5.1 Health

DISCLAIMER: I am not a doctor. This section has information to orient you on common topics among travellers so that you can research them online and in books.

Do not wait to the last minute to get your immunizations as some, such as Hepatitis B, can take up to six months to complete the series due to a waiting period between shots. There is a 'short' series with less waiting period, but the standard series is preferred. If you don't finish them, start looking for clinics along the way. You will find them in all Western countries, and anywhere travellers congregate, like Bangkok and Kathmandu. Remember, no immunization provides 100% protection.

Some immunization shots you should have:
Yellow Fever
Hepatitis-A (Havrix; booster in 6-12 months; good for 10 years)
Tetanus/Diphtheria (repeat whenever you are cut severely or punctured deeply)
Typhoid (65% effective)
Polio Booster (especially if you had the original vaccine as a child back in the 50s and early 60s)
Measles/Mumps/Rubella (adult booster)

Some immunization shots you should consider:
Rabies (highly recommended for areas where there is a risk)
Hepatitis-B (3rd dose in 6 months)
Meningitis
Japanese Encephalitis (depends on the area you will be in)
Malaria (there isn't an immunization yet)

I also had my doctor write "contra-indicated" in my International Certificates of Vaccination Card (The Yellow Card), in case of unreasonable and unsanitary demands for Cholera shots at remote border crossings. They do ask for the card occasionally, and sometimes even try to bribe you for things, like money, if you don't have one, as they will insist you need one to enter. The Cholera vaccine isn't very effective. The only time you might want it is if you are going into an area where it is epidemic.

"The Japanese Encephalitis immunization is recommended for those who will be doing rural travel for over a month in an endemic area (an area that has it most of the time) during the mosquito season. Translated to Nepal that would mean, those who visit the Terai (jungle) in December shouldn't worry. Those going trekking through the Terai during the rainy season should seriously worry. Of those who get the disease, 35% in Nepal die, which is consistent with worldwide figures." <Alan Wald>

Although most countries don't require it, you should carry an Immunization (Yellow) Card. Those that do will check your passport to see if you have recently travelled to certain countries. Most Asian countries will verify that you have a Yellow Fever shot, if you have been to sub-Saharan countries, or certain South American countries.

There are a few travel-medicine books on the market, some very small, some too big, but most don't do a thorough job. Bezruchka's "The Pocket Doctor: A Passport to Healthy Travel" is missing the details I need, but it is a nice backup to Lonely Planet's Pocket Guides: "Healthy Travel Africa", "Healthy Travel Asia & India", "Healthy Travel Australia, New Zealand & The Pacific", and "Healthy Travel Central & South America".

TravMed has the entire book, "The International Travel Health Guide" available for sale, or download for free online. It has impressive details not found other places.

A larger book that covers all the information to fill the gap between First Aid and being a medical practitioner is "Medicine for Mountaineering & Other Wilderness Activities." James Wilkerson, who used to be an Emergency Room doctor at UCLA, edited this 416-page book.

"Medicine for the Outdoors: The Essential Guide to Emergency Medical Procedures and First Aid" by Paul S. Auerbach is another popular book.

You should buy a book months in advance, and read the whole thing to determine which medicines you will need to take, then go take First Aid and CPR courses. I will give you some hints on what you need to know, so when you are reading through, you will look for the answers. Those traveling with young children, or who plan to work with children as a volunteer, should consider taking the more advanced pediatric course as well.

Carry a real (mercury) thermometer, not an electronic one. Don't use 'forehead fever strips' only, the kind that measure your forehead temperature by color change. Start taking your temperature if you get the runs AND feel like you have a fever or flu symptoms. Then get a stool test as soon as possible.

"Remember, even with the best parasitologist, equipment, and technique, some parasites will not be easily detected on a single stool exam. My professor from the UCLA School of Public Health, the eminent Dr. Larry Ash, recommends three examinations over a one-week period (one every other day). Since Giardia is located in the upper intestine, and has little suckers that grip the intestinal wall, it is only found in 50% of stool exams." <Alan Wald>

Most travellers get the runs, or worse, on occasion. The most important thing, regardless of other treatment, is to keep from dehydrating. You should know how to make your own Oral Rehydration Solution (ORS) from salt and sugar (or honey, fruits, or fruit juices), although there are other ingredients in packaged ORS, such as baking soda. Also, the cost of ORS in the West is high. In Nepal for example, the unflavored "Jeevan Jal" costs about six US cents, and the lemon-flavored stuff costs ten US cents.

When diarrhea starts, stick to clear fluids for the first day, such as water, clear soup, weak lemon or plain tea, flat ginger ale, and flat Coca Cola or Pepsi. A glass of water, a spoonful of sugar or honey, and a pinch of salt is my favorite. If a travel companion becomes ill, you will need to keep reminding them to sip small amounts of fluid often.

"If you are sick, I would stay away from honey. You don't want to risk any bacterial contamination which may have occurred in the honey." <Alan Wald>

Do not stop eating completely, as your stomach needs food to stay in balance. Yoghurt will help in getting your system back to normal. If you only had a mild bout, then you might be able to go back to some light foods by the next day, such as dry toast, mashed potatoes (without milk or butter), baby foods (mashed bananas, grated apples that have turned brown), rice, and crackers. Avoid spicy food, alcohol, and coffee.

Later, you may add boiled meats, cooked vegetables, and cooked fruit. Milk, other dairy products, fresh fruit, fresh vegetables, and fried foods should be the last foods to be added.

By taking standard precautions, I stayed very healthy in India for four straight months, but then got pretty sick. I don't want to scare you with the realities of travel outside of the West, but washing your hands, keeping them away from your mouth, face, and eyes, and being careful with your food and water isn't fail-safe. For the full scoop, I highly recommend the short and well-written "Understanding Diarrhea in Travellers" established by Dr. Shlim, who worked in the trenches of a well-respected Nepali clinic for more than a decade.

I am no doctor, so I can only point you in the right direction based on my experiences. Malaria, encephalitis, meningitis, typhoid fever, dengue fever, amoebic dysentery, and bacillary dysentary have common symptoms, such as headaches, general malaise, weakness, fever, flu-like symptoms, etc. When you go to the doctor for blood and stool tests, you should already know the answers to some questions:

"A lot of disease may still be unknown or unfamiliar to your doctors back home, or unidentified (like cylcospora was a few years ago, or Legionnaire's Disease), or beyond the capability of labs in certain countries." <Alan Wald>

A common, but not serious disease is from Giardia Lamblia, a parasite that many travellers get many times in certain regions. It is easily identified by burps and farts that smell like sulfur, or cooked egg-yolks, accompanied with much stomach rumbling and diarrhea. It will go away after a few days, only to recur every month or two. It may go away on its own (self-limited), or you get reinfected. It is easy to cure, but it is important to remember that you may be feeling bad, notice these symptoms, and correctly diagnose Giardia, but you should still need to be tested. You will not know if you have something else -- the worse your environment, the more likely you are to have multiple infections -- you want to know that you don't have amoebic dysentary or typhoid. While you are there, get a blood test for malaria. Stool tests are not expensive, so save those empty film containers for samples.

Learn about the modes of transmission, from: people, food, mosquitoes, rivers, sand, etc.

Learn about worms before you go for a refreshing dip in Africa and Asia. Stay out of fresh water unless you know it is not infected with Schistosomiasis. (Major problem in Egypt; avoid even wading in the Nile.)

Be very careful about buying medicines overseas. In some places, almost everything is either expired, very old, or a counterfeit. Also, some medicines, such as Lariam, are very difficult to find when you need them, so stock up before heading out.

I had some medicine shipped to Asia by regular mail without any customs problems. Regardless of warnings, unless they are illegal (usually pain killers) in the country you are sending to, then anything is allowed for 'personal use'. If you are worried about them not arriving for any reason, ship them to your embassy or consulate as "Emergency Medicines", if your embassy still allows this, otherwise try your hotel or a travel agency.

Doctors in Europe can be inexpensive, so if you have the prescription, and the US version isn't available, they can use the trade name to find the real name in a huge book, then find the same product by another trade name for sale in Europe, or a close equivalent. Also, ask around for low-cost clinics. I will never forget the pharmacies in Beijing -- glass cabinets full of US medicines at good prices, including top of the line heart medicines, requiring no prescriptions, although they might have been past their expiration date. I bought the usual aspirin, vitamin-C, and a multi-vitamin, although the ampicillin and cipro are also good to stock up on when there.

"Technically, when returning to the US, you are allowed to bring in prescription medicine in reasonable quantity for personal use only (as long as it is legal in the USA and non-narcotic). However they expect you to have a prescription for it. If you have a friendly doctor, it wouldn't be a bad idea to have prescriptions for all likely drugs. If they stop you at customs with a bunch of foil strips of cipro, you can show them the prescription from the US, explaining that things are very primitive, and they don't label the packages the way they do in the US, as everything comes in large cardboard boxes with lots of foil strips in them." <Alan Wald>

Visit the American Board of Medical Specialties for detailed information on physicians abroad. They used to print an excellent reference, The Official ABMS Directory of Board-Certified Medical Specialists, but stopped in 2004. It has a short biography with a history of medical education, training, career, and address information. It is separated into sections for each of the 24 approved specialty boards. They are broken down by state, then city, for the US and Canada. At the end of each section is a list, by country, of the physicians residing in other countries. This enormous four-volume directory is usually available in local libraries in the US and Canada.

If you need a list of physicians while you are on the road, email a friend, a reference librarian, or look for an online expert at Experts.com, or OnlineExpert.com. Embassies and consulates abroad also maintain lists of hospitals and physicians. Major credit card companies also can provide the names of local doctors and hospitals abroad.

"One of the main reasons I got an American Express card is for the services it provides to card holders while overseas. One in particular is the "Doctor Finder" service. You can call American Express collect any time of day and tell them your medical situation, then they will give you the names of two or three English speaking doctors/hospitals in your area. They will even make the appointment for you if you want. We used this service a couple of times and it worked well." <Russell Gilbert>

U.S. citizens who will be trekking or rafting should register with the U.S. Embassy (green card holders do not have this right). Also be sure to leave your itinerary with someone at your travel agency or hotel (whichever you consider your 'local address'). The main benefit of being registered is, in the unlikely event that you need to be rescued by helicopter, the U.S. Embassy will guarantee payment (you still have to pay), and this guarantee is needed BEFORE the helicopter takes off. Other nationalities should check with their embassies to find out their policies.

Also remember that there is a US Marine Security Guard on duty at Post One at the US Embassy 24 hours a day, 365 days a year. While the Marine can't leave his post to aid you, he can certainly give you the telephone numbers of doctors, hospitals, and other emergency personnel.

"When in doubt as to what to do or where to go after possible rabies exposure, contact the US Embassy. Even if you are not American. It is a potential medical crisis and not the time to get nationalistic or political. The embassy is always your best source for rabies treatment options. When there is no US Embassy, contact the British or Canadian Embassy. Where they don't exist, try another, such as France, Germany, Australia, or New Zealand." <Alan Wald>

"My experience suggests that eating local food from street-side food sellers and restaurants is fine. Problems arise when you eat at tourist restaurants -- just because somewhere has a menu in English, doesn't mean the kitchen is clean; in fact, probably the reverse. Eat where there will be a faster turnover of food, and things will be cleaner, cheaper, and better. In tropical climates, fake European foods are dangerous, besides boring, tasteless, expensive; the food needs the spices to keep bugs and insects at bay. Look at the food seller -- if they look healthy, especially the whites of their eyes, then that's a far better indication of clean food than a Formica tabletop, Eagles tapes in the background, and banana pancakes on the menu." <Anonymous>

"You never really know what you got sick from unless there is a group all coming down with the same symptoms at the same time. Problems arise when you eat without: an inspection by qualified inspectors, an examination of the food-preparer's health, proper training of the food preparer, and random testing of the food -- don't count on anything. The whites of their eyes will only help you to determine their health status if they have acute Hepatitis. Also, you can't really tell health by looking at someone. Eating where the locals eat isn't always going to help in poor countries with low standards. It is better to eat where the foreigners living and working in the country (expats) eat. I think the general principle of eating in a place doing decent business makes sense because of the turnover of food, whether it is locals or tourist eating there. The embassy has an 'informal' list of recommended places, they can't publish but a friendly consular officer will certainly point you in the right direction." <Alan Wald>

"Everyone should assume they are going to get roundworm, so get a final stool exam about six months after your last exposure. It may take months for the worms to become adults and produce eggs, which is how they are normally detected." <Alan Wald>



Malaria

An important issue that is a mainstay of travel discussions is malaria prevention. I have included a few links specifically about this topic, however, the general health links will have information too. This summary will get you started, but you must read up on this.

The debate revolves around prophylactic (preventative) vs. presumptive (you got it) treatment -- whether to medicate before or after contracting malaria. Family doctors tend not to have any particular knowledge about tropical or Third World diseases (When was the last time that there was a malaria outbreak in New England?), so they take the safe course and medicate. This has led to an increasing resistance among the malaria parasite, and a corresponding increase in the strength of today's medicines, causing strong and noticeable side effects in many who take them. Also, you cannot take the preventatives for more than a few months due to side-effects. Long-term overseas workers are a good example of those surviving without the pills. The best protection is to avoid mosquitoes.

Many who take the drugs do not take precautions to avoid being bitten by mosquitoes, under the mistaken assumption that they are protected. Furthermore, by exposing the parasite to the prophylaxsis, they help to establish stronger and more dangerous strains of malaria; strains that are increasingly difficult to treat, and for which the local populations have no immune defenses.

Malaria is deadly, but not in a high percentage for strong and healthy people, except for cerebral malaria, which is life-threatening to all. Malaria is extremely common in the developing world and can make you very ill. Attacks can recur for years. In some malaria, such as Vivax, they can go into an exo-erthryrocytic cycle (outside the red blood cells) in the liver, where they go to 'sleep' as 'hypnozooites'. They can come out again (wake up) years later.

Available medications aren't completely effective (the parasites are becoming increasingly resistant to the common drugs), but can at the very least, reduce the virulence of an attack and give you time to get treatment if an attack begins. This is most important in areas where cerebral malaria occurs (this attacks the nervous system of the brain and kills within hours, if the patient has no protection). Cerebral malaria is responsible for the deaths of 1.5 million people a year, and is found in sub-Saharan Africa, South America, and SE Asia (particularly Cambodia and Laos, but also Vietnam and Thailand).

The malaria-carrying mosquito is a night-feeder. It does not bite during the day but only comes out when the sun is going down. The dengue fever mosquito on the other hand, bites during the day, but is less wide-spread. From sundown until sun-up, you should wear long dark clothes to cover exposed skin (especially ankles) -- these are the only hours when the malarial mosquito feeds. Do not go out unnecessarily in malarial areas.

Use a mosquito-repellant. Beware of those with too much DEET (more than 30%), which can be toxic. There are natural repellants based on citronella and other herbs. Avon's Skin-So-Soft is also popular. It is important to protect those areas favored by mosquitoes -- your ankles, elbows, and arms, since these are where the arteries and veins are closest to the skin.

Burn mosquito coils in your room and under restaurant tables. At dusk, light a coil, then open your room and the mosquitoes will fly out to the light and fresh air. Some hotels will even supply them if you ask. There are also electric mosquito repellants which heat up a saturated pad, or liquid, evaporating the repellant, so your room doesn't get smoky, nor will it irritate your eyes as much as coils. Electricity doesn't always work, nor is it always available. In addition, you may want to spray your room, especially under the bed and in dark areas of the room.

Use mosquito nets over your bed, but be careful with lighting candles near them. I suggest buying a sturdier Army-Navy Surplus net if you will be in mosquito areas for very long. Many hotels in SE Asia have netting, usually with large holes that can be taped up. (If you have screens on the windows, tape up the inevitably large holes too.) If your room doesn't have any netting, ask them for it. If they don't have any (and especially if there's no ceiling fan over the bed or on a table to blow the mosquitoes away), find another hotel.

Soaking the net in permethrin once a year (air it out good) has proven to be effective in repelling mosquitoes and bed bugs, without being a serious health risk. However, I don't find it necessary after all the basic precautions.


Links
American Society of Tropical Medicine and Hygiene (ASTMH)
Malaria Foundation
The Malaria Debate by Anne T. Merriman
Malaria Vaccine Initiative
Lariam Information


Your Feet

One thing that will pay off is close attention to your feet, since you will be doing plenty of walking. If you cannot get a copy of "Fixing Your Feet" by John Vonhof, or "The Hiking Engine" by Stuart Plotkin, then visit Foot.com or The Podiatry Network.



Health Links
American Society of Tropical Medicine and Hygiene
Center for Disease Control (CDC) Travel Page
CIWEC Clinic Travel Medicine Center
International Society of Travel Medicine (ISTM)
International Association for Medical Assistance to Travellers (IAMAT)
NY Center for Travel & Tropical Medicine
Lonely Planet Health Forum
Medical Advisory Services for Travellers Abroad
MD Travel Health
Shoreland's Travel Health Online
Travellers Medical and Vaccination Centre Group
TravMed
World Health Organization


Vegetetarian Links
International Vegetarianism Union
Vegetarian Phrases in World Languages

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