowed exposure time. If the UV index is 0-2, a person with sensitive skin (pale white to light brown in an unexposed area) can stay in the sun approximately 30 minutes before suffering serious damage. That same person can remain in the sun for 7.5 minutes at a UV index of 8, and for only 4 minutes when the UV index is 15. Are staff members aware of the sun's intensity each day?

Treatment

If all protection and prevention efforts fail, you will most likely have irritable staff and campers to treat.

For a minor sunburn, apply wet compresses of cool tap water three or four times a day. Compresses help to reduce inflammation and swelling. Promote healing with a nongreasy lotion or try a cooling after-sun gel. Drink plenty of water to replace fluids lost.

Make sure they know better next time.

References

Califano, J. (1994, June). Summer survival guide. American Health, (13) 5, 62.

Health Tip: sunburn precautions. (1990, June 19). Woman's Day, (53) 10, 152.

Oxnam, G. (1995, May). Environ-Alert. Sailing World, 12.

Sun-safety News. (1993, June). Parents, (68) 6, 170-175.

Lyme disease 

Many camps give staff an overview of Lyme disease, usually by having them watch a video. Basic knowledge and common sense go a long way in preventing this potential camp "injury."

Lyme disease appears in every state, but it is most prevalent in the Northeast, upper Midwest, and Pacific coastal states. According to the Center for Disease Control, in 1994 over 12,000 cases were reported nationally (a 50 percent increase from 1993).

Most of the time, Lyme disease is easily treated and does not progress to the chronic stage. It causes severe long-term effects in less than 10 percent of untreated patients.

How do you get it?

Lyme disease is caused by a spirochete, a corkscrew-shaped bacterium named Borrelia burgdorferi.

The disease is transmitted by the bite of a tick infected with the bacteria. The deer or black-legged tick (Ixodes scapularis) generally transmits the disease in the East and upper Midwest, and the western black-legged tick (Ixodes pacificus) in Pacific coastal states.

A tick's life cycle

An understanding of a tick's life cycle can make campers and staff more aware of what to look for.

Ticks are parasites and require a blood meal between each active stage of their life cycle. In each stage, the tick can become infected by its host. Once infected, it carries the infection to the next stage of life and is capable of infecting its next host.

The deer tick has a two-year life cycle. Adult females lay eggs (up to 3,000 at one time) in late spring. The eggs hatch into six-legged larvae about the size of a sand grain. Larvae usually seek the white-footed mouse or other small animals as hosts. By the following summer, they molt into nymphs.

Nymphs have eight legs and are about the size of a pin head. Common hosts are mice, birds, dogs, and humans. Infected nymphs cause most cases of Lyme disease because they are difficult to see or feel and are most active from May through July.

Adult ticks can also infect hosts. However, they are much larger (about the size of an apple seed) and are active primarily in late fall and early spring when fewer people are outdoors. In the Northeast, 15 to 30 percent of all deer ticks (50 percent of adult ticks) are infected. In most sections of the Northeast, an estimated 1 to 3 percent of people bitten by these ticks contract Lyme disease.

Prevention

* While walking in the woods, stay on trails and avoid brushing up against low bushes or tall grass.

* Ticks must attach to the skin and travel upwards. Tuck your pants into your socks or boots, and your shirt into your pants.

* Wear light-colored clothing so you can spot ticks more easily.

* Use insect repellents that effectively repel ticks. Use repellents containing DEET (on bare skin) or Permanone (to clothing only). Do not apply DEET to the hands or face of children.

Tick removal

A tick has to be attached to a human host for 24 to 36 hours before an infectious dose of B. burgdorferi will be transmitted. It is important to check carefully for ticks every day.

To remove ticks use a pair of fine-tipped tweezers. Grasp the tick as close to the skin as possible and slowly pull it straight out. The mouth parts of an adult tick might remain in the skin, but will not cause Lyme disease. After removal, apply an antiseptic such as alcohol or an antibiotic ointment. Do not apply mineral oil, petroleum jelly, heat, or anything else to remove the tick. Do not try to pull a tick off with your fingers as this may cause the tick to inject the bacteria into your body.

Symptoms

Although camps are not in the business of treating Lyme disease, early detection is important. Therefore, staff should be aware of the symptoms, particularly when there is an increased chance of exposure to ticks.

The first symptom is usually a rash. Flu-like symptoms, chills, fever and fatigue are often experienced also. Rashes within the first week are about 2 1/2 inches across. More than one rash may appear, and not always at the site of the tick bite. The red patches may be warm, but unlike sun rashes, are generally not painful or itchy. If you suspect Lyme disease, contact a physician as soon as possible.

References

American Lyme Disease Foundation, Inc. 1-800-876-LYME.

Kantor, F.S. (1994, Sept.). Disarming Lyme Disease. Scientific American, (271) 3, 34-39.

Practical Guide to the Ecology and Environmental Management of Lyme Disease. (1995). American Lyme Disease Foundation, Inc.