Healthy Travel - Plan Ahead

Although less than 1% of travelers require hospitalization, 70% of those traveling in less developed countries report an illness during their trip. Here's your check list to help prevent many of the illnesses.

Before you take off:

1. Vaccines.
-- See your doctor 4-6 weeks before your date of departure. Bring any immunization records that you may have to your visit.
-- Vaccine recommendations vary by country. Here are the links for India, China, Brazil, and Ghana. For other countries check the CDC site. Europe, Australia, Canada, and USA do not need any further vaccines than what are recommended during routine health care immunizations.

2. Prescription medications.
-- If you are going for an extended period of time you may need to contact your insurance company to get approval for a longer course of your medications such as birth control pills, allergy medications, or inhalers for asthma.
-- Antibiotics such as Cipro for diarrhea type illnesses are useful. Azithromycin can be used for respiratory or skin infections. It can also be an alternative for Cipro.
-- Epinephrine kit if you have severe allergic reactions to bee stings, food or drugs is necessary.
-- Sterile needle/syringe kit if traveling to an area where the sterility of instruments may be in question.

3. Over the counter medications.
-- Loperamide (Imodium) for diarrhea.
-- Diphenhydramine(Benadryl) for allergic reactions, motion sickness, nausea, and as sleep aid.
-- Loratidine (Claritin) for allergic reactions. Lasts longer than Benadryl and is not sedating.
-- Hydrocortisone for skin reactions.
-- Sudafed for congestion, especially if before a flight.
-- Acetominophen(Tylenol), Ibuprofen(Advil) or other anti-inflammatory medication such as aspirin for pain, fever, joint swelling.
-- Metamucil for constipation.
-- Medical kit including a thermometer, band aids, antibiotic ointment, a roll of gauze, tape, and small scissors, oral re hydration salts such as CeraLyte for severe dehydration, hand sanitizer gel or towelettes, tweezers, and extra pair of glasses.

4. Protective gear.
-- Mosquito repellent. 30% DEET containing repellents are recommended for adults. Read here for more details .
-- Proper clothing. Sporting good stores such as REI have permethrin permeated clothing as well as special materials which allow more comfortable temperature control.
-- Sun protection. SPF of 30 is recommended by most dermatologists. Read here for more details.
-- Condoms if you plan to be sexually active but please be aware that they are not 100% protective.

5. In case of pre-existing medical conditions.
-- Pregnancy. Most airlines don't allow travel after 35 weeks of pregnancy. Pregnancy by itself is not a contraindication to travel. Please check with your obstetrician if you have had any complications during your pregnancy.
-- Asthma and respiratory diseases. If your condition is well controlled then there should not be any difficulty with travel. If you are breathless or cannot walk 50 meters (164 ft.) then you should seek medical advice before travel. During take off, the slight drop in oxygen pressure may cause problems for certain chest conditions.
-- Diabetes. Meals should be arranged with airline before travel. During the trip, stay on home time with regard to medication regimen, but after landing adjust to local times.
-- Heart disease. In general if you are able to walk up a dozen stairs then you should not have any trouble on a flight. If you have had a recent heart attack or stroke then you are advised not to fly without consulting your doctor.

On the plane, train, or automobile:

1. Gas.
As cabin pressure falls, the air in the intestines expands by as much as 25% and causes bloating and discomfort. Avoid carbonated drinks, and eat and drink in moderation during a long flight. If you have a severe problem with gas, then you can try over the counter medications which contain simethicone such as Gas-X.

2. Motion sickness.
Eat small but frequent snacks to reduce nausea. Scopolamine (in patches or pills) and medications for nausea and vomiting such as promethazine may be prescribed by your doctor.
These medicines do cause drowsiness and should not be taken with alcohol.

3. Blocked ears.
Can be relieved by swallowing, sucking on hard candy, chewing gum, or holding your nose and blowing. Sudafed tablets and Afrin nasal spray can also help relieve the blockage if taken ahead of time, about 30-60 minutes before take off or landing. If you suspect an ear or sinus infection before your trip, consult your doctor so to avoid the possibility of a ruptured ear drum. There are also pressure-regulating ear plugs which decrease the pain and are sold at most drugstores.

4. Blood clots in the legs (Deep vein thrombosis).
Please read this link for instructions on staying well hydrated and how to exercise the legs to avoid these clots which can lead to serious complications and even death.

5. Stress/fear of flying.
-- Relaxation techniques. Close your eyes and breathe in slowly through your nose and then slowly breathe out through your mouth. Repeat for 10 minutes. Picture yourself in a place such as a tropical beach and concentrate on relaxing each part of your body individually such as hands, arms, shoulders, back, stomach, legs, etc.
-- Anti-anxiety medications such as Ativan (lorazepam) or Klonipin (clonazepam) may be more immediately effective if your symptoms are so consult your doctor about these medications.

6. Dry eyes/contact lens.
Frequently apply wetting solutions to the eyes. You may also consider carrying an antibiotic eye drop containing a quinolone such as Cipro or Levofloxacin.

7. Heart burn.
Large meals followed by prolonged sitting and an increase in gas can worsen esophageal reflux. Over the counter medications such as Pepcid, Zantac, or Prilosec help relieve the symptoms. Ideally they should be taken before the meal. Maalox and Mylanta are faster but shorter acting and may be taken after meals. Try to eat small but more frequent meals or snacks. Avoid alcohol and caffeine.

On arrival:

1. Jet lag.
It can take 1 day to recover for each time zone that is crossed. Most commonly prescribed medication to help with sleep is Ambien. Melatonin may also be used but its effects are not as guaranteed. It is taken 5 mg per day at 6 pm starting 3 days before travel and continuing for a total of 7 days. Bright light therapy may be helpful as well.

2. Safe Food and Water.
The CDC has a detailed site on this subject. Please see the above link. The basic rules are drink bottled water, and don't eat it if you can't boil it or peel it.

3. Diarrhea.
Most common type of illness encountered. A general recommendation is that if diarrhea occurs, let it pass during the first 24 hours. However, if the diarrhea lasts more than 24 hours or if it is associated with blood or fever, then take the antibiotics such as Cipro.

3. Altitude sickness.
Symptoms include headache, fatigue, and insomnia. These may occur at any altitude above 5000 feet, but are more common at 8000 feet. The definitive treatment is to descend, but there are medications such as Diamox which may help relieve the symptoms.

4. For Medical emergencies.
-- The International Association for Medical Assistance to Travellers (IAMAT) publishes a booklet listing English speaking doctors and facilities worldwide.
-- The Bureau of Consular Affairs website (http://www.travel.state.gov/) has a list of doctors and facilities compiled by embassies in different countries.
-- Of course the local hotels can refer you as well.

5. What about the bird flu?
In general, your risk of exposure is very low as long as you avoid bird markets or any other areas which are high in bird feces. It is safe to eat well cooked poultry. Read here for bird flu basics. There are no vaccines for bird flu yet.

6. Do I really have to take the malaria pills?
Yes, if you are traveling to a high risk area - listed from highest to lowest risk areas - Sub-Saharan Africa, Oceania, India, Southeast Asia or Latin America. Although Sub-Saharan Africa is visited by less than 2% of U.S. travelers, this region accounts for 80% of malaria cases reported among U.S. travelers. The CDC reported a 25% increase in cases of malaria in Americans from 1998 to 2000. Throughout history malaria has killed more people than all wars and plagues combined.

Helpful websites:

Traveler's Health
MD Travel Health
WHO on International Health

References: Please see above links. International Travel Health Guide.

Going to Ghana?

Please don't be overwhelmed, but the the following is a summary of the vaccines and medications which are recommended for your trip. The more you know about your vaccination history, the less shots you may need to get.

• Tetanus/Diphtheria/Pertussis (1 shot)---if your last one was more than 10 years ago.
• Polio (1 shot) ---one time only needed as an adult.
• Measles, (1 shot)--- if you are born after 1957, and you have not had 2 doses of MMR(measles,mumps,rubella) . Please note that measles is a live vaccine and it should not be given to pregnant women or to those with immunosupression.
• Typhoid ( 4 pills)--- which are taken 1 every other day, and will be good for 5 years. If you have had a previous typhoid vaccination but in the form of a shot then that is only good for 2 years. Note that these pills should be refrigerated. This is also a live vaccine and should not be given to pregnant women or to those with immunosupression.
• Hepatitis A ( series of 2 shots) ---if you have never had the series. The first one should be given 4 weeks prior to your trip. You will need a second shot in 6-12 months to be protected long term.
• Hepatitis B---(a series of 3 shots ). The first 2 are given 4 weeks apart and the third is given in 6 months. You should get the first 2 shots before departure. This is especially recommended if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment.
• Hepatitis A/B combination shot may also be given. This follows the same schedule as hepatitis B shots.
• Meningitis vaccine (1 shot)---if you have not received one in the last 3 years.
• Yellow fever vaccine (1 shot)---if you have not had one in the last 10 years. This must be administered at a Certified Center.
• MALARIA PILLS, 2 most commonly prescribed are the following but only one is needed: MALARONE (atovaquone and proguanil hydrochloride)---taken one a day starting one day before entering the area and continue every day until 7 days after leaving the area.
  LARIAM (Mefloquine)--- taken one a week, starting one week before entering India and continuing for 4 weeks after leaving India. This is not recommended for people with depression. It has also been associated with vivid dreams.
• Ciprofloxacin in case of traveler's diarrhea. If diarrhea occurs and if it is lasting more than 24 hours or it is associated with blood or fever then take one tablet of Cipro twice a day for 3 days.

• Over the counter medications to consider depending on your needs are:
• Imodium for diarrhea.
• Diphenhydramine(Benadryl) for allergic reactions, motion sickness, and nausea.
• Hydrocortisone cream for skin reactions.
• Sudafed for congestion, especially if before a flight.
• Acetominophen(Tylenol), Ibuprofen(Advil) or other anti-inflammatory medication.
• DEET containing mosquito repellent.
• Consider DEET permeated clothing, and wearing long sleeves and pants when outside at dusk or dawn which are feeding times for mosquitos.
• See the Safe Food and Water page for a list of links.

Buzzzzzzzzzzzz

Do you know: What percent DEET is needed in insect repellents to be effective?

A. 7%
B. 20%
C. 30%
D. 98%
E. All of the above





Answer is: E. All of the above

What is DEET? DEET is N,N-diethylmetatoluamide which was developed by the U.S. Army in 1946 for use by military personnel in insect-infested areas.

How does it work? It creates a vapor above the area of application as it evaporates which repels the insects.

Children should use the lowest dose effective which can be less than 10%, however, it may not stay on as long as the higher concentrations. See Bug Repellent Comparison.
DEET is not recommended for use in children less than 6 months old, and it should be considered for children up to 2 years old only if very high exposure to insects is expected. Avoid applying it to children's hands if they tend to put them in their mouths.

Adults may consider 30% concentration. Consumer Reports June 2006 concluded that 30% was needed for very good results.

Pregnant women should not use it.

Where is it applied? It should be applied to any exposed skin sparingly. Avoid using it around the eyes and mouth, and any open skin such as scratches and skins. Do not apply it under clothing. Wash your hands after applying it.

Alternative to DEET: Most experts agree that non-DEET containing repellents are not as effective. A panel in Consumer Reports June 2006 thought that Repel Plant Based Lemon Eucalyptus worked better than the other non-DEET products but they did not like its smell. This is also NOT recommended for use in children less than 3 years old.

For more information: see Insect Repellent Use and Safety.

References: Insect repellents: an overview, J Am Academy of Dermatology, 1997.
DEET-based insect repellents: safety implications, Canadian Medical Association Journal, 2003. Dr. J. D. MacLean, McGill University
Photo: courtesy of SoulTek.com/blog

Is It Safe to Eat Chicken in Asia ?

A blogger asks is it safe to eat chicken in Asia.

I assume this is due to conern over bird flu.
As far as we know if the chicken is fully cooked the virus can not be transmitted.

See Bird Flu Basics.
Please note that this post of 10/05 needs to be updated to mention that due to the migration pattern of the birds the virus has appeared in European and Middle Eastern countries as you probably know by now.

Photo: courtesy of poultry.information

Altitude Sickness, How High is Too High

When skiing, mountain climbing, or hiking, please remember that the altered consciousness and dizziness accompanied by the rapid breathing that you are noticing may not be from the natural high that you are experiencing but from the effects of altitude sickness.



Altitude sickness can affect any one of any sex, age or physical fitness. It can occur at any altitude above 5000 ft. (lake Tahoe), but it is more common above 8000 ft. (Machu Picchu, Peru). In a study of hikers in the Swiss Alps, 13% developed symptoms at 10,000 ft. and 34% became symptomatic at 12,000 ft.
BMJ. 1990 Oct 13;301(6756):853-5.
Maggiorini M, Buhler B, Walter M, Oelz O.

It may be prevented by climbing slowly. It is usually not a problem to climb up to 5000 ft in 1 day. Above 8000 ft, a rate of 1500 ft (460 m)/day is recommended. When climbing above 10,000 ft, it would be best to acclimatize by staying at 6000-8000 ft. for 2-4 days. however, many of us hurry through our vacations due to a lack of time and skip the acclimatization process. Staying hydrated can also help.



Early symptoms are headache, insomnia, and swelling of legs which may start 12-24 hours after arriving at the altitude. If ignored, the symptoms may progress to vomiting, dizziness, difficulty breathing, and in worst case scenario death from brain herniation due to increased intracranial pressure.

If any of these symptoms occur, the definitive treatment is to descend. Supplemental oxygen is helpful if available.
There are medications such as Diamox (acetazolamide), and Decadron (dexamethasone) which help the symptoms. Ask your doctor about them if you are prone to altitude sickness. They may be taken preventively.

References:
http://www.ismmed.org
The Medical Letter on Drugs and Therapeutics, May, 2004; (21) pp. 33-40
The MERCK Manual, Sec. 20, Ch. 281
Photo: www.nationalgeographic.com/.../ altitude.jpg

Travel Vaccine Recommendations for China

Please refer to the Travel Recommendations for India post. The recommendations are the same with the exception of the following two items:

1. Polio vaccine booster is not recommended.

2. Malaria pills are not needed for travelers to cities and popular tourist areas, including Yangtze River cruises, Hong Kong and Macau. Malaria prophylaxis is indicated for rural areas only of the following provinces: Hainan, Yunnan, Fuijan, Guangdong, Guangxi, Guizhou, Sichuan, Tibet (in the Zangbo River valley only), Anhui, Hubei, Hunan, Jiangsu, Jiangxi, and Shandong.

Image from: Institut de veille sanitaire (invs.sante.fr)
anaes.fr

Travel Vaccine Recommendations for India

Dear Googlers,

Before packing for the beautiful country of India please consider the following Center for Disease Control recommendations:


--Tetanus-diphtheria-pertussis (1 shot)--->if your last one was more than 10 years ago.

--Polio (1 shot)--> one time only needed as an adult.

--Measles (1 shot)-->one time booster if you were born after 1956 and if you cannot document that you are immune by haveing received either 2 doses of MMR (measles/mumps/rubella) vaccine or by history of having had the disease. A blood test can also be done to see if you have had the vaccine. Please note that measles is a live vaccine and that it should not be given to pregnant women or to those with immunosuppression. Also women are advised not to get pregnant for 4 weeks after receiving the MMR.

Typhoid (4 pills)--->which are taken 1 every other day, and will be good for 5 years. It should be taken at least 2 weeks before the trip. Note that these pills should be refrigerated, and that this is also a live vaccine.

Hepatitis A (2 shots) --->ideally the first dose should be given 4 weeks prior to your trip to be maximally protected. You will need a second shot in 6-12 months to be protected long term.

Hepatitis B (3 shots)---> 2 of which are given 4 weeks apart and the third is given in 6 months. You should complete the first 2 shots before departure. This is especially recommended if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment.

A combination shot of hepatitis A and B vaccines may ge given in 1 shot instead of individual A and B shots.

--Malaria Pills-- 2 most commonly prescribed are the following but only one is needed:
>Malarone(atovaquone and proguanil hydrochloride)---taken one a day starting one day before entering India and continuing every day until 7 days after you have left India.
>Lariam (Mefloquine)--- taken one a week, starting one week before entering India and continuing for 4 weeks after leaving India. This is not recommended for people with depression. It has also been associated with vivid dreams.
See Malaria Information for Travelers to South Asia.

Ciprofloxacin or equivalent antibiotic to have just in case of traveler's diarrhea. If diarrhea occurs and is lasting more than 24 hours or is associated with blood or fever then take one tablet of Cipro twice a day for 3 days.

Depending on your itinerary other vaccines to consider are:
Japanese encephalitis, if you plan to visit rural farming areas and under special circumstances, such as a known outbreak of Japanese encephalitis.
Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.

TB (tuberculosis) test should be considered after your trip especially if you visit India frequently or if you are staying there for one month or longer.

Over the counter medications to consider depending on your needs:
Imodium for diarrhea.
Diphenhydramine(Benadryl) for allergic reactions, motion sickness, nausea, and as sleep aid.
Hydrocortisone for skin reactions.
Sudafed for congestion, especially if before a flight.
Acetominophen(Tylenol), Ibuprofen(Advil) or other anti-inflammatory medication.
DEET containing mosquito repellant.

Additional information: see the Safe Food and Water page for a list of links. Consider DEET permeated clothing, and wearing long sleeves and pants when outside at dusk or dawn which are feeding times for mosquitos.

Please consult your doctors for any specific questions or if you are pregnant.
And if you really want to avoid the vaccines then check with your doctor, parents, or your old records to see if any of your shots are documented and up to date.

Photographer:Maurice Crosby Photography Ltd. Date:1955 Fonds/Collection:Maurice Crosby Reference no.:accession no. 1997-254/003, nos. 4-5