Before leaving home, the medical volunteer must take a few simple
steps to help ensure a healthy return. Many volunteer trips and
foreign vacations have been ruined by an unexpected, but possibly
preventable illness. Medical problems encountered by travelers
can range from a simple sunburn to a life-threatening case of
drug-resistant malaria. One should start several weeks, if not
a few months, in advance to ensure enough time to do the necessary
research, and to make sure that all appropriate vaccinations are
up to date. Yellow fever is the only disease for which vaccination may legally
be required for international travel (though some countries may
ignore the relevant international agreements and require others).
This viral disease is endemic in certain areas of Africa and South
America, and is fatal in more than half of cases in non-immune
adults. The vaccine is extremely effective and is well tolerated.
Even if not specifically required for entry into a particular
country, persons who will be traveling in endemic zones, particularly
outside of major urban centers, are strongly encouraged to receive
this vaccine. Perhaps the most important vaccinations for the international
traveler are those for hepatitis A and hepatitis B. Hepatitis
A can also be prevented by the use of immune globulin, although
its protection is temporary. All health care workers should be
certain of their immunity to hepatitis B. Avoidance of insect bites, particularly mosquitoes, is very important.
Malaria is one of the world's greatest health problems, and the
list of arthropod-borne illnesses also includes yellow fever,
dengue fever, filariasis, viral encephalitides, leishmaniasis,
African trypanosomiasis, onchocerciasis, typhus, Lyme disease,
Rocky Mountain spotted fever, relapsing fever, tungiasis and plague. Dengue and the associated dengue hemorrhagic fever and dengue
shock syndrome are mosquito-borne viral illnesses for which there
is no effective vaccine. Your only defenses against dengue are
avoidance of mosquito bites and prompt, appropriate medical treatment.
The mosquito species which carry dengue are much more likely to
bite during daylight hours, so travelers to areas where dengue
is present should also use mosquito repellents during the daytime.
Dengue is characterized by severe, abrupt headache, eye pain,
and muscle, bone and joint pain, and fever. Scleral injection
(red eyes) is common. Dengue hemorrhagic fever is more likely
to exhibit cough, sore throat, loss of appetite, nausea, vomiting
and abdominal pain rather than bone, joint, or muscle pain. It
may progress to spontaneous bleeding and low platelet count, and
then to agitation and circulatory failure, followed by profound
shock. These latter stages constitute dengue shock syndrome. Diarrhea is one of the most common problems to afflict travelers,
and is largely preventable. The most important preventative measure
is the careful selection and preparation of all food and drink
to be consumed. All foods should be cooked thoroughly, and either
consumed hot or stored at a temperature below 10°C. Water and
other beverages should either be bottled, chemically disinfected
and filtered, or boiled. Perfectly safe bottled water can be contaminated
by using ice made from contaminated water. Fruits and vegetables
should be considered potentially contaminated unless they can
be peeled by you. High risk foods include raw shellfish, unpasteurized
milk, ice cream, and dishes containing raw eggs. Some seafoods
may contain toxins which are not destroyed by cooking; one should
consult local authorities before eating unknown species. The same precautions that apply to sexually transmitted diseases
at home should be used when traveling. Abstinence, or sex with
one mutually monogamous and non-infected partner are the best
ways to prevent sexually transmitted diseases. Latex condoms may
offer some protection against the spread of STDs. Sex with multiple
partners or with prostitutes is extremely hazardous. In many parts
of the world, heterosexual intercourse is the most common route
of transmission of the HIV virus. Other sexually transmitted diseases
are also endemic, including hepatitis B, syphilis, gonorrhea,
and many others. Many STDs are more resistant to antibiotic therapy
overseas. Motion Sickness: Drugs are available to prevent the nausea and
vomiting associated with the movement of cars, boats, and airplanes.
Even over-the-counter medications have associated side effects,
and should be taken only after reviewing the product instructions
and consulting with a physician, if necessary. Medical supplies which may be inexpensive and readily available
at home may be unobtainable while traveling. An adequate supply
of such basic items as bandages, disinfectant, non-prescription
analgesic and antipyretic, mosquito repellent, and sunscreen should
be brought. Depending on the area of travel, appropriate anti-malarial
medications, water purification substances, and oral rehydration
salts are also basic necessities. If prescribed by a physician,
antibiotics and antidiarrheals may be needed. Your health insurance may not cover you for illnesses and injuries
which occur outside your country of origin. It would be prudent
to check with your insurance carrier before traveling, particularly
if you have chronic health problems which are prone to reoccurrence.
Special policies covering medical treatment abroad and/or medical
evacuation are commercially available.
Introduction
This section will discuss the vaccinations which may be legally
required as well as those which are recommended by authorities
such as the World Health Organization; communicable diseases which
travelers may be exposed to; environmental factors influencing
health; and several other related topics. Health conditions around
the world frequently change. For the most current recommendations
about specific countries or illnesses, the reader is encouraged
to consult a qualified travel clinic, WHO publications, or American
Health Consultants Travel Medicine Advisor and to contact the
embassy of the country to which one is planning to travel. The
CDC and other organizations maintain information-rich webpages.
Vaccinations
An International Certificate of Vaccination must be obtained from
an officially designated vaccine center (a list is published by
the World Health Organization) and is valid for 10 years, beginning 10 days after vaccination.
Smallpox has been eradicated and vaccination is no longer necessary.
Some countries have required proof of immunization against cholera
in the past, but this should no longer be the case. There is currently
no safe and effective vaccine against cholera.
Vaccinations which are considered routine in the US and other
developed countries are also highly recommended before foreign
travel. Measles, mumps, rubella, poliomyelitis, tetanus, diphtheria,
and pertussis are all common in various parts of the world and
can be prevented by safe and effective vaccines. The traveler's
immune history should be reviewed before leaving home, and any
deficiencies corrected.
Rabies is much more common in other parts of the world than in
the US. Those who will be working with animals, staying in highly
endemic areas, or will be isolated from medical care should consider
pre-exposure vaccination. If exposed to rabies, the pre-immunized
individual still requires post-exposure vaccination, but does
not require immune globulin.
Other vaccinations recommended by the WHO in 1995 for travelers
in endemic areas include typhoid, BCG (for the prevention of tuberculosis
in children and young adults; contraindicated in the presence
of symptomatic HIV infection), meningococcal meningitis, influenza
(for elderly or otherwise high-risk persons) and Japanese encephalitis.
Insect-Borne Illnesses
Drug prophylaxis against malaria is not 100% effective. The first
step in preventing malaria is preventing or at least minimizing
mosquito bites. Dusk and dawn are the times at which mosquito
bites are most common. Staying indoors and wearing long-sleeved,
dark colored clothing can reduce exposure. The use of "deet" (N,N-diethyl-m-toluamide)
or dimethyl phthalate containing insecticides on the skin is also
recommended. Buildings with tight doors, windows, and screens
help to keep mosquitoes out, but mosquito netting over the bed
may also be needed. After entering the net to sleep, it should
be inspected from the inside to make sure that all edges are tightly
tucked in, there are no holes, and there are no mosquitoes inside
with you. Spraying the netting with permethrin or deltamethrin,
or using mosquito coils or other insecticides is also useful.
Travelers should check with a reliable source before their trip
to establish whether malaria is endemic in the area of travel
(International Travel and Health, WHO). Pregnant women and small children should avoid travel to malarious
areas if at all possible, particularly areas where chloroquine-resistant
p. falciparum exists. Multidrug-resistant malaria has been reported
in certain areas of Southeast Asia for which there is no safe
and effective prophylaxis for pregnant women and young children.
Specific recommendations for malaria prophylaxis are beyond the
scope of this section, but several general points should be made:
Food and Water-Borne Illnesses
There is no single prophylactic drug which can prevent all of
the possible causes of diarrhea. Bacterial, protozoal, and helminthic
infections each requires a different specific medical treatment.
Oral rehydration is vitally important in the treatment of diarrheal
illnesses, and travelers should consider carrying rehydration
salts in their medical kit. Severe cases (such as with cholera)
may require intravenous hydration.
Bathing in fresh water (other than chlorinated pools) and walking
in bare feet in high risk areas may expose the traveler to a variety
of infestations, and should be avoided.
Hepatitis A is spread through contaminated food, and persons from
developed countries are unlikely to be immune unless they receive
proper vaccination or immune globulin pretreatment. Immune globulin
offers temporary immunity, the duration of which is dose related.
Hepatitis E is also transmitted through contaminated food, but
there is no effective vaccine or immune globulin to prevent it.
It is particularly dangerous for pregnant women. Strict avoidance
of potentially contaminated food is the only protection from hepatitis
E.
Vaccination against typhoid is recommended for travel anywhere
that sanitation may be suspect.
HIV and Other Sexually Transmitted Diseases (STDs)
HIV, hepatitis B, and syphilis, among other illnesses, can also
be spread by blood products. Transfusions should only be made
when absolutely necessary, and should use only blood which has
been tested for HIV, hepatitis, and other infectious agents. Poor
countries may lack the technology or funds to adequately screen
their blood supply. If any injections are required while traveling,
one should insist on a brand new, disposable needle, or one that
has been thoroughly sterilized. Other medical and dental instruments
as well as tattoo needles and equipment for body piercing must
also be sterilized to prevent spread of infection.
Environmental Hazards
Extreme Temperatures: Many travelers will be exposed to extremes
of heat or cold during their trip. Typical weather conditions
should be inquired about and the proper clothing brought. Extreme
heat dramatically increases the body's need for water, and an
adequate supply of safe water must be ensured. Protection from
sun, particularly in tropical areas where levels of ultraviolet
radiation are much higher, can be achieved with long-sleeved,
light-colored clothing, hats, and sun-screens. Travelers to hot
locations should be familiar with the symptoms and treatment of
heat cramps, heat exhaustion, and heat stroke. Similarly, if likely
to be exposed to extreme cold, particularly in isolated areas,
one should be prepared to prevent, recognize, and treat frostbite
and hypothermia.
A small number of travelers will be exposed to high altitudes.
The pressurized cabins of commercial airliners prevent altitude
related problems in flight, but prolonged stays in mountainous
areas may expose the traveler to acute mountain sickness, high-altitude
pulmonary edema, and high-altitude cerebral edema.
Travelers who will be in remote or wilderness areas should familiarize
themselves with potential animal hazards. Sharks, jellyfish, other
poisonous marine animals, poisonous snakes, scorpions, spiders,
and carnivores are among the many dangerous animals which may
be encountered, depending on the location of travel.
Traveler's Medical Kit/Traveling with Chronic Illnesses
Persons with chronic health problems or allergies should be sure
to bring an adequate supply of their regular medications, and
should inquire in advance as to what medical facilities will be
available. If injections will be needed (for diabetics, for example),
sterile syringes and needles should be brought, as they may not
otherwise be available. Proper labeling or documentation of a
physician's order should accompany needles or controlled substances.
Some serious medical problems should be considered contraindications
to travel, particularly by air. Severe anemia, serious infectious
diseases, heart failure, recent heart attack or stroke, severe
mental illnesses, uncontrolled epilepsy and other serious medical
conditions should prompt serious consideration as to whether travel
should be attempted.
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