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    Altitude

    People differ considerably in whether or not they react to attitude changes. In general, travelers whose itineraries take them to altitudes above 8,000 feet should be aware of the risk of altitude sickness.

    It is particularly important if you have any underlying medical conditions, sickle cell anemia, asthma, emphysema or other breathing difficulties to talk to your doctor before you plan a high altitude journey.

    The most common type of altitude sickness is acute mountain sickness (AMS), caused by the effects of low oxygen to the brain. A dull and throbbing headache together with nausea, vomiting, loss of appetite, fatigue, dizziness or insomnia are characteristic of AMS. If your itinerary puts you at risk, we can give you more details about the condition and ways to minimize the effects of altitude sickness.

    Jet Lag

    The effects of jet lag are due in part to your body’s biological clock (also known as circadian rhythm being out of sync with your activities. It takes about 24-hours for your body to readjust for each time zone crossed.

    Common symptoms of jet lag include insomnia, fatigue, change in appetite and irritability. Many remedies have been promoted, with varying degrees of scientific evidence to support them. Some general recommendations include:

    • Adjusting pre-travel sleep schedule
    • Light therapy
    • Diet
    • Exercise
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    Deep Vein Thrombosis

    A blood clot that develops in a vein in your arm or leg is called Deep Vein Thrombosis (DVT).

    For the international traveler, the long airline flight(across the ocean or across multiple continents) can lead to prolonged periods of immobility. As per result, there is the opportunity for blood to pool in these veins allowing a clot to form.

    • Heart disease
    • Blood or clotting disorders
    • Recent surgery
    • Varicose veins
    • Diabetes
    • Cancer
    • Cast or splint
    • Previous episode of DVT’s

    Also at higher risk are patients who are:

    • Pregnant
    • Obese
    • Smokers
    • Taking estrogen therapy (including oral contraception and hormone replacement therapy).

    For any traveler, it is a good idea to periodically get up and stretch your arms and legs. In addition, there are simple exercises you can do in your seat to stimulate blood flow through your extremities.

    For travelers at higher risk for DTV, the use of compression stockings and /or anti-coagulant therapy can be an option.

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    Motion Sickness

    Motion sickness is not a disease, but rather it’s an exaggerated response of the body to an unfamiliar motion.

    Motion sickness can be triggered by the movement itself, or even the visual suggestion of the movement. Most people have heard about air sickness or sea sickness, but movement on land can also trigger motion sickness (e.g., riding on the back of an animal such as a horse, a camel or an elephant; downhill skiing; scuba-diving and snorkeling.) Common symptoms are nausea, sweating, salivation and vomiting. If vomiting occurs it is frequently followed by drowsiness and extreme tiredness.

    It is better to PREVENT motion sickness rather than try to treat it after it occurs. It’s a good idea to discuss the various options with us or your primary care doctor.

    Sun Protection

    Tropical sunshine can be very harmful. Be careful about exposing your skin to direct sunlight, especially at first. Sun exposure is clearly linked to acute sunburns, premature aging of the skin, pigmentary changes and worst of all skin cancer.

    If sun is unavoidable, build up your exposure from 15-20 minutes a day and avoid the mid-day sun (11am-3pm).

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    Painful sunburns can be avoided by:

    • Sunscreen! A sunscreen with SPF15 will block approximately 93% of damaging ultraviolet light, while SPF 30 blocks 96%.
    • Apply sunscreen 15-30 minutes before exposure and reapply after washing, swimming or excessive sweating.
    • One ounce of sunscreen (approximately a-full) is needed for complete coverage- spreading it on thinner will lower the SPF.
    • A rule of thumb: for a 1 week trip each person should have their own 8oz. tube of sunscreen.
    • If your trip will result in extensive sun exposure, be sure to discuss your sunscreen needs with your travel medicine provider.
    • Wear clothing that covers arms and legs. Clothing that is UV-protective is available.
    • Wear a hat that has a brim that protects your face.
    • Protect the back of your neck as well (e.g., with sunscreen and /or protective covering).
    • Protect your eyes by wearing polarized, UV sunglasses.

    If you overdo the sun:

    • Treat sunburn with Calamine lotion, which is not usually available abroad-so take some with you.
    • Drink plenty of fluids since they are often lost with badly burnt skin.
    • Avoid oily skin treatments as they trap in heat and can make sunburn more uncomfortable.
    • Several medicines can increase the skin’s sensitivity to sun, including anti-materials, antibiotics and non-steroidal anti-inflamatories. Be sure to check with us or your travel medicine provider about any medications you are, or will be taking.
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    Sexually Transmitted Diseases, Hepatitis B, AIDS & HIV

    The risk of sexually transmitted diseases, including Hepatitis B, HIV and AIDS, exists everywhere in the world. The same way you protect yourself at home, will provide protection when you travel. It's important for you to use condoms PURCHASED IN YOUR HOME COUNTRY to assure reliability.

    While the Hepatitis B vaccine provides a high rate of protection, IT IS IMPORTANT FOR YOU TO TAKE PERSONAL PRECAUTIONS AGAINST INFECTIONS. Avoid unprotected sexual relations with strangers, contact with potentially contaminated needles, medical equipment, blood products or tattooing equipment while traveling.

    Travel & Pregnancy

    • Pregnancy itself is not a contraindication to travel.
    • However pregnancy and the potential complications from it should be considered before embarking on any journey.
    • If you are pregnant or trying to get pregnant, it is important for you to consult your obstetrician to make sure it is safe and healthy for you to travel. Some of the issues you should discuss are:
    • Access to medical care (e.g. obstetrician emergencies)
    • Traveler’s medical insurance
    • Trauma during pregnancy (e.g. auto accidents, falls, injuries)
    • Food and water precautions
    • Traveler’s diarrhea.
    • Vaccinations for travel and prescription drug use
    • Malaria prevention and complications
    • High altitudes, trekking, exercise and air travel

    For more information on pregnancy and travel; www.cdc.gov/travel/pregnant.html

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    Motor Vehicle Accidents

    Traumatic injury accounts for more deaths in travelers than do infectious diseases. Motor vehicle accidents are the leading cause of these injuries. The majority of injuries and fatalities happen to pedestrians, motorcyclists, and bicyclists.

    It is critical that travelers, as both occupants of a vehicle and as pedestrians, be aware of the rules of the road in other countries.

    • Road travel after dark could be dangerous and should be avoided.
    • Use proper vehicle restraints for children and seatbelts for adults.
    • Don’t drink & drive, penalties in other countries can be even more severe than in the USA.
    • When hiring a vehicle, take the time to inspect the tires, breaks, lights and seatbelts. If the driver of the vehicle is reckless, STOP and GET OUT.

    For more information about road safety:
    www.travel.state.gov/travel/tips/safety-1179.html

    For information on International Driving Permit (IDP):

    Recreational Waters

    If your plans include water recreation or sports such as scuba diving, snorkeling, kayaking or rafting, be sure to mention any activities you plan to do to us, even those that are just possibilities. Plan to bring your own equipment and use expert guides.

    Travelers with Disabilities

    Most individuals with disabilities are able to travel, depending on personal limitations. Within the US, recent legislation has been enacted to protect the traveler with special needs against unfair treatment and to improve accessibility to transportation of all types.

    However, this is not necessarily the case in all countries. Proper advanced planning is essential for a fulfilling, enjoyable and healthy travel experience.

    Your personal physician is the best person to determine if the trip is right for you. In addition, you should pay careful attention to travel health insurance and trip cancellation insurance.

    For further information for travelers with disabilities:
    www.faa.gov/passengers/disabilities.cfm
    www.sath.org (Society for Accessible Travel and Hospitality)
    www.cdc.gov/travel/disabled.html

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    International Adoption

    Adoptive parents who travel overseas to pick up their child need to be aware that unexpected complications in the adoption process may delay their trip. This becomes an issue with medications such as antimalarials and antibiotics for travelers diarrhea as well as routine medications. Plan accordingly.

    Take extra medication with you and DO NOT rely on getting a refill overseas.

    It’s also important to remember to protect your health by getting the proper rest, following the food-wise and water safe recommendations and paying attention to the personal protection measures (PMP).

    For further information on International adoption traveling:
    www.cdc.gov/travel/other/adoption.htm
    www.travel.state.gov/family/adoption_485.html

    Travelers Medical Kit

    Your travelers may include some areas where medical care is not readily available or the care that is available is sub-standard. Consequently, it is strongly recommended that all travelers carry at least a BASIC medical health kit including first's aid items.

    Since the most common illnesses during travel to a developing country include diarrhea, respiratory tract symptoms, skin problems, high-altitude illness, motion sickness, accidents and injuries, and fever, your basic medical kit should cover these.

    Keep in mind that all medicines, even over-the-counter ones, can have side effects. Be sure to read the labels and ask any questions you might have before using any medications.

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    Suggested BASIC kit for the short-term traveler (2-4 weeks):

    • Prescription medications (in original containers) all current prescriptions you are taking plus any antimalarial medication prescribed for the trip)
    • Analgesics (aspirin, acetaminophen/Tylenol, Advil/Motrin)
    • Throat lozenges
    • Decongestant
    • Antihistamine (such as Benedryl)
    • Cough suppressant/expectorant
    • Loperamide (Imodium)
    • Antibacterial wipes/ towlettes
    • Bismuth subsalicylate (Pepto-Bismol)
    • Sunscreen
    • Calamine Lotion
    • Antifungal cream
    • Hydrocortisone cream
    • Insect repellent
    • Tweezers, scissors, safety pins (remember to put scissors in your checked baggage)
    • Antacid
    • Digital thermometer
    • Dental supplies:
    • Mouth mirror, dental floss, temporary filling material (e.g. Cavit), cotton balls, dental anesthetic (e.g.Eugenol or oil of cloves)
    • First Aid supplies:Bandages, adhesives, antibiotic ointment, moleskin for blisters, lip balm, alo vera, gel (for burns), wound closure strips, emollient eye drops, sterile dressing, antiseptic wound cleaner.

    You need to remember:

    • Your medical kit should be kept with you at all times during your trip. Pack it in your carry-on luggage. A duplicate supply of medication (if possible) should be packed in checked baggage in case of loss or theft.
    • If you are taking certain prescriptions medicines, you may need to carry with you a letter of authorization from your physician that says you require the medication for personal use. Be sure to discuss this with your travel medicine provider.
    • You should pack enough toiletry items (dental care, eye care, skin care and personal hygiene) for your entire trip unless you know they will be available at your destination.
    • If your trip is longer than 4-weeks or you have specific medical needs, discuss the additional items you should carry in your medical kit with your travel medicine provider.

    • A sample of sources for travel-related products on the internet:
      www.chinookmed.com,
      www.magellans.com,
      www.travmed.com

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    Personal Protective Measures

    You against Mosquitoes and Other Biting Insects

    Yes, there are vaccines against some mosquito-borne diseases (i.e. yellow fever, Japanese encephalitis) and you can take medication to help prevent malaria. BUT you should also take precautions to avoid getting bitten in the first place. Your first line of defense against mosquitoes and insects are known as personal protective measures (PPM):

    Avoidance

    While it’s a fact that a single bite by an infected mosquito can cause a serious disease such as malaria or yellow fever, you know that ANY BITE from a mosquito or other insects can make you miserable.

    So the best action is to try to avoid getting bitten.

    • Avoid outdoor activities at night. Retreat to a well screened in area.
    • Avoid using scented soaps or perfumes.
    • Wear clothes that cover most of the body.
    • Light color clothing won’t attract mosquitos as much as darker clothing.
    • Tuck pants into socks.
    • Wear boots or sneakers, not sandals.

    Insect Repellants

    • Applying the correct insect repellent may be the most effective and easiest way to protect you from getting an insect bite. Not all insect repellents are the same, and careful consideration is needed depending on your planned exposure.
    • Use an insect repellant containing DEET, the gold standard of insect repellents, in a concentration of 20-35% for most activities. Depending on product choice and application, DEET can lasts up to 12 hours. Given its use by millions of people over a 45 year period, DEET has a remarkable safety profile. Apply sunscreen at least 30 minutes before applying a DEET-based insect repellent.

    Further information on the safe use of DEET is available at the EPA-sponsored National Pesticide Information Network: http://npic.orst.edu

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    Protective Clothing

    Proper clothing does provide a physical barrier to biting insects. However using a chemical to treat that clothing will dramatically increase its ability to protect.

    • The use of Permethrin, an insecticide, to spray or impregnate clothing is highly recommended for protection against mosquitoes and other insects. Permethrin will kill or stun insects touching the treated fabric.
    • Treat clothes or mosquito nets according to manufacturer instructions.
    • Treated fabric will last through multiple washings.
    • The combined use of DEET on the skin and Permethrin on clothing is highly effective in protection against insects.

    Mosquito Nets

    Research shows that sleeping under a mosquito net, especially one impregnated with Permethrin, is highly effective against night-biting insects.

    • Mosquito nets should be thoroughly inspected for holes.
    • After you get under the netting, tuck the netting under the mattress, ensuring that no mosquitoes can get inside.

    Be Food-wise & Water-smart

    The familiar advice of Boil it, or forget it is easy to remember and it makes good common sense.However, many travelers don’t find this slogan practical when they travel. IT IS IMPORTANT TO KEEP IN MIND THAT THE FOOD AND DRINK CHOICES THAT YOU MAKE WILL AFFECT YOUR LIKELIHOOD OF GETTING SICK OR NOT.

    Following some simple and logical precautions will ensure that your travel's culinary's experiences are pleasant.

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    Be Food-wise

    Eating contaminated food is more likely to get you sick than drinking contaminated water!

    Be sure to think before you eat.

    • Eat food that has been thoroughly cooked, recently cooked and that is served piping hot. Avoid warm food such as casserole dishes and buffet foods which have been left at room temperature and re-warmed.
    • Cold foods such as salads, raw vegetables and fruits should be avoided. Eat fresh fruit that you can peel yourself, washing the outside surface first to avoid contamination by your own hands.
    • Avoid un-pasteurized milk and dairy products, including cheese.
    • Watch out for fresh sauces (e.g. salsa) and condiments that sit out at room temperature- a perfect place for bacteria to grow!
    • Although tempting, avoid food from street vendors.
    • Such food is not well prepared, often served under unhygienic conditions, and the food storage practices are questionable.
    • Avoid uncooked seafood or raw meat.
    • Also, be aware that even COOKED fish and shellfish can be common sources of infection at home in the U.S. and abroad. Food that is steaming hot is a good rule of thumb.

    Be Water-smart

    Your safest bet is to consider all water in all lesser-developed countries to be unsafe. This includes water from well, streams, ponds, and irrigated areas. In other words, think before any water gets near your mouth.

    • Where water is assumed to be contaminated, the same goes for the ice. Do not use ice in your beverages or add water to your mixed drinks.
    • Drink coffee and/or tea only if you know the water used has come to a rolling boil.
    • Commercially bottled water, carbonated water, soft drinks, fruit juices, beer and wine are considered safe.
    • Make sure to wipe clean and dry the can or bottle before consuming, as it could have been cooling in ice water.
    • Avoid local bottled water. In many countries bottled water is filled from the tap. Make sure the cap was sealed when you opened it. Many locals recycle and refill bottles for tourists.
    • Brush your teeth with bottled water.
    • Don’t lay your toothbrush down on the countertop-protect it with a cover.
    • Tap water is safe for bathing, but try not to get water in your eyes or mouth when bathing/ showering.
    • Tie a colorful ribbon around the bathroom faucet in your hotel to remind you NOT to drink the tap water.
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    You can make the water safe

    If the local water is unsafe, there are ways to make sure the water available for you to drink doesn’t contain infectious agents:

    Boiling

    Water should be brought to a boil for 1 minute (depending on altitude) and allowed to cool at room temperature without adding ice. This will kill most viruses, bacteria and parasites.

    Chemical Disinfection

    When it is not possible to boil water, chemical disinfection is an alternative method. Iodine or chloride tablets are available from most pharmacies and sporting goods stores. Follow the manufacturer's instructions. However, it is best to both purify AND filter your water. There are combination systems available.

    Water Filters

    There are a number of commercially available water filters.

    NOTE: THESE ARE DIFFERENT THAN THE WATER FILTERS YOU MIGHT USE AT HOME.

    For detail discussion on water purification methods and products:www.cdc.gov/travel/food-drink-risks.htm

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    Safety and Security

    Unfortunately, you can be a victim of crime anywhere, home or abroad. However, your risk may increase when you travel, particularly in lesser-developed countries.

    There you leave behind the basic protections you have in the US; where automobiles are subject to stringent safety laws, hotels have sophisticated sprinkler systems, restaurants are routinely inspected by health department, and where crime and violence are policed according to standard laws and ordinances.

    Everyone hears stories and statistics about tourist crime and misfortunes. To be fair, you need to balance these against the staggering numbers of tourists wandering around the world at one time. At the same time, these reports should serve as a warning to you that you do to keep your safety in mind at all times!

    Here are some general guidelines and safety tips worth considering:

    USE COMMON SENSE – If you wouldn't go out at night in an unknown neighborhood at home, DON'T DO it while traveling overseas.

    BE AWARE – Be aware of your general travel environment, as well as social, political or medical conditions in the countries you are visiting.

    BLEND IN – Don’t dress like a tourist,leave the baseball hat, team jackets and Hawaiian shirts at home. Know where you are going.Get directions at your hotel.

    For detailed information on the current events of each country, check the US Department of State Travel Warnings and Consular Information: www.travel.state.gov/travel.

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    Travel Health Insurance

    Before you travel, make sure to check your existing health policy to determine whether coverage applies to:

    • Pre- existing conditions
    • Conditions acquired during travel
    • Hospitalization coverage

    Whether or not medical evacuation from foreign countries is included. Although some insurance companies will pay Customary and reasonable medical cost abroad, very few will pay for medical evacuation, whether back to USA or another Western medical-practicing country.

    It is also important to find out if there is telephone phone access to your insurance provider 24- Hours-a-day, 7 days a week. If so, be sure to pack the telephone number with your passport.

    Ask your insurance carrier what they will do for you if you break a leg or get in a car accident while overseas. If they cannot provide you with the advice and assistance, you may need additional coverage.

    Apart from your regular health insurance, there are TRAVEL HEALTH insurance policies you can purchase to provide specific protection during trip. There are various types of policies available to fit the variety of travelers needs. Just remember, READ THE FINE PRINT BEFORE PURCHASING ANY POLICY.

    For more information on dealing with illness and injuries while travelling:
    www.cdc.gov/travel/other/illness-abroad.htm
    For list of travel insurance companies: www.travel.state.gov/travel/tips/health/health_1185.html

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    The Responsible Traveler

    It is important for you to know about the countries you will be visiting. Understanding cultural, hygienic and ethical differences will help avoid unintended conflicts or disrespect toward the people of the host countries.

    You can help by:

    • Being an informed traveler
    • Know the do’s and don’ts of each country
    • Respect the ways and culture of the country you are visiting.

    The events of September 11/2001 have changed international travel. American travelling abroad, now more than ever need to be more concerned about personal safety. Visibly marking yourself as an American by the way you dress or your public behavior can be unsafe in many countries.

    Dress comfortably, but conservatively. This is particularly true for women, in light of cultural and religious traditions toward women in many societies.

    Minimize the amount of jewelry you wear, whether it is real or costume. The poverty of many countries increases the temptation for crime.

    For more information on being a responsible traveler visit the international Society of Travel Medicines web-site: www.istm.org

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    Resources

    Much information on travelling healthy and smart is available on the internet. Reliable sources include:

    US CDC Traveler’s Health Home www.cdc.gov/travel

    Who On-line International Travel and Health www.who.int

    US Department of State Travel Warning and Consular Information www.tripprep.com

    International Association for Medical Assistant to Travelers www.iamat.org

    Lonely Planet Health www.access-able.com

    HTH Travel Insurance www.hthtravelinsurance.com

    Association for Safe International road travel Association for Safe International road travel www.asirt.com

    Travel Medicine, Inc. (supplies such as repellants, bednets, filters, apparel) www.travelerssupply.com

    In addition to internet resources, there are numerous books on travelling healthy:

    International Travel Health Guide, 13th Edition. Rose, S.R Northampton, MA: Travel Medicine Inc., 2006.(Downloadable in sections from http://www.travmed.com)

    Travelers Health — How to Stay Healthy Abroad, 4th Edition. Dawood R. Oxford University Press 2002.Bugs, Bites and Bowels, Healthy Travel, 4th Edition. Wilson-Howarth, J.Cadogan Guides, 2006.

    Travelers Health — How to Stay Healthy Abroad, 4th Edition. Dawood R. Oxford University Press 2002.Bugs, Bites and Bowels, Healthy Travel, 4th Edition. Wilson-Howarth, J.Cadogan Guides, 2006.

    Travelers Tips, Ist edition. Ed. Tom Hall, Lonely Planet Travel Series; 2003.

    Travel with Children, 4th Edition. Lanigan, C. Lonely Planet Publications; 2002

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