MEDICAL ADVICE FOR THE TRAVELER

A MEDICAL KIT FOR TRAVELERS

A medical kit should be customized to suit each individual. Prescription medications taken on a regular basis, or which have been prescribed for use in the event of a problem or crisis, should accompany you on any trip away from home. One should take a sufficient supply of any regular medication to last for the entire trip, plus a buffer in case of loss or unforeseen delay in returning home. All prescription medications should be labeled with the proper drug name (not just the trade name, as these vary from place to place) and the dosage in each taglet or capsule. It is wise to carry essential medications in your hand baggage lest lost luggage leave you sick as ww
well as angry. The medical kit should also include such basic first aid items as bandages, thermometer, scissors, medicated powder, as irin, and even a small supply of toilet tissue, a nicety that may well be unavailable on the road.
Those with chronic health problems should consult their physicians regarding other items that may be needed. An insulin dependent diabetic, for example, must carry adequate needles and syringes as well as urine or blood testing equipment. It may be necessary to have a formal letter from your doctor stating that you are entitled to carry syringes; at the very least, syringes should be packed in a medical kit so they do not appear as casual drug paraphernalia to a suspicious customs official in a foreign land. Diabetics should also carry a nonsugar sweetener when traveling, as these are often unavailable in other countries.
It is also essential for anyone suffering from a chronic condition in which crises may occur-such as epilepsy, known allergies of a life threatening nature, and continuing corticosteroid therapy-to carry a full medical record. Then, in the event of loss of consciousness or severe injury, healthcare personnel overseas can be aware of your special needs. For those with heart disease a recent electrocardiogram, for example, can be very helpful. People who rely on spectacles or contact lenses should carry an extra set as well as a prescription.

In addition, the following items may prove useful:

Analgesic tablets: a mild pain-killer such as acetaminophen, is a useful item. Stronger analgesics often contain codeine which is prohibited in some countries (e.g., Greece). These medications are useful in relieving pain associated with muscle strain, sunburn, headache, and joint pain. For those embarking on a more risky safari or mountain climb, more potent painkillers are an advisable addition to the kit. It is pain that usually forces patients to seek medical care. If pain can be controlled in a remote area one is more likely to receive superior attention at a central hospital or, even better, at home.

Antihistamine tablets can be useful in reducing ear problems due to pressure changes in air travel especially during takeoff and landing. They also rilieve itching due to insect bites and rashes caused by plants. However, they may make you drowsy and cause blurred vision. Alcohol should not be taken with these tablets. An antihistamine cream is useful for local application to insect bites.

Anti-nausea tablets or the newer transdermal slow release tapes are a good idea if you routinely suffer from motion sickness.

Antacids, either in tablet or liquid form, can help abdominal upsets caused by unfamiliar food and drink or possible overindulgence in either.

Decongestant tablets can provide rapid relief from clogged nasal passages or sinus congestion due to altitude changes or minor colds.

Anti-diarrheal agents may be use~ ful if your trip will take you to areas offering cuisine to which you are not accustomed. It should be noted, however, that most travelers may expect some degree of gastrointestinal reaction. A slight alteration in bowel habit is generally predictable and may require no reme y except patience. Traveler's diarrhea (TD) is a syndrome characterized by a two-fold or greater increase in the frequency of unformed bowel motions. Episodes are generally self-limited and require only simple replacement of fluids and salts lost in diarrheal stools. If severe diarrhea or cramps occur, synthetic anti-motility agents can be useful to provide temporary relief. They should not be used beyond a 48 hour duration or if the traveler has a high temperature or is passing blood in the stool. In such a situation telephone consultation with your own physician is optimal. Local medical aid can be sought, if available, or self treatment with an antibiotic can be initiated. We do not advise routine use of antibiotics to prevent diarrhea. Many antibiotic regimens have been in vogue durin g the past quarter century but have proved either ineffective or dangerous.

Broad Spectrum Antibiotics. One cannot carry a pharmacy when traveling but I do believe that it is prudent to have a single broad spectrum antibiotic available in your medical kit for infections, whether that be an abscessed tooth, severe bronchitis, gastroen~ teritis, or a festering foot wound. Your physician will advise you regarding the indications for therapy, proper dosage, and possible side effects.

Antimalarial Tablets. For those traveling to many parts of Africa, Latin America, Southeast Asia, and the Middle East these are the most important part of the medicaf kit. This topic is considered in a separate section on pages 31-33.

Medical Advicefor the Traveler

INOCULATIONS

There has been heartening progress in the worldwide battle against infectious disease in recent years. However, many epidemics still occur, particularly in the developing countries of the tropics and subtropics. The international traveler can be protected against certain diseases by specific inoculations as well as by prophylactic medications. However, it does not necessarily follow that the more inoculations one receives the healthier one is likely to stay. Inoculations and prophylactic medication should be selectively employed.
Since international patterns of disease are shifting constantly, you should discuss your planned itinerary with your physician or with a specialist in travel or tropical medicine well in advance of your departure. Your doctor or the specialist in travel or tropical medicine can then administer appropriate vaccines or order other prophylaxes suited to your individual needs.
Inoculations should be recorded on a standard yellow International Certificate booklet. Yellow fever and cholera vaccinations must also be stamped by a recognized authority. The following brief comments cover the most common inoculations in alphabetical order:

CHOLERA. The risk of cholera to Europeans and Americans traveling to endemic regions is so low that it is doubtful wgether this vaccination is of much medical benefit to the average tourist. Obviously, those who plan to work in refugee camps or to be in close contact with local residents in endemic areas face greater risk. There have been major outbreaks of cholera recently in Latin America, in troubled areas of Africa and Asia and in large, crowded gatherings such as camps for pilgrims to Mecca. Countries can insist on a valid Cholera Certificate for entry even though Europe and the United States do not have similar requiorements. One cholera ino cu ati n is sufficient to fulfill requirements, but it lasts for only 6 months.

HEPATITIS A. This is a widespread and highly contagious viral infection of te liver. It is husually spread by contaminated water or poor hygienic practices in food preparation. Immunization had traditionally been provided by administering a passive antibody boost in the form of immune serum globulin given just prior to the date of departure; this may still be necessary for those with only a few days lead time before travel. A 4 cc injection lowers attack rates by about 80% for 3 months. In any area where poor hygiene is prevalent, protection against hepatitis A is strongly advised. It should be noted-since it is so often asked about-that gamma globulin, a blood product, is manufactured in such a manner that no living agent, including virus particles, can survive the process. It is a safe and effective agent and should not be denied because of misinformation, ignorance, or the current confused paranoia concerning AIDS.
An attenuated viral vaccine, (Havrex) against hepatitis A has now been perfected. Injections of this vaccine offer an alternative prophylaxis and have become the preferred approach for long-lasting protection. It must be administered at least 2 weeks prior to potential exposure and should have a booster done in 6 months. It should be stressed, however, that no inoculation obviates the necessity to take care in what you eat and drink.

HEPATITIS B. This is also a viral infection but, unlike hepatitis A, is transmitted through direct contact with infected blooc and body fluids; this includes sharing needles, unscreened blood transfusion, and vigorous sexual contact.
Immunization is usually recommended for people who are going to live and work with populations in areas highly endemic with hepatitis B. Three injections are required and, for maximum protection, must be spaced over a 6 month period. A full series will protect for years. Both hepatitis A and hepatitis B vaccines are now part of the regular inoculation series given to infants and children in most developed countries.

JAPANESE B ENCEPHALITIS. This is a serious viral infection that is transmitted to man by mosquito bites in.rural Southeast Asia and Southern India. A series of 3 inoculations spaced over 2 weeks offers good protection.

MENINGITIS. This is a serious, often fatal, infection of the brain that occurs in epidemic form throughout the tropics. The specialist in international health will know where recent outbreaks have been reported and, if one's itinerary indicates exposure, a single multistrain meningitis vaccination is indicated. In recent years meningitis has been endemic in northern India and Nepal and widespread throughout central Africa and Southeast Asia.

POLIO. This paralysing disease, now extremely rare in the United States, is still common in India, Africa and in other developing countries. For adults and children who have been previously immunized, a trivalent booster dose is sufficient. Adults who have had no prior vaccination should receive 2 doses-4-8 weeks apart.

RABIES. Travelers to rabies~ endemic countries should be aware of what action to take in the event of an animal bite. Although dogs are mainly responsible for transmitting rabies to humans, it can be acquired from many animals, and all suspicious bites or scratches should be evaluated properly. Any bite should receive prompt local treatment; cleansing with soap and water will reduce risk of rabies considerably. Travelers should then immediately seek advice on the local incidence of the disease and where to obtain post-exposure immunization if necessary. If at all possible one should try to have the biting dog observed for 10 days; if the animal is still alive one can cease worrying about rabies. If the animal can not be observed for this time, or dies, then post-exposure inoculations are necessary. Upon returning home, one should obtain specialist consultation.
Pre-exposure vaccination with human diploid cell rabies vaccine (HDCV) can provide protection, and is valuable where theri is likely to be sufficient exposure coupled with a probable delay, due to transportation difficulties, in reaching medical aid. It should be stressed that pre-exposure immunization does not offer full pro~ tection from this fatal infection, and prompt attention is essential after any bite in the tropics.

TETANUS. This is an extremely serious and potentially fatal bacterial infection by an organism that can infiltrate any wound, whether major or minor. Most travelers will have been previously immunized and only a booster dose every 5-10 years is necessary. The inoculation for adults can readily be combined with diphtheria. There have been major diphtheria outbreaks in Russia, Eastern Europe, China, and parts of Africa and Asia in recent years.

TUBERCULOSIS. This is a very common disease in tropical countries. It is not a major hazard for tourists, but selected travelers antici ating high exposure to tuberculosis should have a tuberculin test prior to and after travel. Inoculation with BCG is not recommended for travelers.

TYPHOID FEVER. This is another common and serious bacterial infection with transmission rates related to poor standards of personal h ygiene and sanitation. It is prevalent throughout Africa, Asia, and Central and South America. A single inoculation with an improved vaccine will offer adequate protection. Local reactions can occur but these can be minimized by aspirin or Tylenol and by local application of an icepack. Always wrap ice in a cloth before applying or an iceburn may result. Now that typhoid vaccines have been purified, eliminating the anti-paratyphoid A and B corn nents, adverse reactions are far lepsos common. A booster dose is recommended every 5 years. An oral typhoid vaccine is now commercially available and is effica~ cious but side effects are common.

YELLOW FEVER. This is a viral infection transmitted by mosquito vectors. A completed International Certificate of vaccination is required by many countries in Africa and Latin America as a condition for entry; this requirement can apply to travelers who merely stop over in a country which is categorized as an endemic area. The inoculation is valid for 10 years.

SPECIAL CAUTIONS

Special consideration in providing immunization is demanded if any if the following points apply; make sure your doctor is aware of:

ALLERGIES. Some vaccines
contain minute amounts of allergenic substances. If you have an allergy to any drugs, particularly antibiotics, or any food allergies, please tell your doctor.

ALTERED IMMUNOCOMPETENCE. The immune system can be suppressed by disease or drugs. Make sure that your doctor is aware of any alteration in your immunological status before any vaccinations are given. Diseases of particular concern include: leukemia, lymphoma, other forms of cancer, and the acquired immunodeficiency syndrome(AIDS). Treatment with corticosteroids, chemotherapy for malignant disease, or radiation may also suppress the immune system temporarily.

FEBRILE ILLNESS. Minor illnesses, such as the common cold, are not an adequate basis for postponing inoculations. However, if there is moderate to severe febrile illness, immunization should be deferred until recovery has occurred.

PREGNANCY. If you are pregnant, or think you may be pregnant, please tell you doctor before any inoculation is given.

BREAST FEEDING. There may be problems with some vaccines for breast feeding mothers and this should be discussed with your doctor.

FOOD AND DRINK

These are a source of potential grief, as well as great joy, to those who travel. Primarily-but not exclusively-the concern applies to developing countries where modern sanitary facilities are the exception rather than the rule; where sewage disposal-human and animal-is distinctly substandard; where food preparation is rarely handled in a scrup ulously hygienic manner; and where climate and insects add further risks to the unwary traveler. As a basic rule the old adage "If you cannot boil it, cook it, or peel it, then forget it" should apply. Common sense is the indispensable ingredient for a safe and happy journey.
Foods prepared well in advance of serving should be avoided; these incluic cold plates, custards, pastries, and the like. Such foods, particularly when improperly refrigerated, are notorious vehicles for a variety of microbes and parasites which can cause serious gastrointestinal distress.

Vegetables should be freshly cooked and not simply reheated. They should not be eaten raw. Salads should be avoided. Fresh fruits should not be eaten if the skin has been broken, no matter how slight this may appear.

Meats should be thoroughly cooked and consumed while still hot. Undercooked beef and pork are both major sources of tape-worm infestation throughout the tropics.

Fish and other seafood can also be a source of trouble due both to toxins and infectious organisms. Raw or smoked fish can carry tapeworms. Oysters and clams taken from sewage polluted waters and eaten raw or inadequately cooked are proven culprits in hepatitis outbreaks. Contaminated fish, especially in the Caribbean, have been incriminated as the cause of a bizarre, sometimes fatal syndromeci uetara poisoning. All fish and seafood s6ould be -fresh and thoroughly cooked.

Milk, milk products, and foods prepared from them should be avoided in areas where the process of pasteurization is unknown or its sterility may be in question. Boiling milk is one alternative or the traveler may carry a supply of powdered milk. Obviously, the water used to reconstitute powdered milk must itself be clear of disease.

Soft drinks may or may not be safe. One only has to see bottles in some tropical areas being replenished from a syrup and water mixture that is simultaneously serving a large population of flies to appreciate the possible danger. Your safest option is imported canned soft drinks.

Alcoholic beverages may or may not be safe. Brand name imported whiskey, gin, vodka, and wine pose no risk-except if ice cubes are added. Beer is usually safe. Alcohol tolerance may be influenced by heat, humidity, and altitude as well as stress, so beware!

Water-plain water-is a prime source of gastrointestinal disease, especially, but not only, in tropical areas. Water purification tablets do not destroy all infective organisms and the bitter taste they produce is no guarantee of safety. Water filters certainly can reduce the quantity of infecting organisms but do not eliminate small size parasites, bacteria, or viruses. Care should be taken in the very minimal exposure required even for brushing teeth. The freezing of water to produce ice does not destroy all pathogens. To be safe, water shouli be boiled for several minutes. One should bear in mind that water boils at a lower temperature the higher the altitude. Therefore, at 5,000 feet above sea level the boiling point of water may be in fact only 95" C, and a longer period of boiling is required for sterilization. Bottled water is widely available in the tropics, but you should always unseal the cap yourself; refilling bottles from a nearby stream or tap is a common practice.

Dishes and utensils may also serve as a medium for disease communication. A premoistened, foil packaged hand wipe can be used to protect a diner in a developing land where hot water and soap just may not be available.

OTHER PREVENTIVE MEASURES

*EXERCISE ('This section was contributed by Sean Cahill, a personal trainer in New York).
Routine exercise is an essential component in maintaining a healthy body. To enjoy travel fully, one must be as fit as possi61e and, for some journeys, preliminary physical training is definitely recommended. A holiday that demands vigorous mountain trekking, for example, should not be scheduled without allowing for a period of adaptation to exertion at high altitudes and exposure to cold, wind, and sun. Similar challenges may face those traveling to the humid tropics where sweating and intense heat can change a routine exercise program into a poten ially fatal condition of acute dehydration and heat stroke.
There are a few basic principles of muscle and vascular tone that are of particular importance to the air passenger. One shoufd avoid staying in a cramped position for long periods. In the confined space of an economy class seat, it is easy to understand how, sitting upright and immobile, with legs at a right angle at both thighs and knees, one can readily develop a circulatory condition in which stasis of blood leads to clots and emboli. It is important to occasionally extend the legs and stretch the muscles even while sitting. Periodically one should walk in the aisles and try to improve circulation by standing on one's toes or doing a few knee bends. Airport hallways and lounges are usually excellent sites for long walks while waiting for flights or during layovers.

MOTION SICKNESS. On shipboard, one should be aware that a room near the water line and as close as possible to midship will minimize the dizzying effect of rolling ocean waves. Fresh sea air and dietary discretion are also crucial factors in avoiding seasickness.
To prevent the nausea that can ruin a bumpy auto journey, sit as close as possi~ ble to the front of the vehicle with one's seat reclined and eyes closed.

CLIMATIC EXTREMES. Many a tropical holiday has been ruined by the very sun one sought. A whole range of heat stroke disorders caused by depletion of salt and fluid through perspiration can create serious imbalances in the body's essential chemicals. This can lead to a derangement of the internal temperature controls and create a life threatening high fever.
just as one would avoid extreme exercise and exposure on a very hot, humid day at home, similar common sense should be applied overseas, from Karachi to Kowloon. One's dress should also be attuned to the climate. Avoid clothing of tightly woven synthetic fibers that do not allow adequate evaporation of perspiration. Avoid tight fitting clothes that interfere with free air circulation. Loose, long-sleeved cotton garments are the most suitable dress for the tropics.
Noel Coward's musical observation that "only mad dogs and Englishmen go out in the noonday sun" is a pithy and wise dictum for the tropics. If midday ventures outdoors are necessary, protection with broad brimmed hats and taning or sunscreen lotions is strongly advised.
Vacationers to resort areas often try to cram their dreams of basking, bathing, and beachcombing into impossibly brief visits. Their main reward may well be a severe sunburn. That agonizing situation now can be effectively prevented by controlled exposure and/or the judicious use of sunscreen preparations.
Medical evidence suggests that a hot and humid atmosphere places a greater strain on the body than a hot but dry climate. It is also well documented that people suffering from heart disease adapt less readily than others, and that excessive physical activity is often a contributing factor in heat exhaustion and heat stroke. Common sense suggests that the traveler take it slow and easy.
MedicalAdvice for the Traveler

INSECTS. Insects and other arthropods are vectors for many serious diseases in the tropics. Particularly menacing are flies, mosquitoes, ticks, fleas, and sand-flies. Long-sleeved shirts and long pants offer simple and effective protection. Mosquito netting is often advisable. Most camping stores have handy little nylon nets which weigh only a few ounces and require minimal luggage space. Insect repellents may be necessary and are usually available in local cities. Most are based in diethyl toluamude (DEET). These should be applied around the neck, ankles, and wrists, and frequently reapplied if there is copious perspiration. As a basic rule the risks from malarious mosquitoes are greatest in rural areas below 5,000 feet and in the evening hours at dusk. Mosquitoes are also attracted by light and one quickly learns to check screens, if they exist, or foet under a good net if one wants a cornrtable night's sleep in the tropics.

SCHISTOSOMIASIS poses a threat throughout many parts of the world. It is a serious disease caused by a blood fluke that may attack a number of vital organs. It is contracted during exposure to fresh water which harbors specific snails infected with schistosomal parasites. Larval forms, on leaving the snails, seek their ultimate host, the human body. They penetrate the unbroken skin, migrate through the blood vessels, and eventually deposit eggs which can damage the liver, bladder, and intestinal tract. Throughout the world approximately 200 million people suffer from this infection. As a general rule the snails thrive in still, quiet water. When traveling in Africa, Asia, or Latin America, it is wise to stay out of lakes, rivers, and fresh water streams no matter how clear and inviting they may appear.

VENEREAL DISEASES deserve special attention. It is important that the sexually active traveler be fully aware that the incidence of gonorrhea and syphilis in many parts of the world exceeds even the near epidemic proportions currently documented in Europe or the United States. The traveler who contemplates sexual relations with casual acquaintances must also consider the alarming prevalence of fatal AIDS in the tropics.

MALARIA is probably the most serious and significant of all the major tropical diseases. While there is no vaccine yet available, adequate chemoprophylaxis insures fairly good protection in most areas. Because of the changing pattern of drug-resistant malaria, it is advisable to check with a specialist regarding appropriate prophylactic drugs.
Numerous antimalarials are available. Mefloquine, for example, is often prescribed for chloroquine resistant malaria zones. However, the drug may cause fetal abnormalities and should not be given to pregnant women, or those who may get pregnant within a few months of taking the drug. Acute neuropsychiatric complications do occur especially in those with a history of seizure disorders, or in people taking psychotropic drugs. A combination of atovagnone and progu anil (Malarone) is an alternative often prescribed for travelers to East Africa while doxycycline can be used in Southeast Asia.
Whatever drug is suggested must be taken regularly. Drug treatment should be started 1 week prior to travel to insure that adequate blood levels are reached and that any adverse reactions occur at home rather than in a strange land. Malaria chemoprophylaxis should be maintained for 4 weeks after you leave a malaria endemic zone. Additional terminal prophylaxis with primaquine may also be advised for those exposed to P. vivax malaria in Latin America, Africa, India, and Southeast Asia. Finally, it must be noted that complete malaria prevention is no longer possible in many areas of the tropics. Your physician may also prescribe other drugs, such as Fansidar or quinine and doxycycline, for therapy if fever and chills suggest that malaria has developed.

Some common questions concerning the antimalarial drugs.
Are they safe in pregnancy?
Chloroquine is considered safe at all stages of pregnancy and there is no evidence of fetal damage
with the dosage used in malaria prophylaxis. Some tropical physicians use proguanil alone during the first 3 months of pregnancy and then introduces chloroquine or atovagnone but there is no scientific basis for this preference. Mefloquine should not be prescribed to those who are, or about to be, pregnant. It should always be remembered that malaria can be a great threat to both the mother and the unborn baby and that adequate prophylaxis is essential.
Do antimalarials have serious side effects, especially affecting the eyes? The small doses of chloroquine employed in the prevention or treatment of malaria are relatively free from any of the serious side effects, and one would have to remain on chemoprophylaxis for approximately 5 years before any particular ophthalmologic care would be required.
Is the schedule really important? Yes, it is extremely important that the administration of chloroquine and mefloquine is every 7 days, and that proguanil be taken daily.

COMMON SENSE

UItimately one returns to the emphasis on common sense. Inoculations and medications are not a substitute for scheduling adequate rest periods and appropriate exercise intervals during a journey; for avoiding excesses, whether in activity or alcohol; for following basic hygienic practices, especially washing hands after using the toilet and before eating But with common sense an good medical advice, one should be able to travel with joy and in good health.