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COMMON PARASITES
OF MILITARY IMPORTANCE
             BY
KAPT MOHAMMAD BIN HARUN
HEALTH SERVICES DIVISION
         MAF HQ




                           1
CONTENTS
1. Introduction of Parasites
   a. Definition of Parasites.
   b. Types of Parasites.
   c. Classification of Parasites.
   d. Lifecycle of Parasites.
   e. Groups of Parasites.
2. List of Parasites of Medical Importance.
3. Common Parasites of Military Importance.
    a. Pathogenic Intestinal Parasites.
    b. Malaria Parasites.
    c. Blood flukes.
    d. Filarial Parasites
    e. Haemoflagelates parasites
     f. Arthropods of Military Importance.
4. Activities to Modify Risk of Infection.
                                              2
5. Conclusion.
DEFINITION OF PARASITES (1)




1. An animal or organism – lives on or in another organism and
   derives it nourishments there from.
2. An obligate parasite – A parasite which is completely
   dependent upon the host (organism which harbour parasite
   and is usually larger than the parasite).
3. A facultative parasite – An organism which is capable of living
   both freely and as a parasite.
(Last J.M, 4th Edition A Dictionary of Epidemiology)

                                                        3
DEFINITION OF PARASITES (2)


1. Parasites are organism that live inside humans or
   other organisms, who act as hosts.
2. They are dependents on their hosts – unable to
   produce food or energy for themselves.
3. Parasites are harmful to humans or other organism
   because:
   * they consume needed food
   * eat away body tissue and cells
   * eliminate toxics waste which makes people sick.
                                                4
TYPES OF PARASITES


1. Endoparasites - A parasites which lives within the
   body of the host. Example: Plasmodium vivax,
   Enterobuis vermicularis, Brugia malayi.


2. Ectoparasites - A parasites which lives on the
   outside of the host. Example: Fleas, Tsetse Flies
   and lice.

                                            5
CLASSIFICATION OF PARASITES

1. Parasites are classified according to the International
   Code of Zoological Nomenclature.
2. Major divisions of animal kingdom – Phylum, Class,
   Order, Family, Genus and Species.
3. Main criteria – morphology and genetic structure of
   parasites.
4. Each parasites is designated under the binomial (two
   names) system, genus and species: eg:
   Entamoeba histolytica.
                                              6
LIFECYCLE OF PARASITES

1. A parasite is dependent for its survival on transmissions
   from host to host.
2. Lifecycle patterns: simple - involving a single host.
                      : complex - involving 2 or more
                      intermediate hosts
3. Importance of lifecycle: diagnostic stage - diagnosis
                           : infective stage - initiates infection
                           : control program against parasites


                                                  7
GROUPS OF PARASITES

Parasites can be categorized into:
1. Protozoa. eg: Plamodium vivax, Entamoeba histolytica,
   Toxoplasma gondii, and Pneumocystis carinii.
2. Helminths. eg: Wuchereria bancrofti, Trichuris Trichiura,
   Enterobius and vermicularis.
3. Arthropods. Fleas, Tsetse Flies and lice.



                                               8
LIST OF PARASITES OF MEDICAL IMPORTANCE

1. Entamoeba histolytica    12. Taenia saginata
2. Naegleria fowleri        13. Hymenolepis nana
3. Acanthamoeba sp.         14. Schistosoma spp.
4. Giardia lamblia           15. Trichuris trichiura
5. Leishmania donovani       16. Hymenolepis nana
6. Trypanosoma cruzi         17. Enterobius vermicularis
7. Plasmudium falciparum     18. Brugia malayi
8. Plasmodium vivax           19. Ascaris lumbricoides
9. Plasmodium ovale           20. Tsetse Flies
10. Plasmodium malariae       21. Lice
11. Toxoplasma gondii         22. Sarcoptes scabiei
                                           9
COMMON PARASITES PARASITES
            OF MILITARY IMPORTANCE

1. Entamoeba histolytica         11. Leishmania sp.
2. Giardia lamblia                12. Trypanosoma sp.
3. Plasmodium falciparum         13. Soft Ticks
4. Plasmodium vivax               14. Tsetse Flies
5. Plasmodium ovale
6. Plasmodium malariae
7. Schistosoma sp. (Blood flukes)
8. Wuchereria bancrofti
9. Brugia malayi
10. Brugia timori
                                           10
PATHOGENIC INTESTINAL PARASITE – Introduction (1)
 Entamoeba hystolytica
 • Worldwide distribution with higher incidence in developing
   countries.
 • This amoeba is the human intestinal tract parasite.
 • Humans are primary host for this pathogen.
 • It is spread via the anal to oral route.
 • Acquired form contaminated water, or foodstuffs
   contaminated by untreated sewage.
           Entamoeba
           histolytica cyst             Entamoeba histolytica
           (infective stage)            trophozoites




                                                  11
Entamoeba hystolytica – The life cycle (2)




                                        12
Entamoeba histolytica – The Source of Infection in Military (3)


• In military environment - parasite usually acquired by soldiers
  from: drinking water contaminated with fecal material from
  infected person (river/lake),
• Food intake, contaminated with cysts of E.histolytica.
• This happen because: when soldiers are tired, not enough
  facility to cook, lack of knowledge about hygiene.




                                                          13
Entamoeba histolytica of Military Importance (4)
• The most pathogenic amoeba for humans (soldiers).
• Infectious diseases – can be spread(Waterborne & Food borne Ds).
• Worldwide distribution – military more expose to this parasite (jungle
  exercise, UN mission, war).
• E. histolytica causes amoebic dysentery – the trophozoites invade
  intestinal wall, leading to formation of amoebic ulcers: characterized
  by bloody stools and diarrhea accompanied by abdominal pain.
• Trophozoites penetrate the intestinal wall – spread to blood streams
  cause liver abcesses or spread to lungs and brain - resulting in
  death.
•




                                                        14
Giardia lamblia -Introduction (1)
• Giardia lamblia is a flagellate of world-wide distribution.
• It is the most common flagellate of the intestinal tract causing
  Giardiasis. Giardiasis is an infection of the upper small bowel, which
  may cause diarrhoea.
• G. lamblia is transmitted through ingestion of cysts in contaminated
  water or food.
• It is a major cause of waterborne intestinal disease.
• Has a high rate of person to person transmission.
• Groups at increased risk - food handlers, travelers to endemic areas
  (such as St Petersburg, Russia), hikers and campers who neglect to
  adequately purify their water.




                                                         15
Giardia lamblia – The Lifecycle (2)




                                      16
Giardia lamblia – The Source of Infection in Military (3)

• The source of infection is from the contaminated water with
  cysts of Giardia lamblia which can be ingested from the river, lake,
  pond or from the well in rural area.
• The other sources of infection are from food or dirty hands
  which contaminated with the cysts of G. lamblia.
• Giardiasis is the waterborne disease – military may expose to this
  disease because the attitude of themselves who neglect to
  adequately purify their water – lack of hygiene knowledge, shortage
  of time in the war, lack of facilities to cook their food or water .
• The military are always expose to the endemic area. Going for
  UN mission around the world. Military traveling to other countries
  and get infection to this parasite - called travelers disease.



                                                          17
Giardia lamblia of Military Importance (4)

• Why the parasites are importance?
• Parasites can cause many causalities in military. Operations
  can’t be execute with diarrhoeal soldiers.
• Humans are the only important reservoir of the infection .
  Parasites loves soldiers with attitude of neglect the hygiene
  especially in the jungle or rural area.
• G. lamblia has a high rate of person to person transmission.
• The main symptoms of disease are abdominal pain, flatulence, and
  episodic diarrhoea with malabsorptive syndrome (steatorrhea) and
  periodical soreness in severe cases.
• The parasites can be a disaster to military in the endemic area .
  Many soldier get sick and can’t going for war.      18
Malarial Parasites -Introduction (1)
    • Malarial parasites are known as Plasmodium spp. which

     cause the important tropical disease, Malaria. Malaria
CASEVAC/MEDEVAC with 1-3 million deaths per year caused by
      is a global problem
via air ambulance
    falciparum malaria.
   • Plasmodium sp. are sporozoan obligate intracellular
Exercise Planning : 2 Scenarios
  1. parasites of liver Burn blood cells - blood parasites.
       Scenario 1: and red
   • Scenario 2: Appendicitis
  2. 4 species which infect both humans and animals:
        • Plasmodium falciparum
        • Plasmodium vivax
        • Plasmodium ovale
        • Plasmodium malariae

                                                    19
Malarial Parasites – The life cycle   (2)
Schema of the Life Cycle of Malaria




                                            20
Malarial Parasites – The source of Infection and
                    Transmission in Military (3)
  • Jungle is the main source of malarial parasites infection- ¾ of
  Malaysia covered by jungle.
 • The humidity, moderate temperature and clear water in the
 tropical rain forests
CASEVAC/MEDEVAC can enhance the survival of the parasites.
via The Anopheles
  • air ambulance   mosquitoes is the main vector of these parasites.
 • Why soldiers are the easiest group
Exercise Planning : 2 Scenariosacquired the infection?
  1. working environment ; in the jungle - expose to mosquitoes
   - Scenario 1: Burn
  2.bites.
        Scenario 2: Appendicitis
   - lack of facility of battling the malaria - war, jungle exercise.
   - lack of knowledge of anti-malaria drugs - chemoprophylaxis.
 • The transmission of parasites requires two hosts,
 a. Intermediate invertebrate host (vector): Anopheles mosquitoes.
 b. Definitive vertebrate host: Humans (soldiers)
                        Female anopheline mosquito   21
Malarial Parasites of Military Importance (4)
 • The parasite cause the most important communicable disease
 in the field for Malaysian soldier.
 • Malarial parasites has resulted in large number of casualties
CASEVAC/MEDEVAC
via air ambulance in
  when operating      endemic area. Eg; Many causalities in US
 Forces when deployments in Vietnam, Africa, Middle East & Korea -
 weaken the fighting strength.
Exercise Planning : 2 Scenarios
 • 1. Scenario 1: Burn are resistant to anti malarial drug -
   Certain parasites species
 could be one of the enemy during war! - eg; P.falciparum is
   2. Scenario 2: Appendicitis
 resistant to chloroquine and other antimalarial drugs.
 • Parasites attack still become disaster and psychological
 stress in most military troops – no vaccine available to cure & can
 cause to death.
 • Parasites available for research in term of prevention by military.

                                                      22
Blood Flukes(Schistosoma sp.) – Introduction (1)

    • The Schistosoma sp. are blood trematodes.
    • There are 5 species of Schistosoma:
    • S. mansoni, S. haematobium, S. japonicum, S. mekongi, S.
    intercalatum. All with similar life cycle involving freshwater snails.
    • Distribution of parasites – S. haematobium (Africa, M/East,
    India), S.mansoni (Africa, Brazil, Surinam, Venezuela, Caribbean
    islands), S.japonicum (China, Philippines), S. mekongi (Laos,
    Cambodia), S.intercalatum (Central Africa).
    • Only trematodes that live in the blood stream of warm
    blooded hosts.
    • Have two hosts definitive host (human) and intermediate
    (snail).
    • Over 200 million people are infected and over at least 75
    countries with 500 million or more exposed to infection.
    • The disease caused is called Schistosomiasis or Bilharzia.
                                                               23
Schistosoma sp. – The Lifecycle (2)




                                      24
Schistosoma sp. – Source of Parasites
             infection (3)
     How people acquired the
     parasites infection – contact
     with water in the endemic area




                              25
Schistosoma sp. Source of Infection in Military (4)
• Source of infection from the river, lake, valley or any
place
 in the jungle with swampy area where snails can be
found.
• Military can easily acquired this parasites infection -
working environment ; always contact with water
during exercise or in war.
• In the PBB mission especially in Africa and middle
East ; endemic area – military can easily acquired
infection.
• The infective stage of parasite is cercaria can
penetrate the military body through skin – results of
contact with water where the snails are present.

                                                    26
Schistosoma sp. of Military Importance (4)


• The parasites has resulted many casualties when operating in
endemic area.
• Parasites attack can become psychological stress in most
military troops.
• Military more expose to the source of infection – river, lake,
swampy area with present of snails.
• Parasites available for research in term of prevention by military.




                                                      27
Filarial Parasites – Introduction (1)
     • It is estimated that over 140 million people are infected with one
     or more species of filaria.
     • Parasites Inhabit a range of locations within the body; lymph glands,
     deep connective tissue, subcutaneous tissues or mesenteries. Invasions of
     these tissues cause typical symptom of a human filarial infection. In some
     cases these result in fleshy deformities known as elephantiasis.
     • There are 5 commonly pathogenic species infecting man:
     •Wuchereria bancrofti, Brugia malayi, Brugia timori,
     Onchocerca volvulus and Loa loa.
ns




     •W. bancrofti is distributed throughout the tropical regions of Asia, Africa, China, the Pacific and
     isolated locations in the Americas.
                                                                                        28
     •Endemic range of Brugia malayi is confined to South and South-East Asia from India in the west to
     Korea in the east
Filarial Parasites – The Lifecycles (2)




Culcicine           Anopheline     Aedes polynesiensis




                                                         29
Filarial Parasite – Wuchereria bancrofti (3)




•Wuchereria bancrofti is a nematode causing lymphatic filariasis
throughout the tropics and subtropics.

•Transmitted by the mosquito,Culex quinquefasciatus, Anopheles
gambiae and Anopheles funestus.

•Humans are the only known reservoir host of W. bancrofti.
•Infection rates in some communities in East Africa exceed 30% of
adults causing revolting swellings of the legs or genital system,
known as elephantiasis in man.
•The adult worm occurs in tightly coiled nodular masses in the major
                                                        30
lymphatic ducts.
Filarial Parasite – Brugia malayi (4)




• Brugia malayi is a nematode causing lymphatic filariasis in
South East Asia.
• Two strain of B. malayi:
• 1. Nocturnal periodic strain – Asia, microfilariae highest
concentration between hours 10pm and 2 am.
• 2. Subperiodic strain – Malaysia, Indonesia and Philippines,
microfilariae detected between noon and 8pm.
• Nocturnally periodic Brugian filariasis – transmitted by various
Anopheles sp. and Masonia mosquitoes – bites during night.
• Nocturnal sub-periodic B.malayi – transmitted exclusively by
Mansonia sp.
Mansonoa bonneae are important vectors in Malaysia –
                                               31
breeding in swamp forest and bitting by night.
Filarial Parasites – The source of infection in military (5)
• Military can acquired this infection from swampy tropics
and subtropics forests. These the major habitats of the
parasites and the their vectors (Anopheles, Culex and
Mansonia mosquitoes).
Eg: Mansonoa bonneae are important vectors in Malaysia –
breeding in swamp forest and bitting by night.
• UN and other military mission to Africa, South-east Asia,
Indonesia, Philippines, Timor Timor, Vietnam are the other
sources of infection that military can acquired of these
parasites.
 Eg: During Vietnam war, many American soldiers infected by
the parasites including filarial parasite – soldiers had been
quarantine and not allow to donate their blood.
The same practice also in Malaysia - Soldiers going back from
mission are quarantine.
                                                      32
Filarial Parasites of Military Importance (6)
• The infection of these parasites can cause many causalities in
military. Parasites Inhabit a range of locations within the body; lymph
glands, deep connective tissue, subcutaneous tissues or mesenteries. In
some cases these result in fleshy deformities known as elephantiasis.
• During Viet Nam War thousands of returning US troops carried the
parasites - induced disease. Nearly 54,000 soldiers returning from Operation
Dessert Storm carried parasites disease including this parasite!
• Military are the troops on the move, especially by sending them to
the mission. This means military have great expose to this parasite’s
infection in other countries.
• This parasites can be spread easily by the mosquitoes vector and can
cause disaster and psychological stress to military. Patients are
asymptomatic and the attack are drastic!
• The parasites can be transmitted from one person infected to others
by the mosquitoes vectors. Parasites can be spread and cannot be
controlled easily!
• The parasites are useful to military because it can be used as
experiment organisms for R & D by means of the prevention to parasite
disease.
                                                            33
Haemoflagellates parasites (Leishmania sp.)
                              Intoduction (1)




•Two genera are medical importance: Leishmania sp. and
Trypanosoma sp.
• Leishmania sp is endemic in many parts of Africa, Asia and
South America. It is transmitted by Phlebotomus species,
Sandfly.
• 7 species infecting human: L.donovani complex, L.major, L.
tropica, L. aethiopica, L. mexicana complex, L. braziliensis
complex, L. peruviana
•Leishmaniasis is a vector-borne parasitic disease endemic in parts of the
tropics, subtropics, and Southern Europe. The World Health Organization
                                                                  34
estimates that 1.5 million cases of CL and 500,000 cases of visceral
leishmaniasis (VL) occur each year.
Haemoflagellates parasites (Leishmania sp.)
                        Intoduction (2)

• They cause diseases collectively known as Leishmaniasis. 3 types of
Leishmaniasis : visceral, cutaneous and mucocutaneous leishmaniasis.

• Visceral leishmaniasis – sometimes known as kala-azar –caused by L.
donovani complex; L.donovani, L.donovani infantum and L. donovani
chagasi.

• Cutaneous leishmaniasis – a vector- borne parasitic disease, is a risk
for military personnel who travel to tropics, subtropics and Southern
Europe where disease is endemic. It caused by L.tropica, L.major and
L. aethiopica, L.mexicana.
• Mucocutaneous leishmania – L. braziliensis.
                                                        35
Haemoflagellates parasites (Leishmania sp) – The Lifecycles (3)




                                                      36
Haemoflagellates parasites (Trypanosoma sp.)
                           Introduction (4)
•3 species of haemoflagellates Trypanosoma are responsible
for disease in humans:
• T. rhodesiense & T. gambiense
• Salivarian trypanosomes – parasites complete dev. in salivary
system of vector.
-disease known as Trypanosomiasis. (sleeping sickness in Africa).
- Distribution of parasites – T. rhodesiense(E. Africa), T. gambiense
(W. Africa).
-Transmitted of trypomastigotes by bitting flies of Genus Glossina
(tsetse fly).




                                                           37
Haemoflagellates parasites Trypanosoma sp. – Introduction (5)
   Trypanosoma sp.
                                       Two form of trypomastigotes
                                       of T.rhodesiense & T.gambiense


                                       The infective stage is
                                       trypomastigotes which can
                                       invade the lymphatic tissue,
                                       heart, various organs- organs
                                       enlarge. Infection of central
                                       nervous system – leading to
                                       coma and death within several
                                       years.



                                                       38
Haemoflagellates parasites – Introduction (6)
• Trypanosoma cruzi
• Stercorian trypanosomes – complete their dev. in posterior
region of vector, infective forms appear in the insects faeces.
• This the aetiological agent of South and Central America.
• Cause a disease known as Chagas’ disease.
•The vectors are the blood sucking bug of the genera Triatoma,
Panstroglus, Rhodnius.
• Multiplication of T.cruzi at site of infection can produce inflamed
swelling – chagoma. Oedema of upper & lower eyelid may occur
along with conjuctivitis – Ramona’s sign.
•




                                                                   Insect Triatominae
                                                                      39
    T. Cruzi in blood sample   Multiplication of T. cruzi in the
                               muscle                              – Kissing bug
Haemoflagellates parasites (Trypanosoma sp.)
                The Lifecycles (7)




Generalised life cycle of the Trypanosoma sp. which
cause African trypnaosomiasis.                  40
Haemoflagellates parasites -The source of infection in Military (8)

    1. Military acquired the infection of these parasites fm the
    endemic area in many parts of Africa, Asia and South
    America.
    2. All forms of infection starts when a female sandfly
    (Phlebotomus sp.) takes a blood meal from an infected host.
    The countries with dessert eg; (Iraq, Kuwait and Afghanistan)
    usually the habitat for the sandfly, is also the main source for
    the infection this parasites.




                                                         41
Haemoflagellates parasites of Military Importance (9)

1. The parasites, cause many causalities to the soldiers.
   Eg: There are 22 cases of chronic skin lesions of CL in US
   military personnel deployed during 2002-2003 to Afghanistan, Iraq
   and Kuwait.

2. Parasites are easily transmitted from one infected
   soldier to others by sandfly (vector-borne parasitic
   disease) - is a risk for military personnel who travel to the
   endemic area.

3. The World Health Organization estimates that 1.5 million
   cases of CL and 500,000 cases of VL occur each year –
   This amount of cases also can give bad impact to military.




                                                        42
Arthropods as an Ectoparasites - Introduction (1)

1. The 2 most important classes of Arthropods are Insecta
   and Arachnida.
2. Insecta – mosquitoes, flies, bugs, fleas.
    Arachnida – ticks, mites, spiders and scorpions.
3. Arthropods may transmit disease by following methods:
•    Mechanical transmission : diseases producing agent does not
    multiply in the arthropod. eg: Salmonella trasmission by the
    house fly.
•   Biological transmission – arthropod is an integral part of the life
    cycle of parasites; Wuchereria bancrofti and Plasmodium sp in
    mosquitoes.
    (Zaman V. and Keong A.L, 3rd Edition Handbook of Medical Parasitology)

                                                                    43
Arthropods of Military Importance -    (2)


1. Soft Ticks
• Class: Arachnida.
• Genus: Ornithodoros.
•   Worldwide distribution: Europe, Africa, Asia and the Americas.
• Life cycles: hemimetabolous, eggs hatching six legged
  larvae – moult to eight legged nymphs. Larval instars requiring a
    blood meal to proceed for life cycle.
•   Disease – the most important disease is tick borne relapsing
    fever. Which occurs world wide and is spread by spirochaete
    infected Ornithodoros.




                                                           44
Arthropods of Military Importance -      (3)

2. Mosquitoes
• Class: Insecta
• Order: Diptera
• Genus: Anopheles, Culex, Aedes, Mansonia.
•   Mosquitoes are the blood feeders (ectoparasites).
•   Also as vector to certain disease (Vectorborne disease).
•   Anopheles sp – vector for malaria parasites.
•   Culex sp – vectors for Wuchreraria bancrofti, Japanese
    Encephalitis.
•   Aedes sp a - vectors of Bancrofti filariasis and arboviruses such
    as yellow fever and dengue.
•   Mansonia sp – Brugia malayi.
                                                          45
Arthropods of Military Importance -      (4)


3. Tsetse Flies
• Class: Insecta
• Order: Diptera
• Genus: Glossina
•   Tsetse flies are the blood feeders (ectoparasites) to cows and
    humans.
•   Also as vector to certain disease (Vectorborne disease).
•   Tsetse flies are Vectors for African sleeping sickness (T.
    rhodesiense and T.gambiense).




                                                          46
ACTIVITIES TO MODIFY RISK OF INFECTION
1. Foodborne And Water Borne Infection
• Avoid undercooked food, non bottled
  beverage sand non pasteurized dairy
  products.
• Avoid consuming food sold by street vendors
• Avoid salads and raw seafood
• Peel fruit
• Used bottled water for drinking, making ice
  cubes and brushing teeth.
• Wash hands with soap and water or alcohol
  and sanitizers before each meal.
• Carbonated beverages are safe.
• Vaccines are available for hepatitis A and
  typhoid.
                                                47
ACTIVITIES TO MODIFY RISK OF INFECTION

2. Vectorborne Infection
• Wear the uniform with the pants tucked into
  boots, sleeves worn down and undershirt
  tucked into the pants.
• Minimize outdoor exposure during periods of
  insect activity.
• Use 33% extended-duration DEET.
• Impregnate uniform with permethrin.
• Used insect netting sprayed with permethrin
• Check for ticks regularly.
• Use malaria chemo prophylaxis if indicated.
• Vaccines are available for Yellow fever and
  Japanese B encephalitis.
                                           48
ACTIVITIES TO MODIFY RISK OF INFECTION

3. Respiratory infection
• Wash hands regularly or use alcohol hand
  gel.
• Avoid hand contact to the face.
• Do not share drinking or eating utensils.
• Use appropriate control measures when
  dealing with infected or potentially infected
  individuals
• Submit to pre-and post deployment tuberculin
  skin testing.
• Vaccines are available for measles, mumps,
  rubella, diphtheria, pertussis,meningococcus
  influenza, varicella, smallpox and anthrax.

                                              49
ACTIVITIES TO MODIFY RISK OF INFECTION

4. Zoonotic infection
• Do not pet or feed animals (especially dogs).
• Avoid direct contact with animals or animal
  products.
• Do not stray animals as pets.
• Use appropriate control measures when
  dealing with infected or potentially infected
  individuals
• Vaccines is available for rabbies.
• Vaccines are available for measles, mumps,
  rubella, diphtheria, pertussis,meningococcus
  influenza, varicella, smallpox and anthrax.


                                              50
ACTIVITIES TO MODIFY RISK OF INFECTION

5. Water exposure
• Avoid swimming in fresh water, especially if it
  is stagnant or slowly flowing
• Doxycycline chemo prophylaxis available.
6. Soil exposure
• Water toe covered footwear.
• Avoid sitting in sandy areas with uncovered
  skin.
• Avoid ingesting soil.
• Vaccine is available for tetanus.



                                             51
CONCLUSION


1. Parasites are the organism that derives the
   lives on or in another organism and derives it
   nourishments from their host.
2. Parasites can cause many casualty in the
   military operation.
3. Parasites have their own importance whether
   in medical or in military.
4. The effective prevention of parasites infection
   can conserve the military fighting strength.
5. Soldiers must practice all the time the
   activities to modify the risk of infection.
                                           52
QUESTIONS
  AND
 ANSWER

            53

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Common parasites of military importance

  • 1. COMMON PARASITES OF MILITARY IMPORTANCE BY KAPT MOHAMMAD BIN HARUN HEALTH SERVICES DIVISION MAF HQ 1
  • 2. CONTENTS 1. Introduction of Parasites a. Definition of Parasites. b. Types of Parasites. c. Classification of Parasites. d. Lifecycle of Parasites. e. Groups of Parasites. 2. List of Parasites of Medical Importance. 3. Common Parasites of Military Importance. a. Pathogenic Intestinal Parasites. b. Malaria Parasites. c. Blood flukes. d. Filarial Parasites e. Haemoflagelates parasites f. Arthropods of Military Importance. 4. Activities to Modify Risk of Infection. 2 5. Conclusion.
  • 3. DEFINITION OF PARASITES (1) 1. An animal or organism – lives on or in another organism and derives it nourishments there from. 2. An obligate parasite – A parasite which is completely dependent upon the host (organism which harbour parasite and is usually larger than the parasite). 3. A facultative parasite – An organism which is capable of living both freely and as a parasite. (Last J.M, 4th Edition A Dictionary of Epidemiology) 3
  • 4. DEFINITION OF PARASITES (2) 1. Parasites are organism that live inside humans or other organisms, who act as hosts. 2. They are dependents on their hosts – unable to produce food or energy for themselves. 3. Parasites are harmful to humans or other organism because: * they consume needed food * eat away body tissue and cells * eliminate toxics waste which makes people sick. 4
  • 5. TYPES OF PARASITES 1. Endoparasites - A parasites which lives within the body of the host. Example: Plasmodium vivax, Enterobuis vermicularis, Brugia malayi. 2. Ectoparasites - A parasites which lives on the outside of the host. Example: Fleas, Tsetse Flies and lice. 5
  • 6. CLASSIFICATION OF PARASITES 1. Parasites are classified according to the International Code of Zoological Nomenclature. 2. Major divisions of animal kingdom – Phylum, Class, Order, Family, Genus and Species. 3. Main criteria – morphology and genetic structure of parasites. 4. Each parasites is designated under the binomial (two names) system, genus and species: eg: Entamoeba histolytica. 6
  • 7. LIFECYCLE OF PARASITES 1. A parasite is dependent for its survival on transmissions from host to host. 2. Lifecycle patterns: simple - involving a single host. : complex - involving 2 or more intermediate hosts 3. Importance of lifecycle: diagnostic stage - diagnosis : infective stage - initiates infection : control program against parasites 7
  • 8. GROUPS OF PARASITES Parasites can be categorized into: 1. Protozoa. eg: Plamodium vivax, Entamoeba histolytica, Toxoplasma gondii, and Pneumocystis carinii. 2. Helminths. eg: Wuchereria bancrofti, Trichuris Trichiura, Enterobius and vermicularis. 3. Arthropods. Fleas, Tsetse Flies and lice. 8
  • 9. LIST OF PARASITES OF MEDICAL IMPORTANCE 1. Entamoeba histolytica 12. Taenia saginata 2. Naegleria fowleri 13. Hymenolepis nana 3. Acanthamoeba sp. 14. Schistosoma spp. 4. Giardia lamblia 15. Trichuris trichiura 5. Leishmania donovani 16. Hymenolepis nana 6. Trypanosoma cruzi 17. Enterobius vermicularis 7. Plasmudium falciparum 18. Brugia malayi 8. Plasmodium vivax 19. Ascaris lumbricoides 9. Plasmodium ovale 20. Tsetse Flies 10. Plasmodium malariae 21. Lice 11. Toxoplasma gondii 22. Sarcoptes scabiei 9
  • 10. COMMON PARASITES PARASITES OF MILITARY IMPORTANCE 1. Entamoeba histolytica 11. Leishmania sp. 2. Giardia lamblia 12. Trypanosoma sp. 3. Plasmodium falciparum 13. Soft Ticks 4. Plasmodium vivax 14. Tsetse Flies 5. Plasmodium ovale 6. Plasmodium malariae 7. Schistosoma sp. (Blood flukes) 8. Wuchereria bancrofti 9. Brugia malayi 10. Brugia timori 10
  • 11. PATHOGENIC INTESTINAL PARASITE – Introduction (1) Entamoeba hystolytica • Worldwide distribution with higher incidence in developing countries. • This amoeba is the human intestinal tract parasite. • Humans are primary host for this pathogen. • It is spread via the anal to oral route. • Acquired form contaminated water, or foodstuffs contaminated by untreated sewage. Entamoeba histolytica cyst Entamoeba histolytica (infective stage) trophozoites 11
  • 12. Entamoeba hystolytica – The life cycle (2) 12
  • 13. Entamoeba histolytica – The Source of Infection in Military (3) • In military environment - parasite usually acquired by soldiers from: drinking water contaminated with fecal material from infected person (river/lake), • Food intake, contaminated with cysts of E.histolytica. • This happen because: when soldiers are tired, not enough facility to cook, lack of knowledge about hygiene. 13
  • 14. Entamoeba histolytica of Military Importance (4) • The most pathogenic amoeba for humans (soldiers). • Infectious diseases – can be spread(Waterborne & Food borne Ds). • Worldwide distribution – military more expose to this parasite (jungle exercise, UN mission, war). • E. histolytica causes amoebic dysentery – the trophozoites invade intestinal wall, leading to formation of amoebic ulcers: characterized by bloody stools and diarrhea accompanied by abdominal pain. • Trophozoites penetrate the intestinal wall – spread to blood streams cause liver abcesses or spread to lungs and brain - resulting in death. • 14
  • 15. Giardia lamblia -Introduction (1) • Giardia lamblia is a flagellate of world-wide distribution. • It is the most common flagellate of the intestinal tract causing Giardiasis. Giardiasis is an infection of the upper small bowel, which may cause diarrhoea. • G. lamblia is transmitted through ingestion of cysts in contaminated water or food. • It is a major cause of waterborne intestinal disease. • Has a high rate of person to person transmission. • Groups at increased risk - food handlers, travelers to endemic areas (such as St Petersburg, Russia), hikers and campers who neglect to adequately purify their water. 15
  • 16. Giardia lamblia – The Lifecycle (2) 16
  • 17. Giardia lamblia – The Source of Infection in Military (3) • The source of infection is from the contaminated water with cysts of Giardia lamblia which can be ingested from the river, lake, pond or from the well in rural area. • The other sources of infection are from food or dirty hands which contaminated with the cysts of G. lamblia. • Giardiasis is the waterborne disease – military may expose to this disease because the attitude of themselves who neglect to adequately purify their water – lack of hygiene knowledge, shortage of time in the war, lack of facilities to cook their food or water . • The military are always expose to the endemic area. Going for UN mission around the world. Military traveling to other countries and get infection to this parasite - called travelers disease. 17
  • 18. Giardia lamblia of Military Importance (4) • Why the parasites are importance? • Parasites can cause many causalities in military. Operations can’t be execute with diarrhoeal soldiers. • Humans are the only important reservoir of the infection . Parasites loves soldiers with attitude of neglect the hygiene especially in the jungle or rural area. • G. lamblia has a high rate of person to person transmission. • The main symptoms of disease are abdominal pain, flatulence, and episodic diarrhoea with malabsorptive syndrome (steatorrhea) and periodical soreness in severe cases. • The parasites can be a disaster to military in the endemic area . Many soldier get sick and can’t going for war. 18
  • 19. Malarial Parasites -Introduction (1) • Malarial parasites are known as Plasmodium spp. which cause the important tropical disease, Malaria. Malaria CASEVAC/MEDEVAC with 1-3 million deaths per year caused by is a global problem via air ambulance falciparum malaria. • Plasmodium sp. are sporozoan obligate intracellular Exercise Planning : 2 Scenarios 1. parasites of liver Burn blood cells - blood parasites. Scenario 1: and red • Scenario 2: Appendicitis 2. 4 species which infect both humans and animals: • Plasmodium falciparum • Plasmodium vivax • Plasmodium ovale • Plasmodium malariae 19
  • 20. Malarial Parasites – The life cycle (2) Schema of the Life Cycle of Malaria 20
  • 21. Malarial Parasites – The source of Infection and Transmission in Military (3) • Jungle is the main source of malarial parasites infection- ¾ of Malaysia covered by jungle. • The humidity, moderate temperature and clear water in the tropical rain forests CASEVAC/MEDEVAC can enhance the survival of the parasites. via The Anopheles • air ambulance mosquitoes is the main vector of these parasites. • Why soldiers are the easiest group Exercise Planning : 2 Scenariosacquired the infection? 1. working environment ; in the jungle - expose to mosquitoes - Scenario 1: Burn 2.bites. Scenario 2: Appendicitis - lack of facility of battling the malaria - war, jungle exercise. - lack of knowledge of anti-malaria drugs - chemoprophylaxis. • The transmission of parasites requires two hosts, a. Intermediate invertebrate host (vector): Anopheles mosquitoes. b. Definitive vertebrate host: Humans (soldiers) Female anopheline mosquito 21
  • 22. Malarial Parasites of Military Importance (4) • The parasite cause the most important communicable disease in the field for Malaysian soldier. • Malarial parasites has resulted in large number of casualties CASEVAC/MEDEVAC via air ambulance in when operating endemic area. Eg; Many causalities in US Forces when deployments in Vietnam, Africa, Middle East & Korea - weaken the fighting strength. Exercise Planning : 2 Scenarios • 1. Scenario 1: Burn are resistant to anti malarial drug - Certain parasites species could be one of the enemy during war! - eg; P.falciparum is 2. Scenario 2: Appendicitis resistant to chloroquine and other antimalarial drugs. • Parasites attack still become disaster and psychological stress in most military troops – no vaccine available to cure & can cause to death. • Parasites available for research in term of prevention by military. 22
  • 23. Blood Flukes(Schistosoma sp.) – Introduction (1) • The Schistosoma sp. are blood trematodes. • There are 5 species of Schistosoma: • S. mansoni, S. haematobium, S. japonicum, S. mekongi, S. intercalatum. All with similar life cycle involving freshwater snails. • Distribution of parasites – S. haematobium (Africa, M/East, India), S.mansoni (Africa, Brazil, Surinam, Venezuela, Caribbean islands), S.japonicum (China, Philippines), S. mekongi (Laos, Cambodia), S.intercalatum (Central Africa). • Only trematodes that live in the blood stream of warm blooded hosts. • Have two hosts definitive host (human) and intermediate (snail). • Over 200 million people are infected and over at least 75 countries with 500 million or more exposed to infection. • The disease caused is called Schistosomiasis or Bilharzia. 23
  • 24. Schistosoma sp. – The Lifecycle (2) 24
  • 25. Schistosoma sp. – Source of Parasites infection (3) How people acquired the parasites infection – contact with water in the endemic area 25
  • 26. Schistosoma sp. Source of Infection in Military (4) • Source of infection from the river, lake, valley or any place in the jungle with swampy area where snails can be found. • Military can easily acquired this parasites infection - working environment ; always contact with water during exercise or in war. • In the PBB mission especially in Africa and middle East ; endemic area – military can easily acquired infection. • The infective stage of parasite is cercaria can penetrate the military body through skin – results of contact with water where the snails are present. 26
  • 27. Schistosoma sp. of Military Importance (4) • The parasites has resulted many casualties when operating in endemic area. • Parasites attack can become psychological stress in most military troops. • Military more expose to the source of infection – river, lake, swampy area with present of snails. • Parasites available for research in term of prevention by military. 27
  • 28. Filarial Parasites – Introduction (1) • It is estimated that over 140 million people are infected with one or more species of filaria. • Parasites Inhabit a range of locations within the body; lymph glands, deep connective tissue, subcutaneous tissues or mesenteries. Invasions of these tissues cause typical symptom of a human filarial infection. In some cases these result in fleshy deformities known as elephantiasis. • There are 5 commonly pathogenic species infecting man: •Wuchereria bancrofti, Brugia malayi, Brugia timori, Onchocerca volvulus and Loa loa. ns •W. bancrofti is distributed throughout the tropical regions of Asia, Africa, China, the Pacific and isolated locations in the Americas. 28 •Endemic range of Brugia malayi is confined to South and South-East Asia from India in the west to Korea in the east
  • 29. Filarial Parasites – The Lifecycles (2) Culcicine Anopheline Aedes polynesiensis 29
  • 30. Filarial Parasite – Wuchereria bancrofti (3) •Wuchereria bancrofti is a nematode causing lymphatic filariasis throughout the tropics and subtropics. •Transmitted by the mosquito,Culex quinquefasciatus, Anopheles gambiae and Anopheles funestus. •Humans are the only known reservoir host of W. bancrofti. •Infection rates in some communities in East Africa exceed 30% of adults causing revolting swellings of the legs or genital system, known as elephantiasis in man. •The adult worm occurs in tightly coiled nodular masses in the major 30 lymphatic ducts.
  • 31. Filarial Parasite – Brugia malayi (4) • Brugia malayi is a nematode causing lymphatic filariasis in South East Asia. • Two strain of B. malayi: • 1. Nocturnal periodic strain – Asia, microfilariae highest concentration between hours 10pm and 2 am. • 2. Subperiodic strain – Malaysia, Indonesia and Philippines, microfilariae detected between noon and 8pm. • Nocturnally periodic Brugian filariasis – transmitted by various Anopheles sp. and Masonia mosquitoes – bites during night. • Nocturnal sub-periodic B.malayi – transmitted exclusively by Mansonia sp. Mansonoa bonneae are important vectors in Malaysia – 31 breeding in swamp forest and bitting by night.
  • 32. Filarial Parasites – The source of infection in military (5) • Military can acquired this infection from swampy tropics and subtropics forests. These the major habitats of the parasites and the their vectors (Anopheles, Culex and Mansonia mosquitoes). Eg: Mansonoa bonneae are important vectors in Malaysia – breeding in swamp forest and bitting by night. • UN and other military mission to Africa, South-east Asia, Indonesia, Philippines, Timor Timor, Vietnam are the other sources of infection that military can acquired of these parasites. Eg: During Vietnam war, many American soldiers infected by the parasites including filarial parasite – soldiers had been quarantine and not allow to donate their blood. The same practice also in Malaysia - Soldiers going back from mission are quarantine. 32
  • 33. Filarial Parasites of Military Importance (6) • The infection of these parasites can cause many causalities in military. Parasites Inhabit a range of locations within the body; lymph glands, deep connective tissue, subcutaneous tissues or mesenteries. In some cases these result in fleshy deformities known as elephantiasis. • During Viet Nam War thousands of returning US troops carried the parasites - induced disease. Nearly 54,000 soldiers returning from Operation Dessert Storm carried parasites disease including this parasite! • Military are the troops on the move, especially by sending them to the mission. This means military have great expose to this parasite’s infection in other countries. • This parasites can be spread easily by the mosquitoes vector and can cause disaster and psychological stress to military. Patients are asymptomatic and the attack are drastic! • The parasites can be transmitted from one person infected to others by the mosquitoes vectors. Parasites can be spread and cannot be controlled easily! • The parasites are useful to military because it can be used as experiment organisms for R & D by means of the prevention to parasite disease. 33
  • 34. Haemoflagellates parasites (Leishmania sp.) Intoduction (1) •Two genera are medical importance: Leishmania sp. and Trypanosoma sp. • Leishmania sp is endemic in many parts of Africa, Asia and South America. It is transmitted by Phlebotomus species, Sandfly. • 7 species infecting human: L.donovani complex, L.major, L. tropica, L. aethiopica, L. mexicana complex, L. braziliensis complex, L. peruviana •Leishmaniasis is a vector-borne parasitic disease endemic in parts of the tropics, subtropics, and Southern Europe. The World Health Organization 34 estimates that 1.5 million cases of CL and 500,000 cases of visceral leishmaniasis (VL) occur each year.
  • 35. Haemoflagellates parasites (Leishmania sp.) Intoduction (2) • They cause diseases collectively known as Leishmaniasis. 3 types of Leishmaniasis : visceral, cutaneous and mucocutaneous leishmaniasis. • Visceral leishmaniasis – sometimes known as kala-azar –caused by L. donovani complex; L.donovani, L.donovani infantum and L. donovani chagasi. • Cutaneous leishmaniasis – a vector- borne parasitic disease, is a risk for military personnel who travel to tropics, subtropics and Southern Europe where disease is endemic. It caused by L.tropica, L.major and L. aethiopica, L.mexicana. • Mucocutaneous leishmania – L. braziliensis. 35
  • 36. Haemoflagellates parasites (Leishmania sp) – The Lifecycles (3) 36
  • 37. Haemoflagellates parasites (Trypanosoma sp.) Introduction (4) •3 species of haemoflagellates Trypanosoma are responsible for disease in humans: • T. rhodesiense & T. gambiense • Salivarian trypanosomes – parasites complete dev. in salivary system of vector. -disease known as Trypanosomiasis. (sleeping sickness in Africa). - Distribution of parasites – T. rhodesiense(E. Africa), T. gambiense (W. Africa). -Transmitted of trypomastigotes by bitting flies of Genus Glossina (tsetse fly). 37
  • 38. Haemoflagellates parasites Trypanosoma sp. – Introduction (5) Trypanosoma sp. Two form of trypomastigotes of T.rhodesiense & T.gambiense The infective stage is trypomastigotes which can invade the lymphatic tissue, heart, various organs- organs enlarge. Infection of central nervous system – leading to coma and death within several years. 38
  • 39. Haemoflagellates parasites – Introduction (6) • Trypanosoma cruzi • Stercorian trypanosomes – complete their dev. in posterior region of vector, infective forms appear in the insects faeces. • This the aetiological agent of South and Central America. • Cause a disease known as Chagas’ disease. •The vectors are the blood sucking bug of the genera Triatoma, Panstroglus, Rhodnius. • Multiplication of T.cruzi at site of infection can produce inflamed swelling – chagoma. Oedema of upper & lower eyelid may occur along with conjuctivitis – Ramona’s sign. • Insect Triatominae 39 T. Cruzi in blood sample Multiplication of T. cruzi in the muscle – Kissing bug
  • 40. Haemoflagellates parasites (Trypanosoma sp.) The Lifecycles (7) Generalised life cycle of the Trypanosoma sp. which cause African trypnaosomiasis. 40
  • 41. Haemoflagellates parasites -The source of infection in Military (8) 1. Military acquired the infection of these parasites fm the endemic area in many parts of Africa, Asia and South America. 2. All forms of infection starts when a female sandfly (Phlebotomus sp.) takes a blood meal from an infected host. The countries with dessert eg; (Iraq, Kuwait and Afghanistan) usually the habitat for the sandfly, is also the main source for the infection this parasites. 41
  • 42. Haemoflagellates parasites of Military Importance (9) 1. The parasites, cause many causalities to the soldiers. Eg: There are 22 cases of chronic skin lesions of CL in US military personnel deployed during 2002-2003 to Afghanistan, Iraq and Kuwait. 2. Parasites are easily transmitted from one infected soldier to others by sandfly (vector-borne parasitic disease) - is a risk for military personnel who travel to the endemic area. 3. The World Health Organization estimates that 1.5 million cases of CL and 500,000 cases of VL occur each year – This amount of cases also can give bad impact to military. 42
  • 43. Arthropods as an Ectoparasites - Introduction (1) 1. The 2 most important classes of Arthropods are Insecta and Arachnida. 2. Insecta – mosquitoes, flies, bugs, fleas. Arachnida – ticks, mites, spiders and scorpions. 3. Arthropods may transmit disease by following methods: • Mechanical transmission : diseases producing agent does not multiply in the arthropod. eg: Salmonella trasmission by the house fly. • Biological transmission – arthropod is an integral part of the life cycle of parasites; Wuchereria bancrofti and Plasmodium sp in mosquitoes. (Zaman V. and Keong A.L, 3rd Edition Handbook of Medical Parasitology) 43
  • 44. Arthropods of Military Importance - (2) 1. Soft Ticks • Class: Arachnida. • Genus: Ornithodoros. • Worldwide distribution: Europe, Africa, Asia and the Americas. • Life cycles: hemimetabolous, eggs hatching six legged larvae – moult to eight legged nymphs. Larval instars requiring a blood meal to proceed for life cycle. • Disease – the most important disease is tick borne relapsing fever. Which occurs world wide and is spread by spirochaete infected Ornithodoros. 44
  • 45. Arthropods of Military Importance - (3) 2. Mosquitoes • Class: Insecta • Order: Diptera • Genus: Anopheles, Culex, Aedes, Mansonia. • Mosquitoes are the blood feeders (ectoparasites). • Also as vector to certain disease (Vectorborne disease). • Anopheles sp – vector for malaria parasites. • Culex sp – vectors for Wuchreraria bancrofti, Japanese Encephalitis. • Aedes sp a - vectors of Bancrofti filariasis and arboviruses such as yellow fever and dengue. • Mansonia sp – Brugia malayi. 45
  • 46. Arthropods of Military Importance - (4) 3. Tsetse Flies • Class: Insecta • Order: Diptera • Genus: Glossina • Tsetse flies are the blood feeders (ectoparasites) to cows and humans. • Also as vector to certain disease (Vectorborne disease). • Tsetse flies are Vectors for African sleeping sickness (T. rhodesiense and T.gambiense). 46
  • 47. ACTIVITIES TO MODIFY RISK OF INFECTION 1. Foodborne And Water Borne Infection • Avoid undercooked food, non bottled beverage sand non pasteurized dairy products. • Avoid consuming food sold by street vendors • Avoid salads and raw seafood • Peel fruit • Used bottled water for drinking, making ice cubes and brushing teeth. • Wash hands with soap and water or alcohol and sanitizers before each meal. • Carbonated beverages are safe. • Vaccines are available for hepatitis A and typhoid. 47
  • 48. ACTIVITIES TO MODIFY RISK OF INFECTION 2. Vectorborne Infection • Wear the uniform with the pants tucked into boots, sleeves worn down and undershirt tucked into the pants. • Minimize outdoor exposure during periods of insect activity. • Use 33% extended-duration DEET. • Impregnate uniform with permethrin. • Used insect netting sprayed with permethrin • Check for ticks regularly. • Use malaria chemo prophylaxis if indicated. • Vaccines are available for Yellow fever and Japanese B encephalitis. 48
  • 49. ACTIVITIES TO MODIFY RISK OF INFECTION 3. Respiratory infection • Wash hands regularly or use alcohol hand gel. • Avoid hand contact to the face. • Do not share drinking or eating utensils. • Use appropriate control measures when dealing with infected or potentially infected individuals • Submit to pre-and post deployment tuberculin skin testing. • Vaccines are available for measles, mumps, rubella, diphtheria, pertussis,meningococcus influenza, varicella, smallpox and anthrax. 49
  • 50. ACTIVITIES TO MODIFY RISK OF INFECTION 4. Zoonotic infection • Do not pet or feed animals (especially dogs). • Avoid direct contact with animals or animal products. • Do not stray animals as pets. • Use appropriate control measures when dealing with infected or potentially infected individuals • Vaccines is available for rabbies. • Vaccines are available for measles, mumps, rubella, diphtheria, pertussis,meningococcus influenza, varicella, smallpox and anthrax. 50
  • 51. ACTIVITIES TO MODIFY RISK OF INFECTION 5. Water exposure • Avoid swimming in fresh water, especially if it is stagnant or slowly flowing • Doxycycline chemo prophylaxis available. 6. Soil exposure • Water toe covered footwear. • Avoid sitting in sandy areas with uncovered skin. • Avoid ingesting soil. • Vaccine is available for tetanus. 51
  • 52. CONCLUSION 1. Parasites are the organism that derives the lives on or in another organism and derives it nourishments from their host. 2. Parasites can cause many casualty in the military operation. 3. Parasites have their own importance whether in medical or in military. 4. The effective prevention of parasites infection can conserve the military fighting strength. 5. Soldiers must practice all the time the activities to modify the risk of infection. 52
  • 53. QUESTIONS AND ANSWER 53

Notes de l'éditeur

  1. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  2. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  3. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  4. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  5. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  6. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  7. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  8. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  9. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  10. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  11. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  12. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  13. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  14. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  15. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  16. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik
  17. Melindung kesihatan penyelam Memberi perkhidmatan klinikal hiperbarik