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AN OUNCE OF PREVENTION
A Guide to Health Maintenance
during Foreign Travel
by Teri Lupo
GENERAL CONSIDERATIONS
Foreign travel can be both
exciting and dangerous. Travel to foreign lands, particularly in tropical
or sub-tropical zones, may put you at risk of certain exotic infections as well
as other non-infectious dangers. The automobile is a major cause of
accidents in foreign countries since roads may be in poor repair, available
cars, including rentals, may not be properly maintained and local drivers may
lack an appropriate degree of caution or skill. Be sure to familiarize yourself
with local traffic regulations; always wear a seatbelt (they DO save lives) and
the mix of alcohol and driving does not work any better overseas than it does
here. The avoidance of serious accidents that might cause significant bleeding
is particularly important in third world countries that do not routinely or
adequately screen their blood donors for infections such as Hepatitis B or AIDS. As a rule, if you are traveling
to a sunny climate, be sure to bring along adequate sunscreen protection .
Travelers to cold climates should protect themselves against frostbite and
hypothermia with gloves, warm boots, hats, scarves and insulated clothing. If you are traveling to a warm
climate where mosquitoes or other biting insects may be prevalent, be sure to
use an insect repellent, especially where malaria may be transmitted. “Deet” (N,N-diethyl-m-toluamide)
is the best preventive and 30% deet is recommended. Be aware -- the
popular choice “Skin So Soft” does not contain any deet at all. Be sure to
apply the proper repellent to exposed areas every few hours, dawn and dusk in
particular, and if possible, sleep under mosquito netting. Avoid wearing
perfumes and colognes which may attract biting insects. Wherever you go, never approach
a stray dog or cat or any other animal. When walking in rural or
“bush” areas, particularly in the evening, be sure to wear boots and long
trousers to protect against snakebite. In order to avoid, “travelers
diarrhea” be careful of what you eat and drink. Food purchased from street
vendors may be particularly hazardous to your health but proper caution in the
selection of food/drink regardless of the caliber of the restaurant
is recommended. Avoid eating fruits and vegetables that cannot be peeled or
cooked. Fresh salads are a major risk in foreign countries. Meat and fish should
be cooked thoroughly before consumption. Water should be boiled (tea or
coffee is generally safe) or rendered safe by the use of commercial iodine
tablets or the use of tincture of iodine (5 drops per quart of water). Bottled water should be the rule
even for brushing your teeth. Remember that ice cubes are made of water and
should be avoided unless the water source is guaranteed to be from a “safe”
supply. Over-the-counter antidiarrheal
products such as Imodium AD may be useful in some cases and Lomotil can be taken
if symptoms develop. A prescription antibiotic medication might be useful for
your travel medicine kit. Generally, be sure to replenish fluids lost
during such a bout. TRAVEL CLINICS
Beyond these common sense
avoidances and nostrums, safe foreign travel calls often calls for a regimen of
vaccines or a prescribed, pre-travel medication program. While it is true that
any doctor’s office can prescribe these medications, there are compelling
reasons to seek the counsel of specialists at a travel clinic. Knowing which vaccinations are
necessary or recommended for travelers to a certain area and which are not
necessary is the primary distinction. Studies have shown that advice obtained
from primary care physicians, busy travel agents and even foreign embassies of
the host countries often does not measure up. Current and up-to-date
information in this rapidly changing field is paramount and so consulting
medical specialists who are board -certified in the field of infectious
diseases is the best advice prior to any foreign travel. There are
outbreaks of new infections that may occur in an area or prophylactic
treatments that might be recommended following natural disasters such as
earthquake of flood. Also, keep in mind that some
procedures may require a number of doses over a period of time so be sure to
schedule your consultations well in advance of your departure date. SPECIFIC INFECTIONS
Malaria is a major risk to
travelers to many tropical and subtropical regions of the world. It is
transmitted by species of mosquitoes who bite primarily between dusk and dawn.
In addition to the precautions previously mentioned, prevention or
“prophylaxis” of malaria with medication is usually necessary. Chloroquine
phosphate (adult dose 500mg) was the medication primarily used to prevent
malaria until strains became resistant to this drug. While still effective
for the Middle East and Central America, another drug mefloquine (Lariam) is
recommended for other parts of the world. A dose of 250 mg is taken one week
prior to departure, weekly while in infectious areas and for four weeks after
leaving the malarial area. Some people with cardiac electrical conduction
defects, epilepsy or psychiatric disorders should avoid mefloquine. Alternatives
to this drug present other problems. Doxycycline, a tetracycline derivative, can
cause an exaggerated reaction to sunlight. Fansidar, a sulfa product, should not
be taken by pregnant women and can cause severe reactions in those with
allergies to sulfa. At present, no vaccine for malaria is available.
Prevention of this serious infection depends on avoidance of mosquitoes and use
of medications. Yellow fever is a serious viral
infection that is prevalent in certain parts of Africa and South America. Like
malaria, it is transmitted by mosquitoes. The vaccine that prevents this disease
is generally well-tolerated and highly effective but must be administered at a
designated yellow fever vaccination center such as the Foreign Travelers
Vaccination Center in Abington , PA. It is usually given ten days prior to
departure and is good for ten years. In addition to its being
recommended to those traveling to countries where yellow fever is present, proof
of yellow fever vaccination may be required as a condition for entry into
another country if you had stopped off or traveled through a country where the
disease was prevalent. A word of caution -- since the
virus that is used to produce the vaccine is grown in embryonated hen’s eggs
there may be traces of egg protein and so anyone with serious “anaphylactic”
allergy to eggs should not receive the vaccine. Also, since the vaccine is a
“live virus” vaccine, it should not be generally given to persons whose
immune system is seriously weakened by chemotherapy for malignancy or high doses
of “steroid” drugs such as prednisone. Cholera is a diarrheal infection
present in certain parts of the world. In recent years, there has been a
widespread epidemic of this disease in Peru and other Latin American countries. The Center for Disease Control
does not generally recommend cholera vaccine for any international travel.
Prudent food selection ( no raw shellfish or other seafood) and the
avoidance of impure drinking water are the best safeguards against this disease. Typhoid Fever is a serious,
potentially lethal, bacterial infection prevalent in some parts of the world,
particularly where there is poor food and water sanitation. Travel to India,
Pakistan, Peru and other developing nations carries an increased risk of
acquiring typhoid, usually from consumption of contaminated food and drink and
so, a vaccination prior to travel there may be medically advisable. An injectable vaccine, Typham Vi
can provide immunity after one injection but a booster should be given
every two years if there is continued exposure. The vaccine can be given to
adults and children as young as 2 years of age. An oral vaccine is also widely
used in the form of capsule taken with a glass of water every other day for a
total of four doses. The medication should be kept refrigerated until consumed.
Immunity lasts for at least five years; side effects are rare. It should not be
used by children under age six or those with severe immune deficiency. Meningococcal meningitis is a
serious bacterial infection o the brain and spinal fluid that can occur in
epidemics. There is an ongoing epidemic in sub-Saharan Africa (especially from
Mali east to Ethiopia) particularly in the dry season, December through June.
There is an effective vaccination for adults that lasts at least a few
years although its effectiveness and duration of protection in children is less
established. Side effects are generally limited to a sore arm. While not a
requirement to enter any country, it is required for pilgrims going to Mecca,
Saudi Arabia. Polio is a viral infection that
produces paralysis in some of its victims. Once common in the US, the
widespread administration of either the inactivated injectable polio
vaccine (Salk vaccine in 1955) or the oral “live” vaccine ( Sabin vaccine in
the mid-60s) has protected most Americans. However, if
traveling to a developing country where the virus is still prevalent, a booster
shot is recommended. Persons who have impaired immune systems should not receive
the oral vaccine while those with a serious allergy to neomycin or streptomycin
should not receive the injectable vaccine. While pregnant women should generally
avoid taking any drugs or vaccines unless there is a special need, those needing
immediate protection from polio should use the oral vaccine. Measles is a viral infection
that has been largely wiped out in countries with the measles vaccine.
Complications from measles infection include pneumonia and seizures with
adults most likely to experience more serious complications from infection than
children. If you have had measles then you
cannot get it again. However, if you have not (as most people born after 1957
who have been vaccinated) then you should consider a second dose of measles
vaccine to be fully protected. A minority of people receiving the vaccine may
experience a mild fever and rash beginning 5-12 days after vaccination
which usually lasts only a few days. Certain people should avoid this
vaccine -- pregnant women (and those who may get pregnant in the next
three months), people allergic to eggs or neomycin, and those with
impaired immune systems. The effectiveness of the measles vaccine may be
impaired in those who have had a gamma globulin shot (as used for hepatitis A)
in the last three months. Tetanus and diphtheria a serious
disease that have been almost completely eliminated in many countries by
appropriate immunization. Tetanus lockjaw can occur if a cut or open
wound allows bacteria, often present in soil, into the body. Serious
muscle spasms can lead to difficulty in breathing and swallowing and is often
fatal. Diphtheria can cause difficulty breathing, paralysis and heart
failure. Everyone should have at least
three tetanus shots in their lifetime. The primary series was most likely (in
the USA) received in childhood in us form of “DPT” baby shots. Booster shots
are recommended every 10 years after this initial series. However, if you suffer
a “dirty’ or tetanus-prone wound and your last booster was more than 5 years
ago, a new booster is highly recommended. There are different types of
tetanus vaccines but the type recommended for adults by the Public
Health Service is known as “Td,” an acronym for Tetanus and Diphtheria
Toxoid for Adult Use, Absorbed. Reactions may include mild fever, redness,
soreness or swelling at the injection site which can be easily treated with
aspirin or Tylenol. Serious allergic reactions are rare and pregnant women who
need the vaccine should get it. Any past allergic reactions were probably due to
horse serum which is no longer used. Hepatitis A is a serious viral
infection of the liver prevalent in developing countries that may be acquired
through contact with an infected person or by consuming contaminated food or
water. Its symptoms include fever, and jaundice. While travelers with standard
itineraries in developing countries may contract this disease, the likelihood of
infection increases with the duration of travel and is highest in those who
experience poor sanitation conditions in rural and back country areas. Two forms of vaccine are
available to prevent hepatitis A -- immune globulin and the new hepatitis A
vaccine. Immune globulin shots provide immediate but only temporary but
can be used for travelers who will be spending less than 3 months in an area
where hepatitis A is prevalent. A 2cc dose
administered in the buttock will prevent infection; they are safe for pregnant
women but the supply of this product is not reliable. More readily available is
hepatitis A vaccine made from a deactivated (killed) virus that can be given to
adults and children from age two. The vaccine should be given at least two weeks
in advance of departure and protects for one year. A booster dose given 6-12
months after the first vaccine can increase protection to 20 years. Safety for
pregnant women has not yet been established. Other vaccines may be
recommended based upon your personal itinerary (particularly prolonged travel in
rural areas of developing countries) or due to new epidemics that may occur in
the area or as a prudent measure against the consequence of natural disasters
such as hurricanes, floods, and earthquakes. Examples would include hepatitis B
and rabies vaccine. These vaccines tend to be relatively expensive,
often need to be specially ordered and the series may need to begin as long as
six months in advance of departure. This points to the need to consult
knowledgeable authorities well in advance in order to secure necessary, timely
and proper healthcare advice. Final thoughts
If you are being treated for any
medical problems, you should consult your personal physician prior to your
departure. Be sure to take along an adequate supply of any medication that you
are taking. If you wear glasses, take an extra pair with you. If you become ill after you
return from your trip, be sure to tell your physician about your travels, even
if you do not think that your illness is travel-related. If you believe that you have had
a serious reaction to a vaccination, report it to your physician and ask that
the problem be documented on a Vaccine Adverse Events Report form. You may also
report it yourself on this form which can be obtained by calling 1-800-822-7967.
A US government program provides compensation for some persons who have had
problems related to vaccines. For information, call 800-338-2382. Prior to departure, the first
place to go for timely information about your travel destination is the website
maintained by the Center for Disease Control (CDC) at www.cdc.gov
(choose Traveler’s Health). This service can also be accessed by FAX at
1-888-CDC-FAXX (1-888-232-3299). You may
select information by travel region, type of diseases well as up-to-date
information on areas subjected to natural disasters such as Hurricane Mitch in
Central America and the earthquakes in Turkey and Greece. It is critical to obtain medical
advice and preventive care from physicians who are proficient in the area of
infectious diseases and who keep current on the medical situation in
destinations world-wide, both in terms of endemic diseases of an area and the
special considerations that may arise due to changing seasonal and weather
conditions, natural disasters or social factors (evacuations, festivals and
pilgrimages). As professional travelers, in
the last few months we have consulted and received vaccinations appropriate for
our travels to South America and India at a specialized medical group, Foreign
Travelers Vaccination Center in Abington PA (215) 886-5652 and acknowledge our
gratitude for their professional services and the valuable information
contributed by Dr. Roger Nieman for this first of a series of articles on this
important aspect of traveling. By Teri Lupo © All rights
reserved Additional information can be
obtained by accessing these websites: Center for Disease Control
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