HEALTH CONSIDERATIONS FOR INTERNATIONAL TRAVELERS TO THIRD- WORLD COUNTRIES. University Health Center James Madison University

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1 HEALTH CONSIDERATIONS FOR INTERNATIONAL TRAVELERS TO THIRD- WORLD COUNTRIES University Health Center James Madison University 1

2 PURPOSE Highlight health risks for travelers Review vaccinations & disease prevention Minimize health risks Recommend traveler s health kit 2

3 IMPORTANCE Travel can result in exposure to diseases that are rare or non-existent in the US Illnesses can be debilitating or fatal Knowledge of risk allows preventive action Avoiding injury and illness is best Third world medical care is typically limited 3

4 RESOURCES is an excellent resource All travelers to third-world destinations are strongly encouraged to visit this site and read about country specific concerns University Health Center: Travel clinic Vaccinations Prophylactic medication prescriptions Brief overview of health risks with recommendations 4

5 TRAVELER S RESPONSIBILITY Provide destination information, including any stops at 3 rd world airports Visit for country specific recommendations Review/update your vaccination history at MyJMUHealth and be aware of what vaccinations you may need. Make a travel clinic appointment at least 2-4 wks before travel (limited appointments) Vaccinations require 2-4 wks to become effective; some require multiple doses Obtain products for health kit 5

6 VACCINATIONS Routine vaccines recommended: (same as JMU) TD or TDAP, MMR, Polio, Hepatitis B, Meningococcal Other vaccinations recommended or required depending on destination Hepatitis A Typhoid Meningococcal vaccine: For central Africa Yellow fever: Required for some countries Rabies, Japanese encephalitis, pneumococcal: rarely recommended 6

7 RISKS AND PRECAUTIONS Excessive alcohol = bad decisions! Motor vehicle accidents: # 1 cause of trauma deaths Be cautious regarding transportation; wear seat belt Homicide: # 2 Never walk alone; buddy system; vigilance Drowning: # 3 Use life jackets in boats Scuba ONLY if qualified. Never dive alone 3rd world medical and trauma care frequently limited 7

8 WATER AND SANITATION CONCERNS Presume all tap water is contaminated; do not drink or use to brush teeth OK to shower and wash hands; keep your mouth shut Avoid ice Carbonated beverages, commercial water bottles OK but clean surface Fresh water sources typically contaminated by organic waste, pathogens, or inorganic toxins: Cholera, Salmonella, E.coli, Entamoeba histolytica, Giardia, Hepatitis A, Polio Travelers should not swim or wade in fresh water (rivers, lakes) Chlorinated pools are preferred Prevent water from entering the nose or mouth Human & animal waste discharged onto ground, streams, or in open sewers Presume the bottom of shoes have excrement. Children play in dirt; then want to hold your hand. Use hand sanitizer frequently 8

9 FOOD CONSIDERATIONS Restaurant food safety in 3 rd world countries is variable and not to US standards Travelers who eat at restaurants are 3x more likely to get traveler s diarrhea Avoid raw food Eat cooked food when it is HOT Domestic milk and cheese are typically unpasteurized Avoid food from street vendors Dry foods (baked) are usually safe 9

10 TRAVELER S DIARRHEA Definition: 3 or more unformed stools in 24 hours associated with at least one of the following: Fever, Nausea, Vomiting, Abdominal cramps, Bloody stools Usually within the first 2 weeks of travel May resolve (in 4 days) without treatment 80-90% due to bacteria Prevention Bismuth subsalicylate (Pepto-bismol): 2 oz. or 2 chewable tablets 4x daily Treatment Antibiotics (to be prescribed) 10

11 ARTHROPOD BORNE DISEASES Dengue fever (virus): most common mosquito-borne infection Malaria (parasite): second Preventing bites Cover your skin; avoid bright colors Use mosquito bed nets if available Check for ticks Pre-treat clothing with Permethrin DEET or Picardin products should be used all day and night: use just enough to cover exposed skin or clothing. > 50% DEET is superfluous. Sunblock with repellant has 30% less effective sun protection 11

12 MALARIA PROPHYLAXIS Choice of medication depends upon destination (NOT 100% effective) Some start 1 week before and continue through 4 weeks after your return Options will be discussed at your travel medicine visit: see chart next, costs change Travel to malaria areas will disqualify you from donating blood for 1 year. 12

13 MALARIA PROPHYLAXIS OPTIONS Drug Dosing Regimen Precautions/contraindications Doxycycline Chloroquine 100 mg once a day at the same time each day: begin 1 day before travel and continued daily through 4 weeks after leaving the malaria endemic area. 500 mg once a week begin 1 week prior to travel and continue weekly through 4 weeks after leaving the malaria endemic area. Increased risk of sunburn, nausea, abdominal pain/acid reflux symptoms (avoid taking it at bedtime to minimize this risk). Risk of candida vaginitis. GI upset, headache, dizziness, insomnia, itching: but in general side effects are uncommon and very well tolerated. Malarone Mefloquine (Lariam) 1 pill daily begin 1 day prior to travel, continue daily through 7 days after leaving the malaria endemic area. 250 mg once a week begin 1 week prior to travel and continue weekly through 4 weeks after leaving the malaria endemic area. Abdominal pain, nausea/vomiting. Do not use in pregnant or breast feeding women. GI upset, headache, insomnia, vivid dreams, depression, anxiety, and dizziness. Contraindicated in patients with active depression, prior psychosis or seizure history. Used with caution in any traveler with psychiatric illness or history. 13

14 TYPHOID FEVER AND VACCINE Typhoid fever can be a life-threatening illness Highest risk for travelers to southeast Asia Acquired through consumption of water or food contaminated by feces Prevention A secure food and water source will minimize your risk Vaccines (~70% effective) oral capsules (prescription) 5 years protection injection (not available at JMU) 2 years protection Does NOT protect against other food/water borne pathogens 14

15 ANIMAL RISKS Presume rabies in all mammals, including domesticated dogs. Avoid animals or consider Rabies vaccine if working with animals Animals & animal excrement can carry diseases Monkeys, birds, bats, rodents, goats, sheep Venomous snakebites Marine animals - bites and stings 15

16 OTHER HEALTH CONCERNS Blood clots (DVT- deep vein thrombosis) Motion sickness Sunburn Heat illness Altitude sickness (Elevation > 8,000 ft) Scuba diving Sexually transmitted diseases Tattooing 16

17 SEXUALLY TRANSMITTED DISEASES Several that are not present in US Increased risk of antibiotic resistant organisms Increased risk of HIV Prevention: Abstain from sexual activity with local inhabitants of third-world locations Use condoms from a known reliable source: Counterfeit condoms are a known problem. Vaccinations: Hepatitis A, B, and HPV If you develop any symptoms after return, inform your health care provider of any exposures. Sex trade preys on children and the poor 17

18 TRAVELER S HEALTH KIT Medication (prescription) MUST be in original containers with clear labels Take a letter from your physician if you have controlled substances or syringes. Take enough medication for the trip plus extra in case you are delayed. Take these in carry-on bags if possible. Wear a medic alert bracelet for pre-existing conditions or allergies (especially penicillin) Take an Epi-pen if you have one prescribed. Bring any over-the-counter medications you use or might need: Pain (acetaminophen, Ibuprofen), motion sickness, diarrhea, sleep 18

19 TRAVELER S HEALTH KIT Hand sanitizer or antibacterial hand wipes Disposable gloves ( 2 pairs) Band-Aids (multiple sizes), gauze, adhesive tape Elastic bandage Antibiotic ointment 1% hydrocortisone cream Anti-itch gel or cream for insect bites and stings Aloe gel for sunburns Moleskin or molefoam for blisters Tweezers for splinters 19

20 OTHER TRAVEL TIDBITS Passport copy: Keep one somewhere other than your luggage. Scan it and it to yourself so it can be accessed at any time if your passport is lost or stolen. Contact information for family member or close friend in the United States. Make sure someone at home knows your itinerary. Have a copy of your medical insurance card and emergency contacts. Obtain travel insurance and medical evacuation insurance information: Be familiar with the fine print. If you need medical care, ask around to find the best option. Know where the US embassy or consulate in the destination country or countries is located. 20

21 AFTER YOU RETURN Most travel related illnesses resolve spontaneously 1-5% of travel-related illness prompts a medical visit - Describe your travel history Medical complaints: Gastrointestinal 10% Rash 8% Upper respiratory 5-13% Fever 3%: most concerning. Even up to 6 months later 21

22 POST-TEST- QUESTION #1 What is the most common cause of preventable deaths in US travelers abroad? a) Malaria b) Dengue fever c) Homicides d) Motor vehicle accidents e) Snake bites 22

23 ANSWER #1 d- Motor Vehicle Accidents 23

24 POST-TEST- QUESTION #2 Fresh water in third-world countries: a) Is typically safe to drink b) Rarely contain organisms that cause disease in humans c) Is commonly contaminated with organic and/or inorganic toxins d) Is held to similar cleanliness standards as fresh water in the US 24

25 ANSWER #2 c- is commonly contaminated with organic and/or inorganic toxins 25

26 POST-TEST- QUESTION #3 Tap water in third-world locations can be used for: a) Bathing and washing b) Brushing your teeth c) Drinking d) All of the above 26

27 ANSWER #3 a- bathing and washing 27

28 POST-TEST- QUESTION #4 Regarding food eaten in third-world locations: a) In general, raw foods should be avoided b) Food from street vendors is entirely safe c) Local sources of milk and cheese are unpasteurized d) A and C e) B and C 28

29 ANSWER #4 d: Both a and c are correct. Raw foods should be avoided and milk and cheese from a third-world source is typically unpasteurized. 29

30 POST-TEST- QUESTION #5 Regarding traveler s diarrhea: a) >80% is due to bacteria b) Where a traveler eats is unimportant c) Bismuth subsalicylate is not effective in preventing traveler s diarrhea d) Preventative antibiotics are recommended e) All of the above 30

31 ANSWER #5 a- >80% are bacterial in origin 31

32 POST-TEST- QUESTION #6 Which of the following is FALSE in regards to Arthropod-borne diseases? a) Dengue fever is the most common mosquito-borne disease in the world. b) Taking an anti-malarial prophylactic medication is 100% effective in preventing malaria and precludes the need to prevent mosquito bites. c) Ticks, flies, lice and other arthropods are disease carriers in the third -world. d) DEET & Picaridin are the only CDC recommended insect repellants in the US e) The choice of anti-malarial prophylaxis depends upon your travel itinerary. 32

33 ANSWER #6 b- Antimalarial medication is NOT 100% effective in preventing malaria so it is important to minimize exposure to mosquito bites 33

34 POST-TEST- QUESTION #7 Which of the following is TRUE regarding DEET use? a) The CDC has no opinion on the use of sun-block lotions containing DEET. b) Use of DEET under clothes and on open wounds is fine c) Concentrations >50% do not yielded significantly more protection than those of 50% d) DEET should only be used between dusk and dawn 34

35 ANSWER #7 c- there is a plateauing to DEET effectiveness above 50% concentrations 35

36 POST-TEST- QUESTION #8 Other health risks may include which of the following? a) Deep vein thrombosis (blood clots) b) Motion sickness c) Environmental illnesses (heat illness, altitude sickness, diving-related illness) d) Animal related illnesses and injuries e) All of the above 36

37 ANSWER #8 e- all of the above 37

38 POST-TEST- QUESTION #9 Regarding the risk for STD s in the traveler, all of the following are TRUE except: a) Engaging in sexual activity with the local population of a third-world country is strongly discouraged b) Avoid condoms purchased in a third-world country due to the presence of ineffective counterfeit condoms c) The sex trade in third world locations does not prey upon children and the poor who are victims of this activity d) The risk of unusual STDs and HIV are greater in those who engage in sexual activity with the local population of third-world countries. 38

39 ANSWER #9 c- The sex trade in third world locations DOES prey upon children and the poor who are victims of this activity 39

40 POST-TEST- QUESTION #10 Which of the following is TRUE regarding your Travel Health Visit? a) The visit should be scheduled at least one month prior to your trip. b) You should know your full travel itinerary to include the dates of travel and all countries to be visited. c) There are typically extra costs involved with recommended vaccinations and travel medications d) You should have reviewed the CDC website regarding the countries in which you plan to travel. e) All of the above 40

41 ANSWER #10 e- all of the above Now log into MyJMUHealth to complete the online travel questionnaire and make an appointment for your international travel consultation. 41