Health Guide Chapter 2
When traveling overseas, you should:
- Consider visiting a travel clinic prior to departure. Travel clinics can provide specialized immunizations and prescriptions for medications, as well as providing essential advice about how to prevent or treat illness abroad.
- Learn about the availability and quality of health care available at your destination.
- Know how to obtain the names of qualified, English-speaking doctors and which facilities provide the best care at their destination.
- Purchase a travel health policy that directly pays doctors and hospitals abroad and that also coordinates and pays for emergency medical evacuation.
- Carry standby antibiotics to treat travelers’ diarrhea, and bring at least a basic first aid kit.
- Have available copies of key portions of your medical records (e.g., a recent ECG) and a list of their medications, if health problems are a concern.
- See a physician immediately if a fever develops during a trip to the tropics or soon after your return. Malaria is a medical emergency you may need to consider.
- Cefixime is no longer recommended for the treatment of gonorrhrea. The FDA now recommends that instead use combination therapy with ceftriaxone, 250 mg intramuscularly, and either azithromycin, 1 g orally as a single dose, or doxycycline, 100 mg orally twice daily for seven days.
- Travelers should consider carrying the nonabsorbable antibiotic rifaximin (Xifaxan) to treat travelers’ diarrhea (TD). It is effective against E. coli, the most common cause of TD. Also used in the treatment of irritable bowel syndrome (IBS).
- Prophylactic treatment with rifaximin 600 mg/d for 14 days safely and effectively reduced the risk of developing travelers’ diarrhea in US travelers to Mexico. Rifaximin is effective against enterotoxigenic E. coli (ETEC) and enteroaggressive E. coli (EAEC) and has also shown effectiveness in the prevention of shigellosis.
- The non-DEET repellent picaridin is now available in a 20% formulation and is comparable to DEET for protecting against mosquito bites that transmit malaria and other infectious tropical diseases. It has more favorable cosmetic properties than DEET and will not damage synthetic materials, such as plastic.
- Starting in May 2009, Portable Oxygen Concentrators must be allowed on all flights originating or ending in the United States. Certain restrictions apply. This will require all airlines operating in the US, including foreign airlines, to allow the use of approved POCs on-board and in-flight.
When preparing for your trip, list the countries you will be visiting (in order) and the length of time you plan to spend in each one. There are four questions you need to answer about your trip, which will determine the degree of detail needed in planning ahead.
What is My Destination?
You should ask yourself the following questions: What illnesses are prevalent in the region I will be visiting? What is the general level of sanitation? How competent, and close by, is medical care? How harsh is the climate? How safe are the roads? Is the country politically stable?
Also, remember that a trip to Western Europe, for example, doesn’t require as much preparation as an extended stay in a remote village in a less developed region. Because some countries and cities are much safer than others, be careful not to overdo precautions. You don’t need a typhoid shot if you are going to London or Tokyo, nor do you necessarily need a whole series of immunizations if you’re taking a brief trip to a less developed country but staying exclusively in a deluxe hotel in a large city. For updated information on country-by-country disease risks, consult the World Medical Guide section of this book.
What Will I Be Doing?
Staying in rural areas of less developed countries puts you at greater risk of contact with unsanitary food and drink and usually brings greater exposure to disease-carrying insects. (However, some diseases, such as dengue fever, are also transmitted in urban areas. There is also the risk of malaria in most cities in sub-Saharan Africa.)
Traveling on a tour and staying only in air-conditioned, deluxe hotels, typically carries less risk than traveling in rural areas off the usual tourist routes. Planning an adventure or wilderness itinerary with exposure to extremes of heat, cold, or altitude also takes additional preparation, as does trekking or camping in a remote area far from medical care. Driving a car, motorcycle, or moped in a less developed country may be quite hazardous as motor vehicle accidents account for most preventable fatalities among travelers. Higher risk activities also include swimming in unfamiliar, possibly treacherous, waters, or wading/rafting in freshwater ponds, lakes, or streams. Engaging in casual, unprotected sex is another potential health problem. Therefore, a close analysis of your activities is critical in helping you avoid illness and injury.
How Long Will I Be There?
A brief trip usually means less exposure to diseases and less opportunity for an accident. Longer trips increase the likelihoods of side trips and excursions that may place you at an unforeseen risk, perhaps for a mosquito-transmitted disease such as malaria. Longer travel may also cause you to discontinue prophylactic antimalarial medication, abandon safe food and drink practices, or neglect insect protection measures. Long-stay travel also brings with it the risk of “culture shock” and the need to know more about local customs, traditions, and history. Therefore, if you will be working overseas, you must also consider what psychological stresses you, and perhaps your family, will experience while adjusting to life abroad and what resources you will need beforehand to help make a smooth adjustment.
What Should I Bring?
Your itinerary, the climatic conditions you expect to encounter, the duration of your trip, and the disease risks in the countries you will be visiting all influence what you should bring. For example, many travelers to tropical and subtropical regions neglect to take precautions against insect bites necessary to prevent malaria and other insect-transmitted diseases. Be sure you have the necessary supplies (DEET repellents, permethrin insecticide, mosquito netting) described in Chapter 8. Your health status may also require you to take additional precautions.
When traveling overseas, take an ample supply of any medication that you use regularly, as well as copies of your prescriptions and the generic names of the medications; brand names are usually different overseas. Do not carry a mixture of pills in unmarked vials. To avoid problems with customs officers who might suspect that your pills are recreational drugs or illegal narcotics, keep each medication in its labeled original container. Note: Certain countries deny entry to HIV-positive travelers. If you are HIV-positive, be prudent when packing your medications.
Carry legally prescribed narcotics and controlled drugs (tranquilizers, sleeping pills, etc.) only if medically necessary. If you are a diabetic taking insulin and carrying needles and syringes, you may also arouse suspicion at customs checkpoints. Obtain a letter on a professional letterhead from your doctor certifying the need for these medications and certifying your diagnosis and treatment. The same applies if you will be carrying needles and syringes in an HIV/hepatitis prevention kit.
Marijuana is now legal in many states, so the number of travelers with it has increased. Marijuana can be detected in your luggage by dogs that are trained to sniff out the drug. If you have marijuana in your luggage, go on-line to get advice about how to wrap so it can’t be sniffed out.
Consider carrying with you on the plane a drug to prevent/treat nausea and vomiting. The best choice is Zofran ODT (Ondansetron). ODT means orally dissolving tablet so you let the pills dissolve under your tongue, This drug is commonly used for chemotherapy patients to control nausea and vomiting. Lesser doses can be used during travel for motion sickness or other causes of nausea and vomiting.
The initial dose is 8 mg. Can be repeated several times per prescription instructions on label
Use the following checklists as general guidelines and modify them according to your itinerary and specific travel and health needs. A nylon or canvas pack (e.g., the Wallaby Trip Kit by Eagle Creek) or a first aid kit are useful for carrying medications and other healthcare items. Any medical kit containing sharp objects, such as scissors or a scalpel, should be in your checked baggage to avoid possible confiscation at an airline security checkpoint. Medications and other items needed en route should always be carried on your person.
Medical and Personal Care Items
- An adequate supply of your prescription medications—Carry copies of your prescriptions by generic names. Determine how much of each medication you will need for the duration of your trip, and if you will need refills. Check local availability of medications, but know that regionally manufactured drugs may be substandard or counterfeit. The illicit market in bogus, copied, relabeled, adulterated, and look-alike drugs is burgeoning; therefore, be careful. It may be prudent to bring enough medications for your entire trip—or make arrangements for additional drugs to be shipped to you from home.
- Antibiotics for treating travelers’ diarrhea—Fluoroquinolone antibiotics are currently the most effective drugs and include levofloxacin (Levaquin) and ciprofloxacin (Cipro).
- Azithromycin (Zithromax) is the best alternative treatment for travelers’ diarrhea. It is the drug of choice for treating travelers’ diarrhea in children. Rifaxamin is a new antibiotic effective against E. coli (ETEC-see Chapter 6). Ciprofloxacin and azithromycin are available in liquid forms for children.
- Antibiotics for self-treatment of other infections—The fluoroquinolone levofloxacin (or ciprofloxacin or moxifloxacin) and azithromycin are good choices but no one drug covers every illness. The fluoroquinolones are effective against acute bacterial bronchitis, community-acquired pneumonia, urinary tract infections, typhoid fever, skin infections (cellulitis), and nongonococcal urethritis. Fluoroquinolones may not be effective against methicillin-resistant staph aureus (MRSA) skin infections and are no longer recommended for treating gonorrhea. Azithromycin is a good choice for respiratory infections and is also effective against typhoid and cholera.
- Azithromycin is effective against sexually-transmitted diseases. A single 2-g dose of azithromycin is as effective against uncomplicated gonorrhea as a 250-mg dose of ceftriaxone (but has more gastrointestinal side effects). Azithromycin is also first-line treatment for chlamydia infections.
- Cefixime is no longer recommended for the treatment of gonorrhrea. The FDA now recommends that instead use combination therapy with ceftriaxone, 250 mg intramuscularly, and either azithromycin, 1 g orally as a single dose, or doxycycline, 100 mg orally twice daily for seven days.
- Loperamide (Imodium-AD, Diamode)—Use to treat mild to moderate travelers’ diarrhea, or use in combination with an antibiotic to treat more severe diarrhea.
- Antimalarial drugs—Recommended especially if you are going to sub-Saharan Africa—an area where falciparum malaria is a major threat (see Chapter 7). These drugs are usually taken for prophylaxis; occasionally, they are carried for self-treatment.
- Medical kit—At a minimum, carry a basic first-aid kit that contains a thermometer, Band-Aids, gauze pads, 1 or 2 roller gauzes, antibiotic ointment, scissors, and tape. Blister pads (Spenco, moleskin) should be included. The size of the medical kit depends on the number of travelers, length of stay, and the availability of local health care. Some travelers (especially those with multinational corporations) also carry kits with suture supplies and intravenous fluids.
- Sterile needle/syringe kit—Recommended when traveling to countries where hepatitis B, hepatitis C and HIV can be transmitted by nonsterile medical injections or surgical procedures.
- Water filtration/purification supplies—MicroPūr tablets, Katadyn filter, and the Exstream water purification bottle are popular.
- Oral rehydration salts (e.g., CeraLyte)—Use to treat dehydration caused by severe diarrhea. A 1- liter plastic bottle is adequate for storing water or rehydration solution.
- Epinephrine kit—If you have a history of severe bee sting reactions or severe food or drug allergies, have your doctor prescribe an emergency epinephrine self-injection kit (EpiPen). Be sure you know how to use it before you leave.
- Analgesics, such as ibuprofen (e.g., Motrin, Advil) or acetaminophen (Tylenol)—Acetaminophen with codeine, or with hydrocodone (Vicodin), also has antidiarrheal properties. Aspirin can lose potency when exposed to humidity and heat. Acetaminophen is not affected by these conditions.
- Antacids—Maalox or Mylanta are useful.
- Pepto-Bismol—Useful for the prevention and treatment of diarrhea (Chapter 6).
- Cathartics and/or stool softeners. Constipation can be a problem in elderly travelers.
- Motion/sea sickness drugs—TransDerm Scōp patch (for sea sickness on cruises); SCŌPACE (scopolamine tablets), Dramamine, and Phenergan are shorter-acting agents.
- Drugs to prevent or treat altitude illness (see Chapter 15)—These should be considered when ascending above 8,000 feet.
- Jet lag—Sleeping pills, e.g., triazolam (Halcion) are helpful for some people who find insomnia the most troublesome symptom of jet lag. Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) are alternatives. Melatonin has limited effectiveness, and is not approved by the FDA for this indication.
- Contact lens wearers—Antibiotic eye drops containing a fluoroquinolone (levofloxacin or ciprofloxacin) for treating an infected corneal ulcer should be carried. Untreated bacterial infections can cause corneal scarring.
- Hand sanitizer gel or disinfecting skin towelettes—These are convenient when soap and water are not available. Good hand hygiene helps prevent the transmission of travelers’ diarrhea; hand sanitizers also kill viruses that spread respiratory infections.
- Nasal decongestant spray—Afrin or Neo-Synephrine.
- EarPlanes—Pressure-regulating earplugs will reduce pain associated with air travel. Especially recommended if you have trouble clearing your nasal passages during flight.
- Antihistamine tablets—Useful for allergic reactions and rhinitis (hay fever). Zyrtec and Claritin-D are long acting and less sedating. Check with your pharmacist about any possible drug interactions with medications you may be already taking for a chronic condition.
- VōSol solution (2% acetic acid)—This prevents or treats swimmer’s ear.
- Corticosteroid cream, such as Cortaid or Topicort—The steroid creams available by prescription are more effective for treating rashes than the over-the-counter products.
- Antifungal foot powder—Lotrisone and Tinactin are good choices. These are essential when traveling in the heat and humidity of the tropics.
- Antifungal tablets—A single, oral 150-mg tablet of fluconazole (Diflucan) will eradicate a vaginal yeast infection. (These infections can result from using an antibiotic.)
- Extra pair of prescription glasses or contact lenses—Bring a copy of lens prescription.
- Other useful items:
- Other useful items: Tweezers (good for tick and splinter removal), small knife, scissors, or Swiss Army knife (keep out of carry-on luggage). Large safety pins often come in handy.
For Rain, Sun, Heat, and Insects
- Hat, sunglasses, umbrella
- Sunscreens—Broad-spectrum sunscreen, minimum SPF 30.
- Insect repellent—Important when traveling to a country where insect-transmitted diseases, such as malaria, are a threat. Travelers should use a skin repellent that contains at least 30% DEET. A good choice is Ultrathon, which provides 12-hour protection against mosquitoes, as well as ticks and biting flies.
- Clothing insecticide—Permethrin is an insecticide that kills insects that touch the treated fabric (e.g., clothing, gear, tents, mosquito nets). Against ticks, it is more effective than DEET. When used in combination with a DEET repellent (as is done by the U.S. military), up to 100% protection against mosquito and tick bites can be achieved.
- Mosquito bed net (preferably permethrin-treated)
- Insecticide spray (e.g., Raid Flying Insect Spray) to rid sleeping quarters of night-biting insects
Medical kits and other supplies: Sources include Adventure Medical Kits on-line catalog www.travmed.com (603-444-5464) and Chinook Medical Gear, Durango, CO (800-766-1365). On-line catalog www.chinookmed.com
Checking the Weather at Your Destination
Global Weather Information: http://weather.yahoo.com/
Adequate pre-trip planning is essential. If you’re on an adventure itinerary, determine what exposure you will have to heat, cold, or altitude. If you are on a trek, most tour organizers will advise you of what to bring, but you may need to consult experts in outdoor/wilderness travel to determine if what is recommended is truly adequate. A Comprehensive Guide to Wilderness & Travel Medicine, 3rd ed., AMK Publishers, Oakland, CA 2000, by Eric A. Weiss, M.D., is a recommended resource and can be ordered from the publisher (Adventure Medical Kits: 800-324-3517) or amazon.com.
Checklist for campers, hikers, and trekkers—You need to anticipate sudden changes in weather, in particular, high winds, rain, and temperature drops. For your comfort and safety, be sure always to carry an outer shell or parka that is waterproof and breathable, fleece vest or jacket, cap and gloves. Multiple layers of clothing should be worn in more extreme conditions. Review the following checklist for additional items your trip may require.
Can I Bring It with Me?
The Transportation Security Administration (TSA) has guidelines for carry-on items here.
Shipping my Luggage and Other Stuff
You may want to unburden yourself of bringing heavy, bulky suitcases, sports equipment, or other items with you. There are several companies who will ship ahead for you:
Travel Documents You May Need
Passports—The Bureau of Consular Affairs’ website (http://www.travel.state.gov) provides comprehensive information about applying for, or renewing, a passport or visa. Passport application forms can be downloaded from this site.
What if I need a passport in a hurry, or I have lost my passport? Normally, it takes about 6 weeks to get your passport from the U.S. Passport Agency. The Passport Agency will expedite the process for an additional $60 (subject to change), plus overnight shipping, and your passport will arrive in about 2 weeks. Passport/visa service companies, however, can obtain a passport for you in as little as one business day, plus overnight shipping. This assumes you have all your documents in order. Also, if this is a first-time passport, the application must be witnessed and sealed by an authorized passport acceptance agent (found at federal, state and probate courts, post offices, some public libraries, and a number of county and municipal offices) before the passport/visa service company is able to process the application. This expediting can be expensive—you pay the passport government’s passport fee, plus as much as $180, plus shipping for next-day service. Standard expedited service (6 to 9 business days) is about $60 plus the other charges. Contact one of the following:American
- Passport Express, 800-841-6778 (www.americanpassport.com)
- Passport Plus, New York, NY, 212-759-5540 or 800-367-1818 (www.passportplus.net)
- Passport and Visa Expeditors, Washington, DC, 800-237-3270
- Travisa, Washington, DC, 202-463-6166 or 800-222-2589 (www.travisa.com)
- TravelSeeker (www.passportnow.com). Lists numerous online companies that can expedite getting a new or renewed passport.
Lost Passport Overseas
Q. WHAT SHOULD A U.S. CITIZENS DO IF THEIR PASSPORT IS LOST OR STOLEN ABROAD?
A. Contact the nearest U.S. embassy or consulate for assistance. Phone numbers for U.S. embassies and consulates are also available in our Consular Information Sheets and Key Officers handbook. You will need to speak to the American Citizens Services unit of the Consular Section. If you are scheduled to leave the foreign country shortly, please provide the Consular Section with details regarding your departure schedule. Every effort will be made to assist you quickly. You will also be directed to where you can obtain the required passport photos.
Bring a copy of your passport with you to facilitate getting a new one if needed.
If you are notified by a relative or friend that their U.S. passport has been lost/stolen, you may wish to contact Overseas Citizens Services , (202) 647-5225 at the U.S. Department of State in Washington, D.C. providing as much information about possible about the person’s who needs passport services abroad. This will assist us in trying to verify the person’s previous passport, clearing the person’s name through the Department Passport Name Check System, and relaying this information to the U.S. embassy or consulate. Your relative/friend must apply for a new passport at the nearest U.S. embassy or consulate.
Q. WHAT ARE THE REQUIREMENTS TO OBTAIN A REPLACEMENT PASSPORT?
A. You will need to complete a new passport application . The consular officer taking an application for replacement of a lost, stolen, or misplaced passport must be reasonably satisfied as to your identity and citizenship before issuing the replacement. In virtually all cases this can be done through examination of whatever citizenship and identity documents are available, conversations with the applicant, close observation of demeanor and replies to questions asked, and discussions with the applicant’s traveling companions or contacts in the United States. Please note the new requirements for passports for minors under the age of 14 and how this will change the way passport applications for minors are handled abroad.
Q. WHAT INFORMATION WILL I NEED TO PROVIDE THE CONSULAR OFFICER?
A. You will be asked for certain information to assist in verifying your citizenship:
Personal Data: (including, but not limited to)
- your name
- date of birth
- place of birth
- passport number (if available)
- date and place where your passport was issued
If you can provide the U.S. embassy or consulate with a photocopy of your passport identification page, that will make getting a new passport easier since your citizenship and identity information would be more readily available.
Affidavit Regarding Loss/Theft of the Passport/Police Report:
When you report the loss, theft, or misplacement of your passport you must execute an affidavit fully describing the circumstances under which it was lost, stolen. U.S. Department of State form DS-64 may be used for this purpose, or you may simply execute a sworn statement before the consular officer describing what happened. A police report is not mandatory but may be required when the embassy/consulate believes a problem may exist such as possible fraud. An applicant eligible to receive a passport should not be placed in circumstances to miss a plane or unreasonably delay travel to obtain a police report.
Citizenship Verification and Name Clearance:
The U.S. embassy/consulate will confirm your previous passport issuance through the Passport Verification System. The consular section will also attempt to clear your name through the U.S. Department of State name check system to ensure there is nothing preventing issuance of a U.S. passport to you (for example: outstanding arrest warrant, court order, etc.)
Proof of Identity:
You will also be asked for some proof of your identity. If all your personal papers were lost or stolen with your passport, your identity can be established in a number of ways. In most cases the problem of identity is resolved quickly. It should be noted, however, that if there is any indication of possible fraud the consular officer may request additional documentation or other information.
Information From Consular Interview: The consular officer may be satisfied as to your identity based on the interview with you, or may require other information.
Identifying Witness: Persons traveling with a group or with friends, family or associates in the foreign country can have such a person execute an affidavit of an identifying witness before the consular officer. An identifying witness does not have to be a U.S. citizen.
Information From Family, Friends or Associates in the United States: If you are traveling alone and do not know anyone in the foreign country who can attest to your identity, your family, friends, or associates in the U.S. may contact the consular officer by phone or fax confirming your identity. This is usually quite informal. In emergency situations, your contacts may also communicate with the U.S. Department of State, that Overseas Citizens Services , (202) 647-5225.
Information From Previous Passport Records: If necessary, information about your identity may be obtained from your previous passport application which may have to be retrieved by Overseas Citizens Services , (202) 647-5225, in the U.S. Department of State from the Federal Records Center which is located outside of Washington, D.C.
Q. WILL THE REPLACEMENT PASSPORT BE ISSUED FOR THE FULL 10-YEAR VALIDITY PERIOD FOR AN ADULT?
A. Replacements for lost passports are normally issued for the full 10-year period of validity for adults. Occasionally, cases will arise in which the consular officer has some lingering doubt because of statements made by the applicant, or other circumstances, but is still reasonably satisfied as to identity and citizenship. If there is not time to request and receive the Department’s verification, a passport limited to 3 months may be issued. Limited passports may also be issued in cases in which an applicant has, by mistake, packed the passport with luggage being sent to another location, left the passport at home, perhaps in another country, but has to travel immediately, lost or been robbed of multiple passports in a short timespan, etc. When issuing a limited passport in an emergency situation, consular officers will carefully explain to the applicant that the passport is limited for the duration of the present trip only. When the applicant returns to the United States and wishes to travel again internationally, the applicant will have to apply for a replacement passport and pay the regular fee.
Q. ARE FEES CHARGED FOR REPLACEMENT OF LOST/STOLEN PASSPORTS ABROAD?
A. The normal passport fees are collected from applicants for replacement passports. Applicants will be asked to provide names of persons they feel would be able to assist them financially if there is sufficient time. See our information about Financial Assistance to U.S. citizens abroad and Learn About Sending Money Overseas to U.S. Citizen in an Emergency.
However, if: the applicant’s money and documents have been lost or stolen, or the applicant is a victim of a disaster and the applicant does not have and cannot reasonably be expected to obtain money to pay the fees before continuing travel, no passport fee will be charged and a limited validity passport will be issued. When the person applies for a full validity passport on their return to the United States the regular passport fee will be charged for the replacement passport. See the U.S. Department of State Schedule of Fees, 22 CFR 22.1
Q. CAN THE U.S. EMBASSY ISSUE A REPLACEMENT PASSPORT OVER A WEEKEND OR HOLIDAY?
A. U.S. passports are not routinely issued by U.S. embassies and consulates abroad on weekends and holidays when the embassy/consulate is closed. All U.S. embassies and consulates have an after hours duty officer available to assist with life or death emergencies of U.S. citizens abroad. Contact the nearest U.S. embassy or consulate after hours duty officer for assistance if you have an emergency need to travel. Phone numbers for U.S. embassies and consulates are also available in our Consular Information Sheets and Key Officers handbook.
If you are scheduled to travel directly to the United States, the duty officer may be able to assist in issuing a transportation letter to the airline and alerting U.S. Customs and Immigration to the fact that you will be attempting to enter the United States without a passport.Duty officers must focus primary attention on life or death emergencies. Depending on the circumstances and conditions in the foreign country, it is possible that a replacement passport may not be issued until the embassy/consulate reopens for business. At that time the Consular Section will be in a better position to verify your citizenship and identity and clear your name through the Department of State name check system.
- Visas—The best source to obtain up-to-date visa requirements for travel to other countries is the website of the Bureau of Consular Affairs (http://travel.state.gov/travel/tips/brochures/brochures_1229.html).
After verifying the need for a visa, contact the embassy or consulate of the country or countries of your destination to verify information regarding the documents you will need and the processing time required. You can also use one of the passport expeditor companies listed on the previous page to file the application. Go to their websites to view the process and fees.
- HIV testing requirements for entry into foreign countries—Not all HIV testing requirements are found on the U.S. Department of State website, or the requirements may have changed, so check with the embassy or consulate of the country that you plan to visit to verify the requirement for entry, if any. The HIV test is usually required only for those applying for a foreign work permit, prolonged residence, or immigration—not for tourist visits of less than 1 to 3 months. Tests done in the United States or Canada may not be accepted..
- International Certificate of Vaccination (Yellow Card)—Yellow fever vaccinations must be given at official Yellow Fever Vaccination Centers (e.g., a travel clinic, your local health department) as designated by respective state health departments. The international certificate of vaccination (the Yellow Card-pictured below) must be validated with the “Uniform Stamp” and signed by the physician or the physician’s designee. The Centers for Disease Control and Prevention website (www.cdc.gov/travel) lists all the authorized Yellow Fever Vaccination Centers within the United States, by state, that are licensed to administer the yellow fever vaccine and the certificate of vaccination.
You need to have in your possession a validated International Certificate of Vaccination when entering countries that require proof of yellow fever vaccination. Some countries in sub-Saharan Africa require ALL travelers to have a valid Certificate, but for most countries the requirement is only if you are arriving from an infected area or from any country in the yellow fever endemic zones. The Certificate of Vaccination becomes valid 10 days after the immunization is administered. Be sure to take this lag period into account. You should carry the yellow card with your passport.
Newly revised in 2007, the new International Certificate of Vaccination is approved by the World Health Organization as the official document verifying that proper procedures were followed in administering vaccinations for foreign travel. It is used to demonstrate receipt of required vaccinations for entry into foreign countries, and is designed to fit into a passport. In addition, the International Certificate of Vaccination is used to record the following information:
- Date and dose of all vaccinations received for foreign travel
- Medical exemption from receipt of required vaccinations
- Personal health history
- Drug allergies
- Current medications
- Prescriptions for eyeglasses or contact lenses
Note: Currently no country “officially” requires cholera vaccination as a condition of entry. Local authorities in some (usually sub-Saharan) countries, however, may require documentation of vaccination. This tactic may be used to extract a bribe to waive the “requirement.” Depending on your itinerary (and because the cholera vaccine is no longer available in the United States), you may have your health-care provider state on your Yellow Card “Exempt from cholera vaccine” and have the exemption stamped and signed. Note: There is no section for cholera vaccination on the new Yellow Cards. Some travel clinics routinely state that the vaccine is contraindicated; in some cases the clinic will create a cholera stamped area while being sure that the traveler knows that they did not receive the injection.
- Extra photos—Obtain at least eight (8) additional 2¢¢Ž 2¢¢ photos when applying for your passport or visa(s). These extra photos will come in handy if you need additional visas or an international driver’s permit or if you need to replace a lost passport or other document.
- Personal health records—Consider carrying photocopies of your health and hospital records, recent electrocardiogram (ECG), laboratory test results, list of current medications, allergies, etc. Or, you may wish to subscribe to a service that can assemble all of your pertinent medical records, store them in a computer, and fax or e-mail them anywhere in the world within minutes. Contact Global Med-Net (800-650-SAVE) for further information.
- Travel health insurance—It is always a good idea to purchase a travel insurance policy (Chapter 18). These policies pay overseas doctors and hospitals at the time of the visit, and they also cover emergency medical transport. Check your existing health insurance policy to see what benefits are provided in case of illness overseas. Normally, only emergencies are covered. Medicare does not pay for out-of-country illnesses or accidents, so anyone with Medicare should also have MediGap coverage.
- Doctors and hospitals abroad—The International Association for Assistance to Travelers (IAMAT) publishes a booklet listing hospitals and English-speaking physicians overseas. 417 Center Street, Lewiston, NY 14092; 716-754-4883. The Destinations Section of Travel Medicine, Inc. has extensive country listings of doctors and hospitals, with many website addresses.
- Medic Alert bracelet—If you have a serious or chronic medical condition, a history of severe drug allergy, etc., you should consider wearing a Medic Alert bracelet. Call 1-800-ID-ALERT to order.
- Prescription drugs abroad—Worldwide delivery of non-controlled (non-narcotic) medications sent via Federal Express or DHL. Contact: Global RX, 4024 Carrington Lane, Efland, NC 27243; Tel: 919-304-4278; Fax: 919-304-4405; Web site: www.globalrx.com
- Divers Alert Network (DAN)—For non-emergency medical questions and general information, scuba divers can call (919) 684-2948 for DAN’S Dive Safety and Medical Information Line. (Website: www.diversalertnetwork.org). For scuba diving emergencies, DAN’S Diving Emergency Hotline is (919) 684-4DAN (4326) or (919) 684-8111. These lines are open to all divers.
- Telephone number and e-mail address of your personal physician or medical group
- Foreign language telephone assistance—When dealing with medical problems long distance, there may be language barriers. Call AT&T’s Language Line at 800-628-8486 for assistance. The service costs vary per minute, depending on the language being interpreted.
- Traveler’s checks—Make a photocopy of the numbers. Leave the photocopy at home and carry with you the list of numbers that you get with the checks. Copy the date and place of purchase and where to call if the checks are lost or stolen.
- Credit cards—Know your charge card credit limits. U.S. citizens have been arrested in some countries for exceeding credit limits. Keep a copy of your card numbers in case they are lost or stolen. Report the loss immediately.
- Money—ATM facilities in other countries are becoming more prevalent; they offer convenience and usually the best exchange rates. Foreign banks usually will advance cash against your credit card. Be sure you have your PIN number.
- Birth certificate and photo ID—These documents can sometimes be used in lieu of a passport for entry into certain countries. They’re also useful to have if you lose your passport. If you are living overseas or getting married in a foreign country, be sure to have these documents with you.
- Green card for resident aliens—Don’t leave home without it.
- Doctor’s letter—You may want a doctor’s letter describing and authorizing the prescription medications you will be taking on your trip, including needles/syringes if you are a diabetic. The letter should contain the generic names of the medications and the dosages.
- International driver’s permit—This is available at any AAA office. When applying you’ll need two passport-sized photos (they can take the photos), your driver’s license, and $15 for the fee. The international driver’s permit is printed in nine languages and serves as a translation for your license, which is valid in many countries. Note: You also need to take your regular driver’s with you when you drive abroad. A few countries (China, Egypt, Nepal do not allow tourists to drive; check with the embassy before departing for any country where you want to know the requirements on tourists driving).
- Notarized parental consent—Necessary when a minor child is traveling with the noncustodial parent. This permission letter may even be required when one parent is traveling internationally alone with his/her child. You may not be able to board the aircraft or enter a country (e.g., Mexico) without this document.
- Mobile phones overseas—Unless you have a multi-band GSM phone, your own mobile phone (cellphone)) is probably useless overseas, so you may want to buy or rent a phone for your trip. A low-cost option is buying a cheap, prepaid phone on arrival. You can also buy a phone before departure, or at your destination, whose SIM card can be reloaded with airtime purchased locally. Good resources for mobile phones overseas include Telestial (www.telestial.com) and Cellular Abroad (www.cellularabroad.com). NOTE: Camera phones are not allowed in Saudi Arabia and their use in some other countries may arouse suspicion
TRAVELERS WITH SPECIAL NEEDS
If you have a history of coronary heart disease, and your condition is stable, travel is generally low risk, and airline travel is considered safe. Heart disease, per se, is not a contraindication for travel to high altitudes (see Chapter 15, Altitude Illness). No matter where you go, be sure you have:
- An adequate supply of your medications
- A copy of your most recent ECG and any relevant medical records
Pacemakers A pacemaker or an implanted defibrillator/cardioverter (AICD) is not a contraindication to air travel, and these devices are not affected by walk-through airport security magnetometers. However, the handheld security magnetometers should never be used on someone with an implanted defibrillator. Electronic telephone checks of pacemaker function cannot be transmitted by international satellite.
Chronic Lung Disease and Air Travel
The cabins of commercial airlines are pressurized to an altitude of 1524 to 2438 meters (5000 to 7998 feet). Most healthy individuals tolerate this cabin pressure, but symptoms of mild altitude sickness are sometimes reported (fatigue, headache, lightheadedness and nausea) after three or more hours of flight.
If you have chronic obstructive pulmonary disease (COPD, emphysema), air travel is considered safe if you can walk a block or climb a flight of stairs without becoming breathless. In-flight oxygen may be indicated if your sea level arterial oxygen saturation (Pao2) on room air is 67 mm Hg or less or if the expected in-flight Pao2 is less than 50-55 mm Hg.
Starting in May 2009, Portable Oxygen Concentrators must be allowed on all flights originating or ending in the United States. This will require all airlines operating in the US, including foreign airlines, to allow the use of approved POCs on-board and in-flight.
If your doctor advises in-flight oxygen, contact the airline medical department at least 48 to 72 hours prior to departure. There may be a $50 to $75 charge for oxygen for each flight/plane change. The airline will request a physician’s letter stating your medical condition and a prescription for the oxygen. Be sure to carry copies of these documents with you.
Portable Oxygen Concentrators (POCs) can be purchased or rented. If you are interested in renting a POC for short term usage during travel you should contact your regular oxygen supplier. Here are some other companies which specialize in POC rentals.
OXYGEN TO GO
AMERICAN MEDICAL RENTALS
MOBILITY EQUIPMENT RENTALS
TRAVELO2 – Global Travel Oxygen
If you take pills to control blood sugar, no time zone adjustment of dosage is necessary when flying. Take your medication according to the local time.
- If you are a diabetic using insulin, take enough insulin and U-100 syringes to last the entire trip. (Many countries still use U-80 syringes.)
- If traveling by air, call the carrier 72 hours before departure to order a diabetic menu.
- Hand carry your insulin at airport security checkpoints.
- Consider carrying all diabetic supplies in a specially designed case, such as the DIA-PAK. Insulin will keep its full potency for several months even if it’s not refrigerated, but its temperature should be kept below 86° F. The DIA-PAK (two models available) has a refreezable cold pack for keeping insulin cool in hot climates. The company also carries glucose gel pabrkets abbr other accessories. Contact B & A Products at 918-696-5998 or www.baproducts.com.
- Test blood glucose at 6-hour intervals or before each meal during the flight.
- Carry sugar cubes, glucose gel, or a snack in case an insulin reaction (hypoglycemia) occurs.Nomogram for Predicting in-Flight Arterial Oxygen Tension from Cabin Altitude and Preflight Arterial Oxygen Tension
- Dental care—Allow enough time for corrective work. Avoid dental work and injections in countries where HIV and hepatitis B infections are threats. Consider carrying an emergency dental kit to treat broken or lost fillings—a DenTemp kit (for example see Fig. 2.2.)The Den-Temp dental repair kit is available at most pharmacies
Check your feet—Proper foot care is essential, especially for hikers and diabetics. Carefully trim nails, corns, and calluses. Use foot powder to keep feet dry and fungus free. Be sure shoes and hiking boots are broken in and fit properly. Don’t let a painful, infected blister or another preventable foot problem ruin your trip or jeopardize your health.
Schedule an eye examination—Carry an extra set of eyeglasses. Contact-lens wearers should also carry a pair of eyeglasses. Keep a copy of your eyeglass prescription with you. Also, if you wear contact lenses, carry antibacterial eye drops (Ciloxan, containing ciprofloxacin, is a good choice). Contact-lens wearers, especially those who wear their lenses overnight, are at increased risk for developing bacterial keratitis (infected corneal ulcers, which may be caused by Pseudomonas or Serratia bacteria). These infections may cause permanent corneal scarring or perforation if not treated promptly. NOTE: Even daily-wear soft contact lenses are three times more likely to cause bacterial keratitis as are the daily-wear, rigid, gas-permeable lenses.
The HIV-Positive Adult Traveler
Pre-travel evaluation Pre-travel medical screening should include (just as with all travelers) a medical history, immunization history, allergy history, and a history of any problems during previous travel. Those whose CD4+ cell counts are normal or greater than 500/mL are usually at no greater risk than noninfected travelers for travel-related problems, but those whose CD4+ cell counts are less than 200 cells/mL, or who are symptomatic, are at a greater risk of acquiring infections.
Travelers’ Diarrhea In HIV-positive travelers, this disorder can occur more frequently, be more severe, and be more difficult to treat. Infections with Salmonella, Shigella, and Campylobacter species are more protracted and more oftedn associated with bacteremia. The usual 1- to 3-day course of antibiotic treatment for travelers’ diarrhea may need to be extended to 7 days.
Cryptosporidium, a common cause of diarrhea in the tropics, produces severe chronic diarrhea, malabsorption, and, occasionally, inflammation of the gallbladder (cholecystitis). Cyclospora parasites cause similar symptoms. Isospora belli infections are also common and cause malabsorption and weight loss. There is no apparent increased risk for gastrointestinal infections caused by viruses, Entamoeba histolytica, Giardia lamblia, or enterotoxigenic Escherichia coli (ETEC-the most common cause of travelers’ diarrhea).
Other Infections Respiratory illnesses, such as bacterial pneumonia and fungal infections (e.g., histoplasmosis and coccidiomycosis), cause greater mortality in HIV-positive patients. Tuberculosis is a serious risk for those living or working in lower socioeconomic populations in the developing world. Short-term business travelers and tourists are at low risk for acquiring tuberculosis. Visceral leishmaniasis is difficult to diagnose and treat, and the mortality is high. Even short-term travelers to Spain, southern Europe, and other risk areas have acquired this illness. Increased severity of malaria has not been demonstrated conclusively in HIV-infected patients, but this infection must be prevented by chemoprophylaxis and insect-bite prevention measures.
Preventive Measures Food and drink precautions should be carefully followed. Undercooked meat, fish, shellfish, eggs, raw and unpeeled fruits, raw vegetables and salads, tap water, and unpasteurized dairy products should be avoided. Hands should be washed, or a hand sanitizer gel applied, before meals to reduce the spread of gastrointestinal and respiratory diseases. Consideration should be given to giving prophylactic antibiotics to short-term travelers with low CD4+ cell counts to prevent travelers’ diarrhea. All other travelers, including those travelers taking prophylactic sulfa drugs to prevent pneumocystis pneumonia, should carry a standby self-treatment course of a quinolone antibiotic. Taking precautions against insect bites is important to prevent diseases such as malaria, dengue, and leishmaniasis.
Sexually Transmitted Diseases HIV-infected travelers should be counseled against engaging in sexual behavior that might infect others or that will increase their own risks of acquiring infections such as syphilis, herpes simplex, or an intestinal microorganism. Hepatitis B is likely to be more severe as is the chance of becoming a chronic carrier of the virus.
Immunization (vaccination) All HIV-positive travelers should be appropriately immunized, but the antibody response to immunization may be impaired, especially when the CD4+ cell counts are less than 200 cells/mL. Increased doses of hepatitis B vaccine, for example, may be needed in immunosuppressed individuals. Because the antibody response to vaccines is higher in individuals with early HIV disease and higher CD4+ counts, it is best to immunize such individuals at the earliest opportunity. This applies to any HIV-positive person who contemplates possible future travel, as well as any person who has imminent travel plans. In general, live vaccines are contraindicated in those who are symptomatic or who have low CD4+ cell counts.
Evaluation of Illness Acquired Abroad
If you traveled abroad, you may be at risk for having acquired a bacterial, viral or parasitic disease that becomes symptomatic after returning home. You could also infect others close to you if you unknowingly became infected with a disease such as tuberculosis, HIV, or typhoid.
Fever is the most important post-travel symptom and should always be carefully and promptly evaluated. Your doctor must determine if your fever is caused by a travel-related illness or is due to an illness that you acquired later. However, in about 25% of travelers, no cause of the fever can be found, and it is assumed in these instances that the fever is due to a self-limited viral infection.
Important Post-Travel Symptoms
The most common symptoms of a tropical or infectious disease are the following:
- Fever (the most important symptom)
- Abdominal pain
- Weight loss
- Cough or shortness of breath
- Skin rash
Key point: If you become sick after returning home, ask your primary care physician to consult with a travel medicine specialist – when the diagnosis is unclear – if there is any possibility that your illness might be caused by a travel-related or tropical disease.
Diagnosing the Cause of Fever
The length of time after returning home and the length of time after possible disease exposure have diagnostic implications. Some diseases cause symptoms only a few days after exposure, whereas others become evident after weeks to months. Table 2.1 lists the most common travel-related diseases with fever and their incubation periods.
Your travel itinerary helps the clinician determine what illness may be causing the fever. Certain diseases, such as malaria, can immediately be eliminated if they don’t exist in any of the countries you visited. Also, being vaccinated against a disease makes it much less likely to contract it. Consult the World Medical Guide in this book to see which infectious or tropical diseases are present in the countries on your itinerary. Then combine the knowledge of possible disease exposure (e.g., insect bites, exposure to potentially contaminated food or water) with the incubation period data in Table 2.1 to narrow the diagnostic possibilities. Finally, laboratory testing can often clinch the diagnosis.
For example, if you have returned from sub-Saharan Africa and two to three weeks later develop a high fever, malaria is probably the most likely diagnosis; however, if a blood count shows a high percentage of eosinophils (a type of white blood cell), you may have Katayama fever, which is the initial phase of schistosomiasis,.another parasitic disease.
THE POST-TRAVEL MEDICAL CHECKLIST
Although you might have traveled in countries where certain diseases exist, this doesn’t necessarily mean you had any exposure; therefore, a detailed history of your actual activities is essential to assess your risks. Your immunization status is also important. Questions a clinician should ask you are the following:
- Your itinerary: What countries did you visit and for how long? Were you in a disease-endemic area in that country?
- Were you visiting friends or family?
- What were your arrival and departure dates? When did you return home?
- Which vaccinations did you receive prior to departure? For example, if you were given the hepatitis A or yellow fever vaccine, these diseases could virtually be eliminated as diagnostic possibilities. The typhoid fever vaccine, however, is not 100% effective, so vaccination will not entirely eliminate the risk of this disease.
- Did you travel in rural areas of tropical/semitropical countries?
- Did you take measures to prevent insect/mosquito bites?
- Did you adhere to your malaria prophylaxis schedule (if prescribed) and was the drug appropriate?
- Did you adhere to safe food and drink guidelines? Did you eat snails, crabs, prawns, raw fish, or inadequately cooked exotic foods made from beef, pork, bear, walrus, or fish?
- Did you have contact with sick people with respiratory illnesses, such as tuberculosis?
- Did you get sick during your trip? Were you treated by a doctor? Was your illness diagnosed? What medications were you given? Did you receive any injections or blood transfusions?
- When was the onset of your post-travel symptoms—days, weeks, months, after return?
- What was your exposure to the following:
- Unsafe food and drink—Did you eat undercooked or raw meat or fish (e.g., sushi); cold food from salad bars; street vendor food not piping hot?
- Insect and animals bites—Were you bitten by mosquitoes, flies, or ticks? Were you bitten by a dog or other animal?
- Walking barefoot on beaches or moist soil?
- Freshwater swimming, wading, or bathing?
- Unprotected sex with a new partner?
- Recreational drugs (especially by injection), tattooing, body piercing, or plastic surgery procedures?
- People with infectious diseases?
It is only after a detailed history has been taken that a physical examination should be performed and select laboratory tests obtained.
Important Alert Malaria is the most important illness to consider if you develop a fever after having been in a malaria-endemic area, especially one in sub-Saharan Africa or Oceania. If you develop a fever after returning home, be sure to tell your doctor that you have traveled abroad and that a tropical illness, especially malaria, is a possibility. If malaria is a consideration, request thick and thin blood films and have them repeated two to three times over 24 hours if the initial result is negative.