ATLANTA, Georgia (CNN) – This week while you’re traveling, if you happen to spot a man applying hand sanitizer as he gets off an escalator, there’s a good chance it’s Dr. Mark Gendreau, a senior staff physician at the Lahey Clinic in Burlington, Massachusetts.

Travel season can be a germ fest. Make sure to keep your hands clean.

Gendreau studies germiness while traveling, and he knows just how infectious travel can be.

“The risk of contracting a contagious illness is heightened when we travel within any enclosed space, especially during the winter months, when most of the respiratory viruses thrive,” Gendreau said.

Studies show that germs can travel easily on an airplane, where people are packed together like sardines.

For example, a woman on a 1994 flight from Chicago to Honolulu transmitted drug-resistant tuberculosis to at least six of her fellow passengers, according to a New England Journal of Medicine study.

In 2003, 22 people came down with SARS, or severe acute respiratory syndrome, from a single fellow passenger who had SARS but didn’t have any symptoms, according to another New England journal study.

But the airplane isn’t the only place along your travel route where germs thrive. Here are five ways to avoid germs while traveling.

1. Sit toward the front of the airplane

“Pick a seat near the front, since ventilation systems on most commercial aircraft provide better air flow in the front of the aircraft,” Gendreau advised. If you can afford it, sit in first class, where people aren’t so squished together.

Don’t Miss

• Bathroom hot spots: How to use a public restroom safely
• In Depth: Empowered Patient

2. Don’t drink coffee or tea on an airplane

Monitoring by the Environmental Protection Agency shows that water in airplanes’ water tanks isn’t always clean — and coffee and tea are usually made from that water, not from bottled water, according to Victoria Day, a spokeswoman for the Air Transport Association.

The EPA advises anyone with a suppressed immune system or anyone who’s “concerned” about bacteria to refrain from drinking coffee or tea on an airplane.

“While boiling water for one minute will remove pathogens from drinking water, the water used to prepare coffee and tea aboard a plane is not generally brought to a sufficiently high temperature to guarantee that pathogens are killed,” according to the EPA’s Web site.

According to the EPA, out of 7,812 water samples taken from 2,316 aircraft, 2.8 percent were positive for coliform bacteria. Although that sounds like a small number, this means 222 samples contained coliform bacteria.

3. Sanitize your hands after leaving an airplane bathroom

A toilet on an airplane “is among the germiest that you will encounter almost anywhere,” said Charles Gerba, an environmental microbiologist at the University of Arizona who’s also known as “Dr. Germ.”

“You have 50 people per toilet, unless you are flying a discount airline; then it is 75,” Gerba said. “We always find E. coli on surfaces in airplane restrooms.”

You should wash your hands after using the restroom, but because the water itself might have harmful bacteria (see No. 2 above) and because the door handle on your way out has been touched by all those who went before you, Gendreau also advises sanitizing your hands when you return to your seat.

4. Wash or sanitize your hands after getting off an escalator

Gendreau says tests show that escalators in airports are full of germs.

Health Library

• MayoClinic.com: Health Library

To confirm these tests, here’s a fun activity while you wait for your flight this Thanksgiving: Look at your watch, and count how many people get an escalator in a five-minute time period. Multiply that by 12, and you have how many people are on that escalator every hour.

High-volume handrails are why Gendreau sanitizes his hands as soon as he can after he exits an escalator.

5. Wash or sanitize your hands after using an ATM

Gendreau says ATMs, especially in busy places like airports, are full of germs. As with escalators, he sanitizes ASAP after using one.

Gendreau says that keeping healthy while traveling can be summed up in six words: “hand hygiene, hand hygiene, hand hygiene.”

Keeping your hands clean is crucial, he says, when you’re spending the day touching surfaces that have been touched by hundreds or thousands of people before you.

Time for more vitamin D

September brings the end of summer in the northern hemisphere and, for many of us, that means less time in the sun. The sun’s rays provide ultraviolet B (UVB) energy, and the skin uses it to start making vitamin D. (The skin actually produces a precursor that is converted into the active form of the vitamin by the liver and kidneys.) Vitamin D is best known for its vital role in bone health. Without this “sunshine vitamin,” the body can’t absorb the calcium it ingests, so it steals calcium from bones, increasing the risk of osteoporosis and fractures. Vitamin D also helps maintain normal blood levels of phosphorus, another bone-building mineral.

Vitamin D would be essential if it did nothing else. But researchers have discovered that it’s active in many tissues and cells besides bone and controls an enormous number of genes, including some associated with cancers, autoimmune disease, and infection. Hardly a month goes by without news about the risks of vitamin D deficiency or about a potential role for the vitamin in warding off diseases, including breast cancer, multiple sclerosis, and even schizophrenia. In June 2008, a study published in the Archives of Internal Medicine found that low blood levels of vitamin D were associated with a doubled risk of death overall and from cardiovascular causes in women and men (average age 62) referred to a cardiac center for coronary angiography. At a scientific meeting in May 2008, Canadian researchers reported that vitamin D deficiency was linked to poorer outcomes in women with breast cancer. And a large study of aging in the Netherlands published in the May 2008 issue of Archives of General Psychiatry found a relationship between vitamin D deficiency and depression in women and men ages 65 to 95.

The picture of vitamin D’s health benefits beyond bones has been drawn mainly from epidemiologic and observational investigations. The findings of such studies can suggest correlations between disease risk and certain factors - sun exposure or blood levels of vitamin D, for example - but they don’t prove cause and effect. Promising findings from observational studies don’t always pan out when put to the test in clinical trials. However, in one of the few randomized trials testing the effect of vitamin D supplements on cancer outcomes, postmenopausal women who took 1,100 international units (IU) of vitamin D plus 1,400 to 1,500 milligrams of calcium per day reduced their risk of developing non-skin cancers by 77% after four years, compared with a placebo and the same dose of calcium. The 1,100 IU dose - nearly three times the 400 IU per day recommended in federal and other expert guidelines - was correlated with a 35% higher blood level of vitamin D, on average. In the only other randomized trial of vitamin D and cancer - part of the Women’s Health Initiative - researchers found no effect on colorectal cancer. Critics say that the dose, 400 IU per day, was too small to make a difference.

More trials are needed to elucidate vitamin D’s benefits and risks at different doses and in different populations. In fact, a large-scale randomized trial that would include 20,000 U.S. women and men has been proposed by Harvard researchers and will be considered for funding by the National Institutes of Health. In the meantime, the evidence is so compelling that some experts already recommend at least 800 to 1,000 IU of vitamin D per day for adults.

Latitude and vitamin D production in the skin

Except during the summer months, the skin makes little if any vitamin D from the sun at latitudes above 37 degrees north (in the United States, the shaded region in the map) or below 37 degrees south of the equator. People who live in these areas are at relatively greater risk for vitamin D deficiency.

In search of vitamin D

Under the right circumstances, 10 to 15 minutes of sun on the arms and legs a few times a week can generate nearly all the vitamin D we need. Unfortunately, the “right circumstances” are elusive: the season, the time of day, where you live, cloud cover, and even pollution affect the amount of UVB that reaches your skin. What’s more, your skin’s production of vitamin D is influenced by age (people ages 65 and over generate only one-fourth as much as people in their 20s do), skin color (African Americans have, on average, about half as much vitamin D in their blood as white Americans), and sunscreen use (though experts don’t all agree on the extent to which sunscreen interferes with sun-related vitamin D production).

Lack of sun exposure would be less of a problem if diet provided adequate vitamin D. But there aren’t many vitamin D-rich foods (see chart, below), and you need to eat a lot of them to get 800 to 1,000 IU per day. People who have trouble absorbing dietary fat - such as those with Crohn’s disease or celiac disease - can’t get enough vitamin D from diet no matter how much they eat (vitamin D requires some dietary fat in the gut for absorption). And people with liver and kidney disease are often deficient in vitamin D, because these organs are required to make the active form of the vitamin, whether it comes from the sun or from food.

Selected food sources of vitamin D

Food

Vitamin D (IU*)

Salmon, 3.5 ounces

360

Mackerel, 3.5 ounces

345

Tuna, canned, 3.5 ounces

200

Orange juice, fortified, 8 ounces

100

Milk, fortified, 8 ounces

98

Breakfast cereals, fortified, 1 serving

40-100

*IU = international units

Source: Office of Dietary Supplements, National Institutes of Health

For these and other reasons, a surprising number of Americans - more than 50% of women and men ages 65 and older in North America - are vitamin D-deficient, according to a consensus workshop held in 2006. Growing awareness of vitamin D’s benefits coupled with the risk of vitamin D deficiency has led some experts to recommend a blood test that assesses the amount of vitamin D in the body. The test measures the concentration of 25-hydroxyvitamin D₃, or 25(OH)D, the precursor produced by the skin and converted in the body to vitamin D. If you’re over age 70, have darker skin, or live at a northern latitude, you might want to ask your clinician about the test. People who have malabsorption problems or take medications that interfere with vitamin D activity (for example, glucocorticoids) should consider it as well. However, some experts think testing is unnecessary as long as you get 800 to 1,000 IU of vitamin D a day.

Although there’s no agreement on an optimal level of 25(OH)D, deficiency is generally defined as a blood level less than 20 nanograms per milliliter, or 20 ng/mL (see chart). Levels that low have been linked to poor bone density, falls, fractures, cancer, immune dysfunction, cardiovascular disease, and hypertension. Many experts recommend a level of at least 32 and suggest that 800 to 1,000 IU of vitamin D per day is required to maintain that level.

Vitamin D status by blood levels of 25(OH)D*

Vitamin D status

25(OH)D in nanograms per milliliter (ng/mL)

Deficient

Less than 20 ng/mL

Insufficient

20 to 29 ng/mL

Sufficient

30 ng/mL or more

Potentially harmful

More than 150 ng/mL

*25-hydroxyvitamin D₃ (vitamin D precursor)

Source: Holick MF. “Vitamin D Deficiency,” New England Journal of Medicine (July 19, 2007), Vol. 357, No. 3, pp. 266-80.

How to reach 1,000 IU

Unless you live in the South and spend a fair amount of time outdoors, or you like eating lots of fatty fish and vitamin D-fortified foods, supplements are the best way to make sure you’re getting 800 to 1,000 IU per day. (Higher doses may be prescribed if you’ve been diagnosed with vitamin D deficiency.) Most multivitamins contain only 400 IU. But don’t just take two, because getting double doses of other vitamins and minerals can be unsafe (for example, too much vitamin A as retinol can cause hair loss and diarrhea and is associated with hip and other bone fractures, possibly due to an adverse interaction with vitamin D). Many calcium pills contain about 200 IU of vitamin D, so one multivitamin and two or three calcium pills should suffice. Or you can take a vitamin D pill to round out your daily needs. Until we know more, make sure your intake from supplemental sources doesn’t exceed 2,000 IU per day, the current upper limit set by the National Academy of Sciences.

What ? Submit a drawing, sketch or painting about your Subcutaneous Immune Globulin (SCIG) Infusion. The winning entries will have their artwork featured in our SCIG Infusion Log.

Who Can participate? Any child or youth up to 17 years of age who has an immune deficiency OR has a brother, sister, parent, or grandparent with an immune disorder.

What to Draw, Color or Paint? The artwork should have something to do with the entrant’s family or their experiences with SCIG therapy. The entries can be no larger than 8.5 x 11 inches but may be smaller.

Prizes: All entrants will receive a $10 gift card to Toys R Us or Barnes & Noble.

The winners will have their artwork printed in our SCIG Infusion Log.

Entries: Complete the entry form and send it to:

BioRx

SCIG Infusion Log Contest

10828Kenwood Rd.

Cincinnati, Ohio 45242

Entries must be received by December 1, 2008 to be eligible

Kids and parent! A parent MUST sign the entry form on the next page, acknowledging that they have read the entry form and that we may be allowed to use your child’s art. Any entries that are not accompanied with a signed entry form cannot be used.

Name : _________________________________________________________________________ ____

Address: _____________________________________________________________________________

City, State, Zip Code: ___________________________________________________________________

Age, as of December 1: ________

Phone Numbers: ______________________________________________________________________

Email: _______________________________________________________________________________

(We need a way to contact you if you or your child is a winner!)

Contestant is: ___ living with SQ Immune Globulin Infusion

___ the sibling or step-sibling of someone living with SQ Immune Globulin Infusion

___ has a parent or step-parent living with SQ Immune Globulin Infusion

I would like the following gift card as my prize for entering::

___ Toys R Us

___ Barnes & Noble Booksellers

If your child’s art is selected to appear in the calendar, his/her first name and last name initial, age, as well as city and state will appear with the art; i.e. “Billy S. (Age 9), Plano, TX”.

Parent or Guardian’s Signature (Mandatory): ________________________________________________

Parent or Guardian’s name PRINTED ______________________________________ Date ____________

Rules: (copy from Calendar Entry Form) 9 pt.

With kids back to school and the colder weather fast approaching, we are heading into that
wonderful time of year…. Cold and Flu Season. For individuals with Primary Immune Deficiency this can
be an especially stressful time of year. With all the germs that are out there it is hard to know the best
way to protect you and your family.

Wash Your Hands:
The Centers for Disease Control and Prevention (CDC) advise that proper hand washing is the most
important thing you can do to keep from getting sick. Below is their hand washing protocol.
Washing Your Hands the Right Way:

1. Wet your hands with clean running water and apply soap. Use warm water if it is available.
2. Rub hands together to make a lather and scrub all surfaces.
3. Continue rubbing hands for 15?20 seconds. Need a timer? Imagine singing “Happy Birthday”
twice through to a friend.
4. Rinse well under running water.
5. Dry your hands using a paper towel or air dryer. If possible, use your paper towel to turn off the
faucet, as many germs live on faucets.
Alcohol Based Hand Sanitizers:
The CDC states that when soap and water are not available, alcohol?based disposable hand wipes or gel
sanitizers may be used.
• The active ingredient in most alcohol?based hand sanitizers is ethyl alcohol. Alcohol is a natural
antiseptic that has been used in the medical field for over 100 years because it kills most germs
in seconds, without water, and evaporates quickly, leaving no residue on the skin. It physically
destroys most germs.
• Alcohol?based hand sanitizers kill harmful bacterial, such as streptococcus, salmonella,
staphylococcus, E. coli and shigella.
• The level of alcohol in any hand sanitizer must be greater than 60% to be effective. Between
60% and 95% is ideal.
• These products have not been proven to kill viruses or Clostridium difficile otherwise known as
C?diff.
• If hands are visibly soiled, hand sanitizers will not work, making soap and water a better option.
Bottom Line:
Washing with soap and water is better, but the ease and availability of hand sanitizer makes it a good
first step in the fight against germs.
BioRx wishes you a Happy Fall Season and hope that these tips help keep you healthy!
(Information gathered from www.CDC.gov; www.itsasnap.org; and N Engl J Med 2006; 354:1199?1203, Mar 16, 2006)
Our goal is to provide cost?effective care, positive clinical outcomes, and improve quality of life for our Primary Immune
Deficient community.