Rutgers Health Services Travel Guide

TRAVEL INFORMATION The information contained in this guide is a first step in preparing for travel. Please read through it, make notes, and ask any questions you have when you come in for your travel visit.

There is significantly more information available free on line from the Center for Disease Control (CDC), The US State Department, The World Health Organization and many, many other reputable sources.

The Center for Disease Control issues the “Yellow Book� which is considered by many to be the rule book of all things travel related. Many travelers find it helpful to review their travel plans and information on the Yellow Book web site. This can be accessed on line at: http://wwwnc.cdc.gov/travel/yellowbook/2012/table-of-contents Much of the information used in creating this packet was obtained from the CDC web site http://wwwnc.cdc.gov/travel/ and from a paid service called Travax http://www.shoreland.com/

General Health and Safety: ACCIDENTS Each year, 1.3 million people are killed and 20–50 million are injured in motor vehicle crashes worldwide. Most (85%) of these casualties occur in low- or middle-income countries, and 25,000 of the deaths are among tourists. Nearly half of medical evacuations back to the United States are the result of a car crash, and a medical evacuation can cost upward of $100,000.

Roads in foreign countries may be poorly maintained, and traffic laws may be haphazardly followed or enforced. Vehicles may lack adequate safety equipment or be poorly maintained. A crash in a developing country is more likely to be fatal because emergency care may not be readily available, or it may take a long time to get to a center that can provide appropriate care.

Transportation-related injuries are the leading cause of preventable deaths among travelers.

The tips below can help prevent transportation-related injuries:     

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Always choose cars with seatbelts and place children in child safety seats.

Avoid overcrowded, overweight, or top-heavy buses or vans Do not hesitate to ask drivers to slow down if you feel at risk.

Avoid driving yourself, but if you must- than allow a day or 2 to acclimatize and overcome jet lag.

Know the “rules of the road” in your destination country if you intend to drive while there. Also, know in advance what type of license you may need (such as an international drivers license).

Avoid driving at night.

Remain alert and drive slowly—roads could be damaged or too narrow for passage, animals might be gathering, or people could be hiking or crossing, even in remote areas.

Be particularly careful in countries where driving is on the left side of the road.

Be alert when crossing the street, especially in countries where people drive on the left.

If you will be traveling away from urban centers, research in advance where to find fuel, food, and assistance.

Make note of the nearest regional medical facility on your maps.

Some countries have a "zero tolerance" policy and severe penalties for driving under the influence of alcohol or drugs. You may be imprisoned in a foreign land.

Don't ride motorcycles. If you must ride a motorcycle, wear a helmet.

If you plan to bike ride while traveling, choose or bring a good quality helmet.

More Information:    

The Association for Safe International Road Travel at: http://www.asirt.org/ Make Roads Safe: The Campaign for Global Road Safety at: http://www.makeroadssafe.org/Pages/home.aspx CDC Travelers' Health at: http://wwwnc.cdc.gov/travel Injuries and Safety from CDC Health Information for International Travel 2012 (Yellow Book)at: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-travelconsultation/injuries-and-safety

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Slips and falls can be prevented by taking some common sense precautions:      

Organize your hotel room.

Keep a soft light on at night so you can see where you are.

Take extra care in the bathroom where surfaces may be slippery.

Be careful when you are moving around on planes. Narrow aisles, food carts, and improperly stored luggage can be hazardous.

Watch out for the most common shipboard accidents: falling over storm steps, tripping over bulkheads, and catching fingers in doors that swing shut when the ship moves.

Wear low-heeled, slip-proof shoes while traveling.

The US embassy in your destination country can help you locate medical services and will notify your family and friends in the event of an emergency. You can locate the US Embassy in your destination country at: http://www.usembassy.gov/

ALTITUDE The low oxygen levels found at high altitudes can cause problems for travelers who are going to destinations higher than 8,000 feet above sea level. Travelers’ to these areas should be prepared to recognize and respond to the symptoms of altitude illness. Although the human body can adjust to changes in altitude, the process (called acclimatization) takes time. The best way to avoid getting sick is to ascend gradually, but if you have to ascend quickly, medicines are available to prevent altitude illness.

Three types of altitude illness can occur: 1. Acute mountain sickness (AMS) typically appears at altitudes above 2,500 m (8,200 ft), although illness can begin at lower elevations in some individuals. Symptoms usually appear within a few hours and may include: headache, insomnia, irritability, dizziness, muscle aches, fatigue, loss of appetite, nausea or vomiting, swelling of the face, hands, and feet. Children who cannot yet talk may just become fussy. If you experience mild AMS symptoms, limit your activity level and remain at the same altitude for a day or 2 before ascending any farther. For most people, aspirin or ibuprofen can be used for headache. People with altitude illness should not continue to ascend until they have gotten used to the altitude. If symptoms become worse during a day of rest, descend until you begin to improve.

2. High altitude cerebral edema (HACE) is a dangerous form of altitude illness that can lead to coma and death. It is a medical emergency! HACE can be thought of as a worsening of AMS symptoms, with additional changes in consciousness and/or loss of coordination due to swelling of the brain from high altitude. Persons affected may hallucinate, appear confused, and begin to stumble or stagger. They can have severe headaches and extreme fatigue. It is crucial to help victims immediately descend to receive drug and oxygen treatment since they may be too confused to see the problem

themselves. People who have recently experienced HACE should not ascend again, even if they improved.

3. High altitude pulmonary edema (HAPE) is a buildup of fluid in the lungs that can occur along with or without HACE. Like HACE, it is a medical emergency. Victims become short of breath and become tired with little activity. They may develop a sense of fullness or pressure in the chest. As HAPE progresses, the individual will be short of breath even while resting. The illness can rapidly progress from this point to death. Victims must be guided and assisted down to receive drug and oxygen treatment as soon as the illness is recognized as HAPE. They should be kept warm and assisted as much as possible since exertion will make the condition worse. Ascending again after recovering from HAPE is not recommended.

Altitude Illness Prevention and Treatment Medications: There are some drugs available that can help with altitude illness: 

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Acetazolamide has been shown to prevent or lessen AMS symptoms by increasing breathing rate and helping with acclimatization. Side effects may include tingling in hands and feet, nausea, and increased urination.

Dexamethasone can improve AMS and HACE symptoms long enough for severely ill travelers to descend to safety and get medical help, but it is not curative and does not promote acclimatization. Side effects may include sweating, flushing, and nausea.

Nifedipine is often included in treatment for HAPE. It improves blood flow and reduces the need for oxygen. Side effects may include headache, nausea, weakness, dizziness, or edema.

Depending on the severity of illness, additional drugs and oxygen treatment may be necessary.

Preventive Behaviors for Altitude Sickness If you are flying or driving to a high-altitude location, you should try to spend a day or 2 at transitional altitudes to adjust. The same advice that applies to climbers applies to anyone at a high altitude: watch for signs of altitude illness, drink extra water, don't do too much too fast, and avoid alcohol and medications that decrease breathing rate such as sleeping pills, tranquilizers, and narcotic-based pain relievers.

If you are climbing to high altitudes, you have options that those who are flying or driving may not have. Climbers can use these preventive techniques to acclimatize and reduce their chances of altitude illness: 

Many high-altitude destinations are remote and lack access to medical care, so preventing altitude illness is better than getting sick and needing emergency treatment.

"Climb high, sleep low." Altitude illness occurs during ascent, not descent. The simplest way to avoid or reduce symptoms is to ascend slowly to give your body time to become accustomed to changes in oxygen concentration. It’s less risky to take a day trip to a higher altitude and then return to a lower altitude to sleep.

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Do not go from a low altitude to sleeping at higher than 9,000 feet above sea level in one day. Instead, spend a few days at 8,000–9,000 feet before proceeding to a higher altitude to give your body time to adjust to the low oxygen levels.

Once you are above 9,000 feet, increase your sleeping altitude by no more than 1,600 feet per day. For every 3,300 feet you ascend, try to spend a day without ascending further.

Increase your fluid intake. Dehydration occurs quickly due to dry mountain air and increased respiratory rate.

Avoid using alcohol and medications with effects that may be increased at high altitudes. Sleeping pills, tranquilizers, and narcotic-based pain relievers, can decrease your breathing rate to dangerously low levels.

If climbing with a group, agree before the climb that the group will not push past the limits of its individual climbers. If someone becomes ill during ascent, the group should assume the problem is due to altitude and act accordingly.

Keep a log of your altitudes: altitude trip begins at; the amount gained each day, and the altitude at which you sleep each night. If someone becomes ill, this information is very important.

If you have had altitude problems previously, have heart or lung problems, or are planning to go to extremely high altitudes, consult your health care provider to discuss your options for prevention and treatment of illness.

People with diabetes need to be aware that complications of diabetes may be triggered by altitude illness and may be hard to treat if they are taking medicine for altitude illness.

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Pregnant women can make brief trips to high altitudes; however, they should not sleep at altitudes above 12,000 feet.

ANIMALS 

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Any animal, even if it appears to be friendly or harmless, can be dangerous. Animals can bite, scratch, kick etc and injure you, even if you did nothing to provoke it. Animals are often frightened of humans or trying to protect their territory or their young, so stay away from all animals.

Some diseases can cause an animal to behave aggressively toward people, even if it had previously been friendly. In some countries, pets may not be vaccinated against rabies and other diseases the way they are in the United States.

Never try to pet, handle, or feed unfamiliar animals, even pets.

If you are bitten or scratched by an animal- Immediately wash the wound with plenty of soap and water. See a doctor as soon as possible. In some countries, the care needed after a bite may not be available. Medical evacuation insurance would pay to fly you to a country where you can get the best care.

Rabies is almost always fatal if an exposed person is not promptly given rabies shots. (see more under the Rabies section)

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Monkeys and Apes can spread rabies, as well as transmit serious infections such as Ebola and similar viruses, herpes B virus, and tuberculosis. If you are traveling to places where monkeys roam wild, such as certain temples in Southeast Asia, never try to touch or feed a monkey. Monkeys and apes can also be aggressive if they smell food in your pockets or bags, so leave all food in the car or hotel.

Bats often have rabies. In addition, bats can spread diseases such as histoplasmosis and Marburg fever. Stay away from caves or mines where there are a lot of bats.

Bats could find their way into your place of lodging. If you find a bat in your room after you wake up, you should consult with a local health authority to discuss your risk of rabies. Bat bites are small, and may go unnoticed. This is especially true in children, heavy sleepers, intoxicated persons, or individuals with a developmental disability.

Rodents (such as rats and mice) can spread many diseases through bites and scratches, urine, feces, or fleas. These diseases include plague, leptospirosis, Hantavirus, and rickettsia. Avoid places that look like they may be infested with rodents, and do not touch anything that may be contaminated with rodent urine or feces.

Snakes can be poisonous and a hazard in many locations. Snakebites usually occur in areas where dense human populations coexist with dense snake populations, such as Southeast Asia, sub-Saharan Africa, and tropical areas in the Americas.

Common sense is the best precaution. Most snake bites are the direct result of startling, handling, or harassing snakes. Leave all snakes alone.

Travelers should be aware of their surroundings, especially at night and during warm weather when snakes tend to be more active. For extra precaution, when practical, travelers should wear heavy, ankle-high or higher boots and long pants when walking outdoors in areas possibly inhabited by venomous snakes.

Seek prompt medical care for snake bites.

Arthropods and insects: Bites and stings from spiders and scorpions can be painful and can result in illness and death, particularly among infants and children. Other insects and arthropods, such as mosquitoes and ticks, can transmit communicable diseases (see more information on the CDC web site in Chapter 3 of the Yellow Book at: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseasesrelated-to-travel/amebiasis. Bites and stings can occur without the traveler’s awareness of the bite.

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There has been a recent resurgence in bed bug infestations worldwide, particularly in developed countries, thought to be related to the increase in international travel and insecticide resistance. Bed bug infestations have been increasingly reported in hotels.

Bed bugs may be transported in luggage and on clothing.

Exposure to bed bugs can be avoided by inspecting the premises of hotels or other unfamiliar sleeping locations for bed bugs on mattresses, box springs, bedding, and furniture. Keep suitcases closed when they are not in use and try to keep them off the floor when traveling.

Insect bites can be avoided by using repellents and insecticides, wearing long sleeves and pants while hiking, sleeping under mosquito nets, and shaking clothing and shoes before putting them on (see the Protection against Mosquitoes, Ticks, and Other Insects and Arthropods in chapter 2 of the Yellow Book at: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-travelconsultation/protection-against-mosquitoes-ticks-and-other-insects-and-arthropods ).

Travelers should seek medical attention if a bite or sting causes redness, swelling, bruising, rash, or persistent pain or fever.

Travelers who have a history of severe allergic reactions to insect bites or stings should also ask their healthcare provider to evaluate them for the need to carry an epinephrine auto-injector (such as an EpiPen) to use, in case of recurrence.

Marine animals can cause injury as well. Most species responsible for human injuries live in tropical coastal waters, including stingrays, jellyfish, stonefish, sea urchins, and scorpionfish.

Travelers should use protective footwear and maintain vigilance while engaging in recreational water activities. In case of injury, identifying the species involved can help determine the best course of treatment.

Symptoms of venomous injuries can range from mild swelling and redness at the site to more severe symptoms, such as difficulty breathing or swallowing, chest pain, or intense pain at the site of the sting, for which immediate medical treatment should be sought. Management will vary according to the severity of symptoms.

Ill birds have been associated with outbreaks of severe illnesses in humans.

If traveling in an area that is experiencing an outbreak of avian influenza, travelers should avoid all contact with live poultry (such as chickens, ducks, geese, pigeons, turkeys, and quail) or any wild birds and should avoid settings where avian influenza A

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(H5N1)-infected poultry may be present, such as commercial or backyard poultry farms and live poultry markets.

Travelers should not eat uncooked or undercooked poultry or poultry products, including dishes made with uncooked eggs or poultry blood. Other diseases from birds may potentially infect humans through infected feces or by aerosol. These would include diseases such as histoplasmosis salmonella, psittacosis, or avian mycobacteriosis. Travelers should avoid contact with ill birds and should wash their hands if they come in contact with bird feces.

If you become ill during or after your trip and you came into contact with an animal while traveling, make sure to tell your medical provider about your contact with animals.

If you are planning on traveling with your pet, - tell your veterinarian about your travel plans as soon as possible. Your pet will need veterinary appointments and paperwork completed before travel. Some countries require blood tests at least 6 months before departure to prove that your pet is vaccinated against rabies. Warning: If the destination country’s requirements are not met, your pet may be detained or quarantined upon arrival.

For further information on travel with pets visit the web sites below: Center for Disease Control travel with pets at: http://wwwnc.cdc.gov/travel/page/pets The International Air Transport Association at: http://www.iata.org/whatwedo/cargo/live-animals/Pages/index.aspx CDC Animal Importation Form at: http://www.cdc.gov/animalimportation/forms.html US Department of Agriculture at: http://www.aphis.usda.gov/import_export/animals/animal_import/animal_imports_p ets.shtml

BEACHES AND SWIMMING  

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Drowning accounts for 14% of deaths of US citizens traveling abroad.

When possible, limit swimming to chlorinated pools and unpolluted ocean beaches far from the mouths of streams. Avoid freshwater lakes and rivers in the tropics—they may contain the snails that transmit schistosomiasis to humans (microbes that enter the skin).

Walking barefoot exposes you to poisonous plants and animals, parasite and fungal infections, puncture wounds, and cuts and bruises. Wear footwear at all times. Bring shoes that are specially made to be worn in the water.

Areas frequented by animals may have contaminated sand and soil. Avoid contamination by sitting on a towel, blanket, or piece of clothing if chairs are not available. Shake out all fabrics thoroughly after use so you don't bring any "unwanted guests" back with you.

In tropical waters, watch for jellyfish, sea anemones, and corals, which can give nasty stings. If you are stung, rinse the affected area with isopropyl alcohol (rubbing alcohol), vinegar, or seawater, and scrape or shave the area gently to remove any remaining stingers. Do not rub the area or rinse with fresh/tap water. Acetaminophen, aspirin, or ibuprofen will help with pain, and antihistamines such as diphenhydramine (Benadryl) can relieve itching and swelling. If symptoms are severe seek medical help immediately.

Strong currents and submerged objects can cause injury and drowning.

Typically there are no lifeguards at beaches in tropical and developing countries. Never swim alone, at night or in unfamiliar waters. Know what to do to help yourself or others if injured or in danger.

Learn about the local water conditions, currents, and rules before entering the water.

Use proper safety equipment such as lifejackets.

Make sure your gear, such as scuba masks and tanks, are properly fitted and maintained. Only rent equipment from reputable, knowledgeable groups.

DO NOT drink alcohol before or during swimming, diving, or boating. Alcohol affects balance, coordination, and judgment.

DO NOT dive in shallow or unfamiliar water. Always enter water feet first.

Be aware of and avoid hidden obstacles in the water.

Supervise children closely around water.

Obey posted signs and warnings, and recognize that warnings may not always be present.

Know the meaning of and obey warnings represented by colored beach flags. These may vary from one beach to another.

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Only use experienced guides when boating, scuba diving, or participating in other waterrelated activities.

Learn the risks associated with local sea animals, such as urchins, jellyfish, coral, and sea lice, before you get in or on the water.

Watch for signs of rip currents (water moving quickly in a channel away from shore); if you are caught in a rip current, swim parallel to the shore until free, then swim diagonally toward the shore.

Don’t swallow the water you are in or on.

Don’t swim with open cuts, abrasions, or wounds. Breaks in the skin can let harmful germs into your body.

Don’t swim in cloudy water.

Infections such as schistosomiasis and leptospirosis are spread by contact with fresh water. These microbes can penetrate your skin, so swallowing water isn’t necessary to cause infection. Avoid contact with any fresh water (lakes, rivers, streams) where these infections are a problem (check the destination pages on the CDC web site for more information at: http://wwwnc.cdc.gov/travel/destinations/list).

BLOOD CLOTS (DVT) 

Blood clots called deep vein thrombosis (DVT) can occur in the large veins of the leg or pelvic area during or after long trips. Sitting still for long periods of time, especially with knees bent, can cause blood to pool in your legs, which increases the risk of a clot forming. If not treated, DVT can lead to pulmonary embolism (PE), a potentially lifethreatening condition in which part of the clot in the leg dislodges, travels to the lungs, and blocks a blood vessel.

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Almost anyone can have DVT. Most people who develop travel-associated DVT have additional risk factors, including: o A previous blood clot o Family history of blood clots o Pregnancy or <6 weeks post delivery o Known clotting disorder o Recent surgery or injury o Use of estrogen-containing birth control or other estrogen containing medication o Older age, >50yo o Obesity o Active cancer (or undergoing chemotherapy) o large varicose veins or chronic venous insufficiency o Recent heart attack or congestive heart failure o Limited mobility

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You can take steps to help prevent DVT. These steps include:  

Getting up every hour and walk around. Choose an aisle seat if possible.

Do not sit with your legs crossed, as it slows down return blood flow.

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Wear loose, comfortable clothing. Avoid clothing that binds at the knees or waist.

Exercising your calf muscles and stretching your legs while you're sitting. Try: o Raising and lowering your heels while keeping your toes on the floor. o Raising and lowering your toes while keeping your heels on the floor. o Tightening and releasing your leg muscles.

Remaining well hydrated with water. Avoid alcohol, beverages with caffeine in them, and sleeping pills.

For some high risk travelers: o Wearing properly fitted, graded, medical compression stockings (20-30 mmHg at the ankle level). o Taking medication before departure to prevent DVT. It is helpful to know the signs and symptoms in the event that you develop DVT or PE. If you have symptoms of DVT get medical care right away. If you have symptoms of PE you should seek immediate medical care from the emergency department. Early detection and treatment can prevent death or complications.

DVT Symptoms: 

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Swelling, pain, or tenderness in the affected limb (usually the leg) Redness and increased warmth of the skin in the affected limb

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Unexplained shortness of breath Faster than normal heartbeat Chest pain Cough (which may be bloody) Lightheadedness or fainting

DVT and PE are treatable, although a large PE can result in sudden death. Sometimes medicines and devices are used to dissolve the clot. Typically, medicines are taken for several weeks to months after the clot to prevent more clots from forming and give the body a chance to dissolve or heal existing clots.

For more information on DVT’s and PE’s, traveler’s can go to the Clot Connect education and support program at: www.clotconnect.org

Or the Venous Disease Coalition at: http://patientblog.clotconnect.org/2010/11/22/long-distance-travel-and-blood-clots

CHILDREN AS TRAVELERS 

Car crashes are the leading cause of death in children who travel, and drowning is the second-leading cause of death. Children should always ride in age-appropriate car seats when traveling, and be supervised closely. Children should always wear a life preserver around water.

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If you are planning to travel to another country with children, be familiar with the risks of travel to help them stay safe and healthy.

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When planning, include frequent food, beverage, and rest stops. Have toys, books, and games available to keep children quietly occupied when necessary.

Give children an identification necklace or card to keep with them at all times. It should include your address and phone number while abroad (but no names), as well as medical or emergency information.

Prearrange a meeting place in case you are separated.

Some people have children carry whistles to use if they become lost or fear for their safety.

Make sure children know the name and number of the person or place you want them to call if they become lost and you are not available. Teach them how to use foreign telephones and let them practice making several calls.

Travel agents or airline web sites can provide airplane seating charts and help in selecting the best travel times and seats for children.

Some airlines will allow you to carry an infant safety seat or collapsible stroller on board, - check your airline's policy.

Call your airline in advance to order special meals for children, or pack your own meal for them. Bring along familiar foods or snacks and a 24-hour supply of food for infants in case of extensive delays.

Traffic regulations at your destination may be different than those at home. Be sure children understand the rules in the countries you visit, especially if traffic lights or signs are different than those they already know.

Do not assume child or infant car seats can be rented at your destination—bring one with you unless you know a safe one will be available.

Always schedule a travel visit with the child’s pediatrician to be sure all vaccines are up to date and any needed travel related vaccines or medications are obtained.

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Diarrhea is among the most common illnesses experienced by children who are traveling. Diarrhea can be serious in infants and small children because of the risk of dehydration.

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For infants, the best way to prevent diarrhea is breastfeeding.

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Diarrhea in older children should follow basic food and water precautions: eat only food that is cooked and served hot, peel fresh fruits and vegetables or wash them in clean water, and drink only beverages from sealed containers or water that has been boiled or treated. Children should wash their hands or use alcohol-based hand cleaner frequently.

Children should also avoid putting their hands in their mouth.

The best treatment for diarrhea in children is to give plenty of fluids; there is usually no need to give medicine.

Oral rehydration salts (available online or in stores in most developing countries) may be used to prevent dehydration if approved by your pediatrician.

Over-the-counter drugs that contain bismuth (Pepto-Bismol and Kaopectate) should not be used in children. Antibiotics are usually reserved for serious cases.

A child who appears to be severely dehydrated (little urine, dry lips, “sunken” eyes or “sunken” soft spot on infants heads), or who has a fever or bloody stools, should get immediate medical attention.

Children who travel to areas where malaria is a risk should take drugs to prevent malaria (see the malaria section). Your pediatrician can tell you which malaria medicine is best for your child. Many of the malaria medications have a bitter taste, but a pharmacist can pulverize the capsules and put the powder in a flavorless gelatin capsule. Because of the risk of overdose, malaria drugs should be stored in childproof containers and kept out of the reach of children.

Malaria drugs are not 100% effective, and other diseases (such as dengue, leishmaniasis, and trypanosomiasis) also are spread by insects, so children (and adults!) need to avoid bug bites. Children should wear bug spray and long pants and sleeves. Permethrin can be applied to clothes for extra protection. At night, children should sleep in screened, air-conditioned rooms or under a bed net.

Rabies is more common in children than in adults because children are more likely to try to pet strange animals. Children need to be told to stay away from all animals; however, they also need to be assured that if they do get bitten, they won't get in trouble and should tell an adult immediately. Any animal bite should be washed thoroughly with soap and water and must receive medical attention as soon as possible.

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COLD CLIMATES

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When traveling in cold climates wear warm clothing in several loose layers. Pockets of air between the layers -create additional insulation. You can add or remove layers if the weather changes.

Wear an outer layer of windbreaker-type material. A chilling wind can pull away all the heat you generate and turn a cold day into a dangerous one.

If there is any chance of precipitation, wear a moisture-resistant covering (such as Gore Tex) as your outermost layer.

Gloves should protect your hands, and a hat or hood should protect your head.

In wet conditions, shoes should be waterproof and have good traction.

Make sure that your cold-weather gear does not restrict your movement or block your eyesight.

When engaging in adventure activities in cold weather or around cold water, have safety equipment and gear that will keep you warm and dry.

Hypothermia is a dangerous drop in the body's core temperature to below 95°F. Many hypothermia deaths have occurred in weather that is between 30 and 50° F (-1 and 10° C).

Mild hypothermia can make you feel confused, and you may not think anything is wrong until it is too late. Being too cold can also cloud your judgment and cause you to make mistakes, which can be deadly.

Early symptoms of hypothermia include shivering, slurred speech, decreased awareness, irritability, stumbling, feeling tired, being clumsy, and being confused. As your body loses more heat, the shivering may stop (this is a sign of exhaustion), your skin may turn blue, the pupils of your eye may expand, your pulse and breathing may slow, and you may pass out.

Frostbite happens when a part of the body freezes, damaging tissue. Fingers and toes are most at risk. If the tissue can’t be saved, the body part may need to be amputated or cut off.

Warning signs of frostbite include numbness, itching, tingling, stinging, or pain where you are most exposed to the cold.

Frostbite is treated by warming the body part in warm water. However, Do not thaw a frozen body part unless it can be kept thawed. Refreezing causes damage that is even worse than the original frostbite.

If you suspect frostbite or hypothermia, find warm shelter and seek medical attention.

Remove cold, damp clothing and place the victim between blankets until help arrives.

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Avoid interim measures such as rubbing or rapid re-warming, which can lead to complications Modern clothing and equipment have decreased the risk for adventure travelers, but frostbite still occurs after accidents, as a result of poor planning, and in severe, unexpected weather.

CRIME 

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The U.S. Department of State provides a free travel registration service to U.S. citizens who are traveling or living in another country. Registration allows you to record information about your trip so that an American consular officer can contact and assist you in an emergency. Registration is very helpful if you find yourself in a situation where there is unexpected civil unrest or a natural disaster, such as an earthquake or hurricane. Remember, a consular officer cannot assist you if they do not know where you are. For more information, see Registration of Traveler Emergency Contact and Itinerary Information at: https://step.state.gov/step/ Find the American Embassy or Consulate in your destination by going to the list of website of U.S. Embassies, Consulates and Diplomatic Missions (at the U.S. Department of State) at: http://www.usembassy.gov/ . Consular personnel at U.S. Embassies and Consulates abroad and in the U.S. are available 24 hours a day, 7 days a week, to provide emergency assistance to U.S. citizens.

For specific questions regarding an emergency involving an American citizen overseas, contact the Office of Overseas Citizens Services at 1-888-407-4747 (from overseas: 202501-4444).

To learn more about services available during an emergency, see the information at Emergencies: Consular Assistance and Crises Abroad at: http://travel.state.gov/travel/tips/emergencies/emergencies_1212.html Know where health-care resources are located in your destination before you leave. See Doctors/Hospitals Abroad at: http://travel.state.gov/travel/tips/emergencies/emergencies_1195.html In addition to preparing yourself for your trip, it is important to also prepare someone at home for a possible emergency. Ask a family member, friend, or employer to be your contact person while you are traveling.

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Before you leave: Make arrangements to check in at regular intervals during your trip with this contact person.

Leave them a copy of your passport, as well as details of your travel plans and how to contact you.

Leave them a copy of your prescription for any medicines that you are taking and the contact information for your doctor.

If there is an emergency at home, or if a family member is worried about a traveler’s welfare, they can ask the embassy or consulate for help. They can contact the Welfare/Whereabouts Services Abroad section on the U.S. States Department site for specific services available.

Many countries have government offices that supply information for travelers. Check for advisories on political or civil unrest, criminal activity against tourists and other travel concerns frequently, before your trip.

Know the phone number and location of your government's (USA) closest embassy or consulate and carry this information with you at all times. A duty officer is usually on call in case of crime or other emergency.

Know how local law enforcement agencies operate and how to access help in the area you are traveling in.

Unless local law requires you to carry your passport, keep it locked in a safe location and carry a photocopy of it with a legal entry stamp. If your passport is stolen, you will need identification to receive a new one. You will also need a new passport to get back home.

Prepare your tour routes before setting out. This avoids looking at maps on the street,which calls attention to the fact that you do not know where you are.

Lock your room before setting out for the day.

Make sure at least one other person knows your whereabouts and expected schedule at all times.

Familiarize yourself with common local scams and distraction techniques. Groups of small children sometimes act as distractions so you can be robbed.

Ask at your hotel if any areas are dangerous, or if there are any areas that they would recommend avoiding.

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Use extra caution in tourist sites, market places, elevators, crowded subways, train stations, and festivals, and avoid marginal areas of cities.

Be constantly attentive to surroundings and be wary of any stranger who engages you in any form of conversation or touches you in any way, no matter how accidental the contact may appear to be. Especially beware of pickpockets around train stations and other crowded areas.

If you are confronted, give up your valuables. Money and jewelry can be replaced—you cannot.

Do not wear expensive clothing or jewelry and avoid carrying expensive cameras, computers, or luggage.

Avoid clothing that declares your nationality, religious or political beliefs.

Never carry valuables or large amounts of cash. Use traveler's checks or credit cards for large purchases, but first make sure they are accepted in the areas you will be visiting.

Learn about local exchange rates and pay close attention to all monetary transactions.

Exchanging money is sometimes seen as an easy way to deceive tourists. Avoid black market exchanges.

Do not carry purses or money belts that can be cut or torn off.

Wear your handbag across your chest or under a jacket or shirt.

Carry your wallet in a front pocket with rubber bands wrapped around it so it cannot be easily removed.

Keep suitcases locked and out of sight if you are using a car for transportation. Do not leave valuables in the car.

When driving, keep car doors locked and windows rolled up. Use cars with air conditioning.

Carjacking and thefts happen when stopped at gas stations, parking lots, or in slow city traffic.

Avoid driving at night or alone and never drive outside urban areas after dark.

Do not pick up hitchhikers.

Do not drink and drive.

Avoid cars with rental markings, as these can attract unwanted attention.

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Never drive a motorcycle or scooter abroad.

Consider locally purchasing a mobile phone to have with you in case of emergencies.

Use only "registered" taxis, preferably radio taxis.

Negotiate the fee before entering the taxi and carry small denominations so you will have change for the taxi bill.

Avoid sharing taxis with strangers.

Avoid overcrowded public transport if possible.

Do not accept food offerings—they may contain sedatives to induce sleep and allow you to be robbed.

If the driver is acting in an unsafe manner, or appears to be intoxicated, disembark at the next stop.

Beware of bogus porters who may disappear with your luggage.

Hotel rooms on floors 3 to 6 are generally regarded as optimal for safety and security.

Lock your hotel room when you go out, but also keep the door locked at all times when you are in it.

Do not open your hotel room door without knowing the person on the other side of the door. If they claim to be from the hotel, call down to the front desk to verify their story before opening the door.

Meet visitors in the lobby. Do not advertise your room number.

When out of the hotel, leave your key with the concierge. Inform someone, including the front desk, when you expect to return if you will be out late at night.

Look for fire safety instructions in your hotel room and familiarize yourself with escape routes upon arrival.

Keep valuables in the hotel safe. Room safes are less secure.

DISEASE DIRECTORY

The CDC has a listing of diseases that are possible with travel. To review the list, or to get further information about a specific disease, please look at their web site at http://wwwnc.cdc.gov/travel/diseases

DENTAL CARE ď&#x201A;ˇ

If you have a current dental concern or any pending dental work, please take care of this before you travel. Dental care in some countries is difficult to find, and can be of poor quality. Improperly sterilized dental instruments and the risk of infectious disease are some of the problems you may encounter. A routine checkup should be done before you leave if it is possible.

EMERGENCIES • Check with your medical insurance to determine your coverage, if any, while out of the USA. Policies may or may not cover air rescue, ambulance transport, help in making hospital arrangements, coverage of medical or hospital bills, cash advances, evacuation to your home country, or 24-hour telephone assistance.

• Know how your policy works, and if there are requirements for payment such as precertification. Know how to reach a representative while you are traveling, in case a question arises.

• Most foreign medical providers require cash payment; make sure you have access to funds while traveling.

• Determine if a travel insurance policy is something you should purchase for your trip.

Some people have some coverage through travel related memberships such as AAA, and others may have some coverage through their credit card company if they charged their trip.

• You can explore these resources to get further information about purchasing travel health and medical evacuation insurance as well as recommendations for providers in some areas: •Department of State (www.travel.state.gov) •International SOS (www.internationalsos.com) •MEDEX (www.medexassist.com)

•International Association for Medical Assistance to Travelers (www.iamat.org) •American Association of Retired Persons (www.aarp.org) • Try to have someone to advocate for you, with you, if you need medical care. You may need a translator as well. Some travel insurance companies cover this expense, others do not.

• Persons with a medical condition should wear medical alert tags. Those individuals may want to invest some time in making a list of key words related to their condition in the foreign language of their destination to bring with them.

• Avoid injections, dental procedures, or skin piercing while traveling. Even manicures and shaves can be risky in some areas as you can be exposed to HIV (human immunodeficiency virus) and other blood-borne pathogens.

• If injected medication is advised during travel, ask if there is an oral formulation that you can take instead. If injections are absolutely necessary, insist on individually wrapped, disposable needles.

• If you have a condition requiring injections, bring your own supply of needles and syringes. Carry a letter from your health care provider explaining your medical need.

EYE CARE • If you have eye or vision problems, see your eye care specialist before your trip. Also, if it is time for your routine eye exam, schedule this appointment before you leave for travel.

• Bring an extra pair of glasses or contact lenses with you, along with any solutions you might need.

• If using contact lenses, your hands must be washed with purified water before insertion.

If traveling to remote areas, - consider switching to eyeglasses.

• UV radiation from the sun increases your risk of cataracts. Wear sunglasses when outdoors, especially if you are at high altitudes or if the sunlight is intensified by water, sand, or snow.

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Keep a written copy of your lens prescription with your other health information.

FLYING WITH A COLD • Traveling by airplane when you have swollen mucous membranes can cause pain during ascent and descent. Drink plenty of fluids and use a nasal spray such as Afrin before takeoff and landing. Over-the-counter cold remedies work effectively, you can ask your pharmacist for help in choosing one if needed.

FOOD AND FLUIDS PRECAUTIONS

• It is impossible to guarantee the safety of food and beverages when traveling. Without strict public health standards, bacteria or parasites in food or water may go undetected and cause illness such as traveler's diarrhea, hepatitis A and E, giardia, typhoid, and paratyphoid.

• Enjoying local foods is part of the pleasure of international travel. Just be sure to follow food and water precautions and concentrate on eating the types of food that tend to be safest.

• Eat food that is cooked and served steaming hot, hard-cooked eggs, fruits and vegetables you have washed in clean water or peeled yourself, and pasteurized dairy products.

• Don't eat food served at room temperature, food from street vendors, raw or softcooked (runny) eggs, raw or undercooked (rare) meat or fish, unwashed or unpeeled raw fruits and vegetables, condiments (such as salsa) made with fresh ingredients, salads, flavored ice or popsicles, unpasteurized dairy products, or ”Bushmeat” (monkeys, bats, or other wild game).

• Drink water, sodas, or sports drinks that are bottled and sealed (carbonated is safer), water that has been disinfected (boiled, filtered, treated), ice made with bottled or disinfected water, hot coffee or tea, and pasteurized milk and dairy products (cheese, yogurt).

• Don't drink tap or well water, fountain drinks, ice made with tap or well water, drinks made with tap or well water (such as reconstituted juice), or unpasteurized milk. 

Don’t brush your teeth or rinse tooth brushes in tap water.

• Eat at establishments that are known to cater to foreigners or that are specifically known by other foreigners to be safe.

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Eat breads, tortillas, crackers, biscuits, and other baked goods.

• Eat fruits, nuts, and vegetables with thick skins, peels, or shells that you remove yourself.

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Eat canned foods.

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Always wash your hands with soap before eating and after using the toilet.

• Don’t eat large carnivorous fish, especially from reef areas. Many contain concentrated toxins.

• Be particularly wary of ice cream and other frozen confections that may have been made or stored in contaminated containers, or inadequate refrigeration.

• Don’t eat cold sauces such as mayonnaise, salad dressing, chutneys, or salsas, which are usually raw and made by hand.

• Do not eat buffet foods such as lasagna, casseroles, and quiches—unless you know they are fresh (not reheated) and have been kept steaming hot. Avoid buffets where there are no food covers or fly controls.

FOOD AND FLUID RELATED ILLNESSES 

HEPATITIS A is a viral infection of the liver. It can be spread through contaminated food and water or by person-to-person contact. Symptoms appear suddenly 2 to 6 weeks after infection and can range from a mild (fatigue, fever, decreased appetite, nausea and mild discomfort just under the rib cage on the right side), to a full-blown illness that can progress to jaundice (yellowing of the skin and the white part of the eyes) and liver failure. Hepatitis A occurs worldwide.

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To help prevent Hepatitis A, practice good personal hygiene and follow food and water precautions carefully. Make sure you get a Hepatitis A vaccine before you travel.

Hepatitis A vaccine provides long-lasting immunity; it is given in a single dose with a second dose 6 months later. (A combined hepatitis A/B vaccine is also available.) You can also receive temporary protection with an immune globulin injection.

TRAVELER'S DIARRHEA is a common concern of travelers. It is caused by ingesting contaminated food or water. Most traveler’s diarrhea is caused by bacteria (e.g., E. coli), but it can also be caused by protozoa (e.g., Giardia) or a virus (e.g., rotavirus). Up to 60% of traveler’s will experience it. Traveler’s diarrhea is characterized by the passage or 3 or more unformed stools in a 24-hour period. Episodes typically last 3-4 days on average, but some cases can persist longer. Some destinations are more frequently associated with traveler’s diarrhea (Africa, Central and South America, Asia, and the Middle East are considered high-risk areas).

To reduce your chances of acquiring traveler's diarrhea, strictly following food and water precautions and pay close attention to hygiene (wash your hands!). A vaccine (Dukoral™) that has been shown to be effective against some types of diarrhea is available in Canada and elsewhere (not in the U.S.). However, despite prevention strategies traveler’s diarrhea still occurs. Therefore, it is important to learn how to recognize and manage traveler’s diarrhes if it occurs.

Symptoms of traveler’s diarrhea caused by bacteria include: an abrupt onset (you can identify the exact time the illness began) of uncomfortable diarrhea. Fever, nausea, or vomiting may also occur. The symptoms are quite bothersome from the beginning. If you experience an abrupt onset of uncomfortable diarrhea you can be reasonably confident that the cause is bacterial, and you can treat yourself with an appropriate antibiotic to shorten the illness.

Travelers are often in areas where medical care is unavailable. Therefore, it is more practical to self-treat bacterial diarrhea with antibiotics that have been prescribed and purchased prior to leaving for the trip.

For treatment of suspected bacterial diarrhea, quinolone antibiotics (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin) are preferred. Quinolones may be used with caution in children of all ages, although only ciprofloxacin is FDA-approved for children less than 18 years of age. Safety of quinolone antibiotic use during pregnancy and breast feeding has not been established.

When quinolones cannot be used, azithromycin may be an effective alternative in treating bacterial traveler’s diarrhea; azithromycin is also the drug of choice for children and pregnant women.

Rifaximin (Xifaxan) is an alternative when neither quinolones nor azithromycin can be used; rifaximin is approved for treatment of traveler’s diarrhea caused by E. coli in

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persons 12 years of age and older (only for use in persons who do not have fever or bloody stools). Safety of rifaximin in pregnancy and breast feeding has not been established.

In contrast, to the abrupt onset of bacterial diarrhea, protozoal diarrhea begins gradually, with looser stools occurring in distinct episodes during the day. These episodes may be associated with gas, bloating, upper abdominal discomfort, and fatigue. Persons with protozoal infections often do not seek medical care for 2 weeks or more due to the generally mild nature of the symptoms. Antibiotics such as metronidazole (Flagyl) or tinidazole (Tindamax) are usually prescribed for protozoal diarrhea. In general, you should not carry these drugs for self-treatment. A proper diagnosis should be made and the drugs administered under supervision.

If you do bring medication with you, make sure that written information on symptoms, precautions, correct dosage and scheduling is included. Many drug treatments for diarrhea should not be used by pregnant women, and some that are recommended for adults can cause complications for children.

Anti-motility drugs such as loperamide (Imodium) or diphenoxylate (Lomotil) may be useful on a temporary basis to slow bowel movements and reduce frequency of stools.

These drugs are not curative. If used inappropriately they can cause constipation. Do not use them for more than 48 hours.

Some people take bismuth subsalicylate (Pepto-Bismol) preventively to reduce their risk of traveler's diarrhea. Side effects include darkening of the tongue and stools and, occasionally, nausea, constipation, or ringing in the ears. It should not be used by children less than 12 years of age or people who have an aspirin allergy, are taking aspirin, have renal insufficiency, or have gout. (Use with caution in older children and teens with a viral infection.) It should be used this way only if recommended by your health care provider and only for less than 3 weeks if at all.

If you have diarrhea you will need to take measures to prevent dehydration, especially during prolonged episodes.

Adults can replace fluids and electrolytes (body salts) by eating salted crackers and drinking plenty of nonalcoholic, no caffeinated beverages, and soups. If there is any question about the purity of your water source, make sure all beverages and soups are prepared with purified water.

If signs of dehydration appear (dizziness, weakness, dry skin, sunken eyes, deep-yellow urine, reduction or lack of tears and urine), seek medical help immediately. Dehydration can quickly become serious for infants, children, and the elderly.

When you begin to pass soft stools, try eating easy-to-digest foods such as bread, potatoes, tortillas, and rice. Eat lightly for a few days, and stay away from dairy products and foods that are spicy or greasy.

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Infants must be given food and fluids throughout the course of any diarrheal episodes and watched closely for signs of dehydration.

Oral rehydration solutions (ORS) may be helpful in replacing lost fluids. They were designed to decrease childhood mortality rates and are absorbed rapidly from the intestine. ORS packets are available in most developing countries. They should be reconstituted with boiled, bottled, or purified water.

See a health care provider or travel medicine specialist if the diarrhea does not improve after a few days, you have fever, shaking chills, severe fluid loss, or blood or mucus in the stools, or you are taking antibiotics and have a rash or hives that might indicate an allergic reaction POLIOMYELITIS (POLIO): Best known as a virus that causes paralysis in infants and children, adults are also vulnerable to polio. Polio is usually spread via the fecal-oral route, by ingestion of water or food contaminated with the virus. After an incubation period of 1 to 2 weeks, the virus causes a sudden fever, headache, sore throat, and vomiting. Most people recover at this point, but in some cases the virus invades the central nervous system and results in paralysis.

Polio continues to occur in many developing countries, particularly in Africa and the Indian sub-continent as well as in Indonesia and the Arabian Peninsula, especially in areas with inadequate sanitation and poor hygiene practices.

Food and beverage precautions may help reduce the risk of exposure to polio virus; however vaccination is the only reliable protection against polio. If you have never been vaccinated against polio, the full series of injected polio vaccine requires at least 2 months to complete. Even if you have previously received the full series, your health care provider may recommend a one-time booster dose, especially if you will be

traveling to developing countries.

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TYPHOID FEVER is a bacterial infection of the digestive tract caused by Salmonella typhi.

It is prevalent in countries with warm climates and poor sanitary conditions, it is spread via food and water contaminated with fecal matter from an infected human carrier.

Typhoid has an incubation period of 1 to 3 weeks. Symptoms appear over the course of a month, beginning with fatigue, dull headache, intermittent fever, abdominal pain, and, sometimes, a rash. If untreated, it may progress to a more severe illness with ongoing high fevers, "pea-soup" diarrhea, disorientation, multiple organ involvement, and coma.

Vaccination provides some protection, and is available by injection and in oral form in some countries. The injection (1 shot) should be given at least 2 weeks before departure, and the oral vaccine series (4 doses) should be completed at least 1 week before departure for optimum protection. Your health care provider may recommend vaccination if you will be traveling in endemic areas or areas with a recent typhoid outbreak.

Whether you are vaccinated or not, it is important to follow food and water precautions since the vaccine is only 50-80% effective in preventing illness.

Additional illnesses, but less common, that may be contracted from food and water include: anthrax, brucellosis, leptospirosis, and tapeworm.

HEAT, HUMIDITY & SUN • Traveling in hot climates can make you sick, especially if you are not accustomed to the heat.

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Stay in an air-conditioned building as much as possible.

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Drink plenty of fluids.

• Wear loose, lightweight, light-colored clothing. Linen and cotton fabrics are good choices. Also wear a loose fitting, light colored, wide brim hat.

• Try to schedule outdoor activities during cooler parts of the day. The sun is strongest 10am – 2pm.

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Rest often, and try to stay in the shade when outdoors.

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If you will be doing strenuous activities in the heat, try to get adjusted before you leave.

• Wear sunscreen with a sun protection factor (SPF) of 15 or more, and protects against both UVA and UVB light. Reapply sunscreen often, and especially after swimming or perspiring.

Protecting your ears, neck, tops of feet and lips is essential. For children, a PABA free sunscreen is best.

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Where sunlight is very strong, wear sunglasses that have side shields.

• Some medications cause” photosensitivity”- another way of saying that they increase your risk of sunburn. Find out if any of the medications you are taking cause photosensitivity and be extra careful about sun exposure if they do.

• Avoid alcohol and caffeine which can cause dehydration, and increase water consumption.

• Heat rash (“Prickly Heat”) can appear as an area of raised spots or as reddened, sensitive skin. This most often occurs on areas of the body not exposed to air, such as underarms and groin. Cool baths or compresses can help soothe irritated skin, and hydrocortisone cream will decrease itching.

• Mild sunburn discomfort can be relieved by bathing in cool water or applying cool compresses to affected areas. Anti-inflammatory drugs such as ibuprofen can help as well.

• Overheating can result in heat exhaustion (an elevation of the body core temperature) or heat stroke (extreme elevation of the temperature from untreated heat exhaustion).

Symptoms include excessive thirst, profuse sweating, headache, rapid heart rate, dizziness or confusion, and nausea. If the individual is progressing to heat stroke, their symptoms may progress to irrational behavior, confusion, low blood pressure, vomiting, shortness of breath and unconsciousness. If you or anyone you are traveling with develops these symptoms, immediately get out of the sun and try to cool off by fanning, removing clothing or wetting their clothing, take plenty of fluids. Heatstroke is a life-threatening medical emergency; get medical attention if symptoms persist.

HAJJ AND OTHER MASS GATHERINGS 

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The annual Hajj pilgrimage to Mecca, Saudi Arabia, is among the largest mass gatherings in the world. It draws about 3 million Muslims from around the world, and more than 11,000 Americans make the pilgrimage each year. Because of the number of people crowded into a relatively small space, mass gatherings such as the Hajj are associated with unique health risks. If you are planning to perform Hajj—or attend any other large gathering—follow these tips to stay safe and healthy.

Avoid Injury. Being caught in a human stampede is a major fear of many people attending a mass gathering. To protect yourself, try to avoid the most densely congested areas and always be aware of the location of emergency exits.

Saudi religious authorities have expanded the times during which certain rituals can be performed, and pilgrims can expect fewer crowds if they perform these rituals during nonpeak hours.

Temperatures in Mecca can exceed 100°F in October and November, and heat exhaustion and heatstroke are leading causes of illness during Hajj. Pilgrims should drink plenty of water (bottled), wear sunscreen, rest, and seek shade as much as possible.

Some rituals can be performed at night to avoid daytime heat.

Symptoms of heat-related illness can include profuse sweating, chills, headache, dizziness or confusion, and nausea. Travelers who develop these symptoms should move to a cool area and seek medical attention.

Mass gatherings such as the Hajj, bring together people from all over the world. They create an ideal environment for spreading infectious diseases.

Those who participate in a pilgrimage to Mecca are required to produce a certificate of vaccination against meningococcal meningitis issued not more than 3 years and not less than 10 days before arrival in Saudi Arabia.

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Saudi Arabia also recommends immunization against influenza.

Hajj visas cannot be issued without proof of vaccination.

Since not all infectious diseases can be prevented by vaccines, you should also wash your hands often, sneeze into a tissue or your sleeve (if no tissue is around), and keep your distance from people who look sick.

Diarrhea is common during Hajj, so eat only food that is cooked and served hot and drink only beverages from sealed containers.

Men are required to shave their heads after Hajj, and unclean blades can transmit disease. Male pilgrims should go to officially designated centers to be shaved, where barbers are licensed and use disposable, single-use blades.

Knowledge of the country or region being visited is essential. This can be obtained from destination pages on the CDC Travelers’ Health website (http://wwwnc.cdc.gov/travel/destinations/list.htm), which provides destinationspecific information and will also often post specific guidance for major events. The Department of State website (http://travel.state.gov/travel/travel_1744.html) may provide additional information about countries or specific events.

The World Health Organization http://www.who.int/wer/2012/wer8730.pdf can also provide information about infectious diseases you might encounter at a mass gathering.

INSECT PRECAUTIONS 

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Many diseases are spread by insects such as mosquitoes, fleas, and ticks. In the tropics, insects can transmit significant illnesses such as malaria, dengue, and yellow fever— some potentially life-threatening.

To the extent possible, travelers should avoid known outbreaks of epidemic disease transmission. The CDC website provides information on regional disease transmission

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patterns and outbreaks (www.cdc.gov/travel). Travelers should check this site prior to departure.

Diseases transmitted by insects are best prevented by personal protective measures. In some cases (e.g., malaria or yellow fever), preventive drugs or vaccines are available but should never replace careful attention to personal protection measures.

Be aware of peak exposure times and places. Exposure to arthropod bites may be reduced if travelers modify their patterns of activity or behavior. Although mosquitoes may bite at any time of day, Mosquitoes that transmit malaria are night biters, so when traveling in a malarious area, be especially vigilant in applying repellent from dusk to dawn. Mosquitoes that transmit dengue are day biters, so when in areas of dengue risk apply repellent during daytime hours (and especially early morning and late afternoon until dusk).

Place also matters; ticks are often found in grasses and other vegetated areas. Local health officials or guides may be able to point out areas with increased arthropod activity.

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Travelers can minimize areas of exposed skin by wearing long-sleeved shirts, long pants, boots, and hats. Tucking in shirts, tucking pants into socks, and wearing closed shoes instead of sandals may reduce risk. Don't use cologne or scented soap, shampoo, or deodorant. All of these tend to attract insects.

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Repellents or insecticides, such as permethrin, can be applied to clothing and gear for added protection.

Travelers should inspect themselves and their clothing for ticks during outdoor activity and at the end of the day. Prompt removal of attached ticks can prevent some infections.

When accommodations are not adequately screened or air conditioned, bed nets are essential to provide protection and to reduce discomfort caused by biting insects. If bed nets do not reach the floor, they should be tucked under mattresses. Bed nets are most effective when they are treated with a pyrethroid. Pretreated, long-lasting bed nets can be purchased before traveling, or nets can be treated after purchase. Nets treated with a pyrethroid insecticide will be effective for several months if they are not washed.

Long-lasting pretreated nets may be effective for much longer.

An increasing array of products to be used as spatial repellents (containing active ingredients such as metofluthrin and allethrin) are commercially available. These augment the aerosol insecticides, vaporizing mats, and mosquito coils that have been available for some time. Such products can help to clear rooms or areas of mosquitoes (spray aerosols) or repel mosquitoes from a circumscribed area (coils, spatial repellents). Although many of these products appear to have repellent or insecticidal activity under particular conditions, they have not yet been adequately evaluated in

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Peer-reviewed studies for their efficacy in preventing vectorborne disease. As such, travelers should supplement the use of these products with topical or clothing repellents or bed nets in areas with the potential for vectorborne disease transmission or if biting arthropods are noted. Since some products available internationally may contain pesticides that are not registered in the United States, it may be preferable for travelers to bring their own. Insecticides and repellent products should always be used with caution, avoiding direct inhalation of spray or smoke.

Repellents for use on skin and clothing have been evaluated by the Center for Disease Control (CDC) and Environmental Protection Agency (EPA). Products containing the following active ingredients typically provide reasonably long-lasting protection: 

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DEET (chemical name: N,N-diethyl-m-toluamide or N,N-diethyl-3-methyl-benzamide).

Products containing DEET include, but are not limited to, Off!, Cutter, Sawyer, and Ultrathon.

Picaridin (KBR 3023 [Bayrepel] and icaridin outside the United States; chemical name: 2(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester). Products containing picaridin include, but are not limited to, Cutter Advanced, Skin So Soft Bug Guard Plus, and Autan (outside the United States).

Oil of lemon eucalyptus (OLE) or PMD (chemical name: para-menthane-3,8-diol), the synthesized version of OLE. Products containing OLE and PMD include, but are not limited to, Repel. This recommendation refers to EPA-registered repellent products containing the active ingredient OLE (or PMD). “Pure” oil of lemon eucalyptus (essential oil) is not the same product; it has not undergone similar, validated testing for safety and efficacy, is not registered with EPA as an insect repellent, and is not covered by this recommendation.

IR3535 (chemical name: 3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester). Products containing IR3535 include, but are not limited to, Skin So Soft Bug Guard Plus Expedition.

The EPA characterizes the active ingredients DEET and picaridin as “conventional repellents” and OLE, PMD, and IR3535 as “biopesticide repellents,” which are derived from natural materials.

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Some insect repellents are for use on clothing, hats, shoes, bed nets, mesh jackets, and camping gear. Permethrin is a highly effective insecticide-acaricide and repellent.

Permethrin-treated clothing repels and kills ticks, mosquitoes, and other biting and nuisance arthropods. Clothing and other items must be treated 24–48 hours in advance of travel to allow them to dry. As with all pesticides, follow the label instructions when using permethrin clothing treatments. Alternatively, clothing pretreated with permethrin is commercially available, marketed to consumers in the US as Insect Shield.

Permethrin-treated materials retain repellency or insecticidal activity after repeated laundering but should be retreated, as described on the product label, to provide continued protection. Clothing treated with the other repellent products described above (such as DEET) provides protection from biting arthropods but will not last through washing and will require more frequent reapplications.

In using repellents, travelers should take the following precautions:      

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Apply repellents only to exposed skin or clothing, as directed on the product label.

Check the product label for re-application needs and time schedules.

Do not use repellents under clothing.

Never use repellents over cuts, wounds, or irritated skin.

Do not apply repellents to eyes or mouth, and apply sparingly around ears.

When using sprays, do not spray directly on face—spray on hands first and then apply to face.

Wash hands after application to avoid accidental exposure to eyes. Children should not handle repellents. Instead, adults should apply repellents to their own hands first, and then gently spread on the child’s exposed skin. Avoid applying directly to children’s hands.

Use just enough repellent to cover exposed skin or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, apply a bit more.

After returning indoors, wash treated skin with soap and water or bathe. This is particularly important when repellents are used repeatedly in a day or on consecutive days.

Wash treated clothing before wearing it again. This precaution may vary with different repellents—check the product label.

Pregnant and nursing women should minimize use of repellents since about 6-9% of the chemical is absorbed through the skin.

If a traveler experiences a rash or other reaction, such as itching or swelling, from an insect repellent, the repellent should be discontinued and washed off with mild soap and water, and a local poison-control center should be called for further guidance.

Travelers seeking health care because of the repellent should take the repellent to the medical providers office and show it to the provider.

Permethrin should never be applied to skin but only to clothing, bed nets, or other fabrics as directed on the product label.

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Most repellents can be used on children aged >2 months. Protect infants aged <2 months from mosquitoes by using an infant carrier draped with mosquito netting with an elastic edge for a tight fit. Products containing OLE specify that they should not be used on children aged <3 years. Other than the safety tips listed above, EPA does not recommend any additional precautions for using registered repellents on children or on pregnant or lactating women.

Some useful links include: o Using Insect Repellents Safely (EPA): http://epa.gov/pesticides/insect/safe.htm o Insect Repellent Use and Safety (CDC): www.cdc.gov/ncidod/dvbid/westnile/qa/insect_repellent.htm o National Pesticide Information Center: http://npic.orst.edu/index.html

INSECT RELATED ILLNESSES  

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Wherever your travels take you, find out about the risk illness or diseases caused by native insect life.

DENGUE FEVER is a viral infection that is spread to humans by the bite of Aedes mosquitoes. Dengue is endemic in tropical regions of Africa, the Americas, Asia, the Caribbean, and the Pacific Islands. Dengue occurs more frequently during warm, humid seasons, and transmission is more intense in urban areas, including downtown business areas. Anyone in an endemic area who previously has not been exposed to the currently circulating serotype is at risk of acquiring dengue.

About 4 to 7 days after being bitten, the victim experiences a sudden high fever, headache, generalized weakness, and intense muscle, joint, and back pain. A rash may appear in some people.

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Dengue is usually self-limited, with an average duration of 6 days. Most persons with dengue do not need to be hospitalized, but those with persistent fever should seek medical attention as soon as possible.

Travelers who have had a previous episode of dengue fever and will be re-entering a dengue-endemic area should be aware of the increased possibility of acquiring a severe form of dengue (dengue hemorrhagic fever or dengue shock syndrome) and should seek medical attention immediately if symptoms appear.

There is no vaccine against dengue, so it is vital to take personal protection measures and to use repellents. Make sure you are especially vigilant using repellent during the mosquitoes' peak biting times; mosquitoes that spread dengue are daytime feeders with 2 peaks of biting activity during the day—early morning and mid-to-late afternoon hours. During overcast days or when indoors, however, mosquitoes will feed all day.

JAPANESE ENCEPHALITIS (JE) is a viral disease that is spread to humans by the bite of the Culex mosquito. JE occurs in Asia, and most human infections occur in rural, agricultural areas. Risk is very low for short-term rural travelers not engaging in extensive unprotected outdoor activities. Risk for travelers who confine their travel to highly urban environments is nearly non-existent, although rare cases have been reported from suburban areas adjacent to agricultural land.

In its early stages, Japanese encephalitis appears flu-like, with headache, fever, chills, nausea, and vomiting. If the illness progresses to inflammation of the brain, it can lead to paralysis or death—JE is fatal in up to 30% of cases and 50% end in permanent disability. There is no effective drug treatment for JE; the disease can only run its course, but it is still vital to seek supportive medical treatment.

Personal protection measures and the use of repellents are vital if you are traveling in risk areas for JE. Make sure you are especially vigilant using repellent during the Culex mosquitoes' peak biting times: between dusk and dawn. A vaccine is available, but is not recommended for all travelers to risk areas. Your health care provider might recommend vaccination if you will be traveling extensively in rural areas or visiting an epidemic area. The vaccine series consists of 2 doses given 28 days apart and should be completed at least 1 week before potential exposure; therefore you will need to start the series at least 35 days before departure.

MALARIA is transmitted through the bite of the Anopheles mosquito and is the most frequent infectious cause of death for travelers to the tropics and subtropics. Malaria is found in many parts of the world including Africa, Central and South America, Southeast

Asia, the Indian subcontinent, the Middle East, and the islands of the South Pacific.

(Most malaria occurs in sub-Saharan Africa.)

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Symptoms of malaria usually develop within days of exposure, or—less commonly— months or even years later. Symptoms always include fever and can include flu-like symptoms that may come and go, such as chills, sweats, headaches, muscle aches, and/or a vague feeling of illness. Vomiting, abdominal pain, diarrhea, cough, and jaundice (yellowing of the skin and whites of the eyes) can also occur.

There are 4 types of malaria. Of the 4 types, P. falciparum usually occurs about 10-12 days after infection and is a medical emergency. If not treated immediately and properly, it can be fatal. Illness caused by the milder types (P. vivax, P. ovale, P. malariae) is not usually life-threatening but can be a serious health risk for the very young, the elderly, and persons with underlying illness. Malaria caused by P. vivax and P. ovale may eventually resolve without treatment but can relapse periodically until properly treated.

If you have been in a malaria endemic area within the past year and have a fever or flulike symptoms, seek immediate medical attention.

Preventive medications and personal protection measures against mosquito bites are important safeguards when traveling to a malarious area. Remember to follow insect precautions even if you are using preventive medications and to be especially vigilant using repellent between dusk and dawn when Anopheles mosquitoes are most active.

Your health care provider can best inform you which destinations require preventive measures and can help you choose an appropriate anti-malarial drug for that destination. You must take the anti-malarial drug before, during, and after travel to a malarious area. Taking the drug before travel allows the drugs to build up to an effective level and gives your health care provider time to assess any side effects. Continuing the drug after you leave a malarious area suppresses most attacks of longer-incubating malaria.

Chloroquine is the drug of choice for areas where there is no resistance to this drug.

Chloroquine is effective and safe, and has also been shown to be safe for infants and pregnant women. Minor side effects include upset stomach, headache, dizziness,

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blurred vision, and itching. Serious side effects are uncommon. Rarely, seizures or psychosis have occurred. If you have epilepsy you may be at risk for seizures. Do not take chloroquine if you are allergic to the drug or have an eye problem called retinopathy.

Chloroquine is taken by mouth once a week. Start taking the drug 1 week before arrival in a malarious area, continue taking it while in the risk area, and take it for 4 weeks after leaving the risk area. If you experience stomach upset when taking chloroquine, take it with meals or in divided, twice-weekly doses. If you miss a dose, take it as soon as possible that same week and then resume your normal schedule the next week. Do not take a double dose if you completely missed a dose one week.

There are many areas of the world where malaria is resistant to chloroquine. When traveling in these areas, you must use a different drug; three drugs are equally effective: mefloquine, Malarone, and doxycycline.

Mefloquine is one of the drugs that can be used when traveling to areas of chloroquine resistance, and for long-stay travelers to these areas is often the most convenient regimen. Minor side effects include stomach distress, dizziness, headache, and vivid dreams, which tend to be mild or temporary. (If you plan to drive, pilot a plane, or operate machinery, be aware that mild dizziness is a possible side effect.) Severe side effects such as psychosis and seizures may occur rarely, mostly in persons with a previous history of one of these problems. Stop taking the drug if you experience acute anxiety, depression, restlessness, or confusion; you will need to obtain an alternative medication from your health care provider. Do not take mefloquine if you are allergic to mefloquine or related compounds, have a history of epilepsy, or have active depression or a recent history of depression, anxiety disorder, or other major psychiatric disorder.

Mefloquine is taken by mouth once a week. Start taking the drug 2-3 weeks before arriving in a malarious area, take it while in the risk area, and continue to take it for 4 weeks after leaving the risk area. If you miss a dose, take it as soon as possible that same week and then resume your normal schedule the next week. Do not take a double dose if you completely missed a dose one week.

Malarone (a combination of atovaquone and proguanil) is another drug that can be used when traveling to areas of chloroquine resistance, and the drug of choice among shortterm travelers. Malarone should not be used by pregnant women, people with severe renal failure, or those who are allergic to either of the drug components.

Malarone is taken by mouth once daily. Start taking it 1 day before you arrive in a malarious area, take it daily while in the risk area, and continue to take it daily for 1 week after leaving the risk area. Take this drug with a meal or milk, at the same meal time each day. If you miss a dose you can take it later in the day but do not double the next day's dose if you miss a dose completely.

Doxycycline is another drug that can be used when traveling to areas of chloroquine resistance. It may also be recommended for travel to areas where malaria is resistant to both chloroquine and mefloquine, or for people who can't use chloroquine, mefloquine, or Malarone. Skin sensitivity to sunlight is an uncommon side effect but can lead to severe sunburn. To lower this risk, use a sunscreen that blocks both UVA and UVB rays, avoid prolonged exposure to the sun, and wear protective clothing and a hat. Women

who take doxycycline may develop yeast infections and should bring with them an antifungal drug. Do not take this drug if you are pregnant, younger than 8 years of age in the U.S. (or 12 years of age in the U.K.), or allergic to doxycycline or tetracycline. 

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Doxycycline is taken by mouth once daily. Start taking it 1 day before you arrive in a malarious area, take it daily while in the risk area, and continue to take it daily for 4 weeks after leaving the risk area. Take this drug with food or at least 8 ounces of fluid while sitting or standing, to prevent throat or stomach irritation. Do not take Pepto Bismol or antacids as they can interfere with absorption of doxycycline. Late doses can be made up the same day, resuming the normal schedule the next day. Do not take a double dose if you completely missed a dose one day.

For travelers to chloroquine-resistant areas who cannot take mefloquine, Malarone, or doxycycline, chloroquine may still be prescribed but should be taken simultaneously with proguanil if possible. Proguanil is not available in the U.S. but can be purchased in Canada, Europe, and many African countries.

Primaquine is not considered to be one of the first-line drugs of choice for prevention of malaria and is slightly less effective against P. falciparum malaria than the 4 drugs noted above. It should be used for prevention of malaria only when none of the other drugs can be used and only for travel to areas that have only P. vivax malaria. Do not take this drug if you are pregnant or have low levels of G6PD (glucose-6-phosphate dehydrogenase).

For prevention, primaquine is taken by mouth once daily. Start taking it 1 day before arrival in the malarious area, take it daily while in the risk area, and continue to take it daily for 1 week after leaving the risk area. Take with food in order to reduce stomach upset. Late doses can be made up on the same day. Do not double the dose if you miss a dose completely.

Another use for primaquine is in preventing certain kinds of malaria (P. vivax and P. ovale) from occurring ("relapsing") months or even years after routine preventive medications have been In very rare situations it may be prudent to carry a drug for self-treatment of malaria; however, this is a temporary measure and medical attention should be sought as soon as possible. Take the drug promptly, according to your health care provider's

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instructions, if fever and illness occur during travel and medical care is not available within 24 hours.

Either Coartem (co-artemether; artemether/lumefantrine combination) or Malarone (atovaquone/proguanil combination) should be used for self-treatment.

The adult self-treatment dose for Coartem consists of 6 doses taken over 3 days. The first day 4 tablets are taken followed by 4 more tablets 8 hours later. On the second and third days, 4 tablets are taken every 12 hours. Coartem needs to be taken with food. (Do not take with grapefruit juice.) Coartem should not be used by pregnant women, persons with a heart condition called QTC prolongation, or those with an allergy to either component of the drug.

The adult self-treatment dose for Malarone consists of 4 tablets taken once daily for 3 days. Malarone should be taken with milk or a meal. Malarone should not be used by pregnant women, persons with renal failure, or those who are allergic to either component of the drug.

An alternative to Coartem or Malarone for self-treatment is quinine plus doxycycline, but this drug has a much more complex schedule of doses and is frequently associated with adverse effects.

It is important to note that the treatment drug should not be the same as the drug you are using for prevention.

YELLOW FEVER is a viral disease transmitted by Aedes mosquitoes; the major areas of risk are parts of Africa and South America. While incidence of infection among travelers is very low, the fatality rate in non-immune travelers is over 50%. Yellow fever is named for the characteristic jaundice (yellow eyes and skin) that results from viral invasion of liver cells in severe cases. Most cases are mild, beginning with a sudden headache, fever, and exhaustion.

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Yellow fever is prevented in two ways: personal protection measures and vaccination.

The vaccine consists of a single injected dose, given at least 10 days before you will enter a risk area. It is effective for 10 years. Since the disease can be fatal and the vaccine is highly effective, your health care provider may recommend vaccination if you are traveling to an area of yellow fever risk. Whether you receive the vaccine or not, personal protection measures are vital; there may be risk of other mosquito-borne illnesses at your destination as well.

Under International Health Regulations, health officials of some countries are allowed to require proof of yellow fever vaccination as a condition of entry. Some countries will require yellow fever vaccination for entry if you have also visited or had a layover in certain other countries during your trip. Check requirements carefully to avoid problems.

Other illnesses that may be contracted from insects or other arthropods include: bartonellosis, chikungunya fever, filariasis, leishmaniasis, onchocerciasis, Rocky Mountain spotted fever, trypanosomiasis, typhus.

JET LAG

• Jet lag can be a problem for travelers who are crossing several time zones. It is more commonly felt when flying east. Jet lag can affect mood, sleep, ability to concentrate, and physical and mental performance. Most symptoms completely resolve by the 5th day- after traveling across a 6 hour time zone. Compensating for jet lag for trips shorter than 3 days is difficult.

• Before traveling- exercise, eat a healthful diet, and get plenty of rest. A few days before you depart, start going to bed an hour or two later than usual (before traveling west) or earlier than usual (before traveling east) to shift your body’s clock.

• During Travel- Avoid large meals, alcohol, and caffeine. Drink plenty of water. On long flights, get up and walk around periodically. Sleep on the plane, if you can.

• After You Arrive- don’t make any important decisions the first day. Eat meals and sleep at the appropriate local time for your destination. Spend time in the sun. Drink plenty of water, and avoid excess alcohol or caffeine.

• If you are sleepy during the day, take short naps (20–30 minutes) so you can still sleep at night.

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When possible, choose daytime flights to minimize loss of sleep and fatigue.

• Some people ask about treating jet lag with medications. Sedatives are no longer recommended on airline flights due to the risk of blood clots in the legs during prolonged immobility. Sedatives also place travelers at risk for injury and to be victims of crime.

• Zolpidem (Ambien) is a hypnotic that has been shown to be as effective as melatonin. It can be used to induce sleep after arrival at the appropriate destination time-zone sleeping time, when the body is jet lagged and cannot fall asleep • The use of melatonin for relieving jet lag symptoms is still under debate. In the U.S. it is not regulated by the government, so its purity and potency cannot be guaranteed. Melatonin can cause sleepiness and reduced attentiveness. Do not drive, operate heavy machinery, or perform tasks requiring alertness for 4-5 hours after taking melatonin. Timing of the dose of melatonin must be precise or it can actually worsen your symptoms. Persons who suffer from psychiatric problems or migraine headaches or who may be pregnant should use melatonin with caution, if at all.

MEDICATIONS 

Depending on where you travel, prescription and familiar over the counter medications may not be available. In some locations, medications might not meet the standards for

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safety, quality, and consistency found at home, and “counterfeit medications” produce an income stream in other locations.

Whenever possible, bring your medications from home. Leave them in their original containers, and carry a copy of the prescriptions with you.

All medicine should be packed in carry-on luggage, in case checked luggage gets lost.

Pack 1 week of additional doses of all medications in case your travel is delayed for some reason. You may not be able to get the medication at your destination.

Before you go, list all your medications and their generic names, as well as usage instructions, and keep this list with you in case you need to replace any of the medications. Also keep a copy of the drug information leaflets (package inserts) from the manufacturers and your health care providers contact information.

If you have an extensive or significant medical history, ask your health care provider to summarize the information on letterhead stationary to bring with you in case of illness while traveling.

If you are allergic to any drugs you should carry medical alert information, preferably a Medical Alert wristband or tags listing the allergy.

Remember to pack any over the counter products you think you might need. Also remember to pack birth control and condoms if you plan to be sexually active during your travels.

MENTAL HEALTH AND TRAVEL 

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International travel can be fun, but it can also be stressful. Travel can spark mood changes, depression, anxiety, and uncharacteristic behaviors (violence, suicidal thoughts, and excessive drug and alcohol use), or it can worsen symptoms in people with existing mental illness. Anticipating the possible stresses of travel can help you cope with some of the thoughts and feelings that you may have before, during, or after your trip.

Before your trip talk to your health care provider about your physical and mental health history. Don’t forget to mention any treatments for substance abuse, depression, or psychological problems, and any prescription or over-the-counter medicines or supplements you may take. If you are staying a long time or moving abroad, you may also want to get a referral for a mental health professional, especially if you are seeing one at home. Find out if your health insurance will cover mental health care received while abroad. If not, consider buying supplemental travel medical insurance that will. A policy that includes medical evacuation can help get you home in case of an emergency.

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During your trip take care of your health by eating healthfully and exercising regularly.

Get help immediately if you feel stressed, anxious, depressed, very angry, or as if you want to hurt yourself or someone else. The US embassy in your destination (http://www.usembassy.gov/) can help you locate medical services and will notify your family and friends in the event of an emergency.

Seek support if you need it. Groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) may have English-language meetings in your destination.

If you take medicines to treat a mental health condition, continue your normal routine.

Don’t let your travels steer you off course with your treatment.

Symptoms of a mental health condition may not present themselves until you return from your trip. Go see a health professional as soon as you think you need help. Tell him or her about your recent trip, activities, and any medicines or supplements you have taken.

MOTION SICKNESS 

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Our body has a delicate system of equilibrium that relies on fluid in the inner ear, visual sensors, and other physical input to maintain a sense of balance. When incoming signals are in conflict,-this system is disturbed, causing the symptoms of motion sickness. Vague discomfort becomes nausea, your face pales, and you begin to sweat. Lightheadedness and exhaustion may be followed by vomiting. Some people are more prone to this condition than others, but factors such as turbulence, anxiety, and illness can also trigger motion sickness.

Antihistamines can prevent or relieve motion sickness, especially if taken 30 to 60 minutes before travel and continued during the trip. Over-the-counter medications approved for this use in the U.S. are cyclizine (Marezine), dimenhydrinate (Dramamine), diphenhydramine (Benadryl), and meclizine (Bonine).

Side effects of antihistamines may include drowsiness, dizziness, or dry mouth.

Antihistamines should not be used by anyone with glaucoma, or urinary difficulties caused by an enlarged prostate. Check labels carefully for appropriate dosages, precautions, and age restrictions.

Some people may require prescription drugs such as scopolamine if over-the-counter medications are not effective.

Scopolamine comes as a patch to be placed on clean, hairless skin behind your ear. The patch should be applied at least 4 hours before its effects will be needed. Each patch is

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good for 3 days. At the end of 3 days, or when the scopolamine patch is no longer needed, remove the patch and throw it away. Wash your hands and the area behind your ear thoroughly to remove any traces of scopolamine from the area. If a new patch needs to be applied, place a fresh patch on the hairless area behind your other ear.

Some other things that would be helpful include: eating lightly before and during travel.

Avoiding alcohol, sitting in the most stable section of a moving vehicle (The best seats are those over the wings on an airplane; in the front seat of a car (except infants and children); near the front of trains; amidships, on deck if possible; and just forward of the midsection on buses).

Face forward and look out a window, keeping your eyes fixed on the horizon or on a stationary point in the distance. Stay as still as possible, and avoid any rapid head movement.

Sleep if you can. If not, it may help to wear dark glasses or close your eyes to reduce visual stimulation.

Children are more prone to motion sickness than adults are. For symptomatic treatment of motion sickness, dimenhydrinate or diphenydramine may be considered. The first dose should be given 1 hour before travel and then every 6 hours. A test dose should be given in advance, as this medication can cause excitability rather than drowsiness in some children.

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As you prepare for your trip, make a list of the items you will need to pack.

Tag all luggage on the inside and outside.

In a carry-on bag, include items you might have trouble replacing or can't do without for a day. Valuables, traveler's checks, important documents, medications, eyeglasses, toiletries, 2 changes of undergarments and a change of clothing, should all be included in your carry-on luggage.

When traveling, frequent hand washing can help lower the risk of infection. Bring disposable antibacterial wipes or "waterless" antibacterial gel if soap and clean water will not be available.

Pack heavy items at the bottom of the suitcase so they don't wrinkle the lighter items. If you are using wheeled luggage, pack heavy items closest to the wheels to help keep the luggage upright.

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If there are clothes you want to keep unwrinkled, lay them flat and slip them inside plastic dry cleaning or jumbo garbage bags; fold them as few times as possible. The plastic bags reduce wrinkling. Keep each pair of shoes in a plastic or cloth bag. This protects the shoes and the clothes.

When you are done packing walk around with your luggage to check to see if it is too heavy or unwieldy for you to manage?

Make sure plane tickets, itineraries and passports are safe in a zippered pocket yet easily accessible.

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A passport is issued to you by your home country as proof of citizenship.

Visas are stamped into your passport by a foreign government. It allows you to enter a country for a specific reason and period of time.

Although there are exceptions, you are usually required to display your passport when entering or leaving a country.

Once you arrive at your destination, carry a photocopy of your passport and keep the original in a safe place.

Start applying for visas as soon as your passport is available so that all your documentation is completed well before your departure date.

To receive a visa you need to send your passport to an embassy or consulate of the country you want to visit. Most countries have embassies and consulates worldwide, and travel agents can usually tell you where the nearest ones are located.

Keep in mind that your passport may be tied up for days or weeks until the paperwork is done, so plan accordingly. In addition, some countries require proof of yellow fever vaccination before they will issue you a visa.

The amount of time spent mailing your passport to the various agencies involved can really add up if you are visiting several countries. Plan ahead if possible.

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If you only have a few weeks to prepare, a commercial visa service can often speed up the process.

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PESTS

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BEES and all other insects of the order Hymenoptera (fire ants, hornets, wasps, and yellow jackets) can deliver bites and stings that are painful but rarely fatal. Humans are usually stung as a result of disturbing the insects or their nests. Insects inject venom into the skin, sometimes leaving a stinger embedded, and the venom causes pain, redness, and swelling. Remove the stinger as quickly as possible, since more venom can be injected as long as it remains. (Studies suggest the method of removing the stinger is unimportant—speed is what counts.) You can choose from any number of topical products for pain relief, some made especially for insect bites and stings. If ice is available, use it to reduce swelling. Oral antihistamines such as Benadryl or ChlorTrimeton can alleviate swelling and itching but may cause drowsiness.

Multiple stings or hypersensitivity (allergy) to venom can cause an anaphylactic reaction within minutes in some individuals. Instead of a local response, the body's defenses overreact to the venom, causing symptoms that may include flushing, dizziness, nausea, headache, blurred vision, shortness of breath, irregular heartbeat, or fainting. If any of these symptoms occur, get medical help immediately. In the most severe reactions, throat tissue begins to swell, leading to death from airway obstruction.

People who know they have sensitivity to bites or stings should wear a medical alert tag and carry an epi pen at all times. It is important to know how to use the epi-pen before an emergency occurs.

Avoid disturbing insects or their nests. Wear shoes and socks in brush, grass, or forest; tuck trousers into socks when necessary. Inspect bedding carefully, and shake out clothing before putting it on. Whether or not you are prone to allergic reactions, consider carrying a sting kit if you will be outdoors and away from medical help.

FLEAS- are tiny, wingless bugs that live wherever there is blood to feed on. Some types can jump several feet, so in addition to looking for moving dark spots on your ankles and bedding, check your knees and arms as well. Fleas are an uncomfortable nuisance for travelers, and they also carry disease. Follow insect precautions carefully to avoid being bitten. Look for clean lodgings; vacuuming is especially helpful in getting rid of fleas, flea eggs, and larvae. Flea bites are small, raised red spots that itch fiercely. Use topical creams with hydrocortisone to control itching.

FLIES- can transmit parasites and spread disease among humans and animals when they

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bite or sting. Even more common is their role in carrying bacteria, viruses, and parasites from feces and other filth to food products. Follow food, water, and insect precautions carefully. Try to stay away from areas where flies congregate, such as garbage dumps and fields where manure is used as fertilizer.

LICE- are small gray or brown bugs that live on blood and can pass disease to humans.

Head lice and crab lice (which usually reside in the pubic area) infest the roots of hair shafts, leaving tiny white eggs which are difficult to remove. They can cause itching and rash. Body lice usually live in the seams of clothing, taking frequent side trips to feed.

You can acquire lice from contact with infested people or fabrics.

Lice can be combed out of hair using soap or vinegar and a fine-toothed comb, but the most efficient method is the use of chemical dusts, lotions, or shampoos made for this purpose. Since some of the chemicals may be toxic if overused, it is important to follow directions exactly. Infested clothes, bedding, and other fabrics must be cleaned thoroughly in very hot water (use the hottest cycle on washers and dryers), treated with insecticides, or heated at 160°F (70°C) for 30 minutes. Antihistamines can help control itching.

MITES- cause an intensely itchy, raised red rash called scabies. Mites burrow into human skin to lay their eggs and are spread among people through physical contact with skin or fabric. Because of the length of the mite life cycle, it may be 6 to 8 weeks after contact before symptoms appear. These start with small itchy bumps, followed by the rash— usually at the waist, underarms, inner thighs, and/or backs of legs. Itching may increase at night. Various chemical lotions and creams are made to kill mites. They are applied over the entire body, left on for several hours, and then washed off. Everyone living or traveling with an infested person must also be treated, even if they don't yet show any symptoms. Antihistamines help relieve itching, which can continue for up to 2 weeks after treatment. All clothing, bedding, and other fabric should be cleaned thoroughly in very hot water (use the hottest cycle on washers and dryers), heated at 160°F (70°C) for 30 minutes, or sealed tightly in plastic bags for 3 to 5 days until the mites are dead.

MOSQUITOES- are found everywhere in the world. Mature female mosquitoes feed on blood to produce their eggs and are responsible for transmitting many disease-causing parasites and viruses. All mosquitoes breed in standing water, and their numbers increase during rainy seasons. Make sure any containers that hold water are emptied regularly to prevent breeding.

Three types of mosquito are of special concern to travelers: Anopheles mosquitoes spread diseases such as malaria and bite primarily at night. Aedes aegypti spread yellow fever and dengue; they feed during the day and at night. Culex mosquitoes help spread numerous viruses, including the one that causes Japanese encephalitis; they bite primarily at night. Since it's not easy to identify individual types by sight, it's best to avoid all mosquitoes and use mosquito precautions as much as possible when traveling in areas where they spread serious disease.

SANDFLIES- are found mainly in tropical and subtropical climates. The bite of the female spreads leishmaniasis and bartonellosis to humans. Sandflies are tiny, and the grid of most window screens and mosquito netting is not small enough to keep them out. Use a

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permethrin-based insecticide spray on screens and netting to kill sandflies on contact.

Keep bed netting tucked in tightly around the base of the mattress at all times. Sandflies tend to breed in garbage and manure, so try to avoid disposal areas or fields where manure is being used as fertilizer. Sandflies are most active between dusk and dawn and hide in dark corners during the day. Follow insect precautions when traveling in areas where sandflies are responsible for spreading disease.

SCORPIONS- live in desert or warm tropical climates. They are most active at night; during the day they usually hide indoors or outdoors in cool, shaded areas. They can deliver an extremely painful, sometimes fatal sting from a barb on the tail if disturbed.

To avoid being stung, wear shoes and socks during outdoor activities in risk areas, and shake out all clothing, shoes, and bedding before every use. If you see a scorpion, don't disturb it. Scorpion venom can cause sweating, nausea, nervousness, vision and breathing problems, muscle spasms, high blood pressure, seizures, or paralysis. If you are stung, apply ice, immobilize the affected area, and seek medical care immediately.

SNAKES-can sense nearby humans and will try to get away from you. Let them. If you are bitten by a snake, get help immediately, even if there are no symptoms. Not every bite contains venom (about 25% of bites are "dry"), but medical help is called for because of the potential for injury.

SPIDERS are equipped with venom to disable or kill insects. They also bite people, but only about 40 of some 30,000 known species are dangerous to humans. Of these, most fatal bites are from the groups that include the brown recluse (varieties found in the Americas, the Mediterranean, North Africa, and Israel) and the black widow (varieties found in Africa, the Americas, the Mediterranean, Australia, and New Zealand). You also want to watch out for the Brazilian "banana spider" and the funnel-web spiders of Australia and Tasmania.

Get medical help immediately if you are bitten or if you are unaware of being bitten but experience symptoms such as sweating, nausea, rapid heartbeat, muscle spasms, blurred vision, or breathing problems. Don't disturb the nooks and crannies where spiders hide. Wear shoes, and think carefully before you reach into any place you can't see. Wear gloves when it seems prudent and practical to do so, for instance if you are gardening or digging. Shake out towels, clothing, and bedding before each use. Be especially careful in outdoor toilet facilities, which are notorious spider hideouts.

TICKS are found worldwide, often in brushy or leafy undergrowth or caves. Before feeding they can be as small and dark as a freckle; when engorged they might be the size of a button. Adult ticks have 8 legs. Their jaws are built to latch onto skin as they feed; making them difficult to remove once they are in place. Before ticks can drink blood they have to inject saliva to thin it, and any organisms they carry can be transmitted to you. Ticks spread diseases such as typhus, Lyme disease, and encephalitis. It takes hours for ticks to get completely anchored, so don't assume they are fully embedded if you find them on you. To remove a tick, first flick or pull gently to see if it comes off. If the tick is already embedded, pull it up from its back end and work it out firmly until the mouth parts have disengaged. Any parts left in can cause infection.

Reduce your chances of tick-related illness by closely following insect precautions.

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Perform full-body checks for ticks every day; don't forget to check the scalp, behind the ears, the back, and other hard-to-reach areas. You can use a mirror for this, or employ the buddy system with traveling companions.

WORMS and other parasites can cause multiple health problems, including intestinal and neurological ailments. Some enter the body via food or drink; others burrow through the skin when you swim in infected water or walk barefoot on infected ground.

Virtually all cases can be treated, but prevention is much preferred. Be aware that these creatures live in sand, soil, water, and food—especially in developing countries—and take measures to avoid them. Wear shoes and follow food, water, and insect precautions.

PHYSICAL CONTACT  

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Some diseases are transmitted through physical contact, sexual activity, or contact with blood, body or animal secretions.

HEPATITIS B is a liver infection that can be transmitted via blood (e.g., contaminated needles, razors, medical or dental instruments), sexual contact, tattooing, blood transfusion, wound contamination, and even nicks during haircuts or manicures.

Symptoms, which typically begin 3-4 months after infection, include loss of appetite, nausea, vomiting, extreme fatigue, and stomach pain; dark urine and jaundice (yellow skin and eyes) are also common. People who develop chronic hepatitis can spread the disease to others for the rest of their lives and can develop long-term liver disease such as cirrhosis (which destroys the liver) or liver cancer. Prevention of hepatitis B involves avoiding blood and body secretions of others, practicing safe sex and vaccination with the Hepatitis B vaccine which consists of three vaccines over a 6 month period.

RABIES is a serious viral infection of the central nervous system that is transmitted through contact (bites, scratches, licks) with the saliva from infected animals. Many animals can transmit rabies (e.g., skunks, raccoons, bats, coyotes, foxes, dogs, cats, ferrets). Risk of rabies varies widely between countries, but rabies occurs in every country except New Zealand. There are usually no symptoms during the incubation period, which can last from 5 days to more than a year. The disease is still reversible during the incubation period so prompt treatment is vital. Once symptoms appear, the disease is almost always fatal. Early symptoms are similar to flu, often accompanied by itching or irritation at the site of entry. The victim eventually experiences sensitivity to light, sound, and touch, and will have severe throat spasms when trying to drink water.

Dementia, convulsions, and paralysis precede death.

Avoid direct contact with animals, including strange or wild animals, bats, and dogs. The need for vaccination will be based on factors such as whether rabies is present at your destination, the duration of your stay, activities that you have planned, and age; children who play outdoors in developing countries are at increased risk for rabies.

Another factor is the availability within 24 hours of modern rabies vaccine and immune globulin for post-exposure use.

If an exposure does occur, the most reliable methods of preventing rabies are immunization and thorough wound cleaning. If you receive a bite, scratch, or are licked on broken skin, scrub the area thoroughly with soapy water, alcohol, or povidone iodine, and seek immediate medical help. Never presume an animal is free of rabies.

Any contact with animal saliva in a rabies endemic region should be evaluated by a medical professional. If exposure is suspected, even those who have received the preexposure vaccine must have a limited series of post-exposure injections. Those who have not received the pre-exposure vaccine series must receive longer treatment, including both vaccine and rabies immune globulin injections.

SEXUAL CONTACT with new or casual partners can lead to numerous sexually transmitted diseases and should be avoided. Unprotected casual sex is always high risk regardless if it is with other travelers or with paid sex workers.

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If prostitution is legal in a country, human trafficking, sex with a minor, and child pornography are always crimes. Someone who engages in these activities in a foreign country can still be prosecuted under US law after returning to the United States.

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Although the age at which someone is considered a minor may vary by country, federal law makes it a crime for US residents to engage in sexual or pornographic activities with a child younger than 18 years anywhere in the world. It is also illegal to travel abroad for the purpose of having sex with a minor.

If you do engage in sexual activity with new partners during travel, use condoms to reduce your risk of sexually transmitted diseases. Since safety standards differ worldwide, bring a supply of high-quality latex condoms with you. (Remember to protect them from sun and extreme temperatures.) Condoms do not entirely eliminate the risk of HIV transmission. Human papillomavirus (HPV) is also sexually transmitted and can cause cervical cancer and genital warts; an HPV vaccine is available for persons ages 9-26 years and is given as three vaccines over a six month period.

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SKIN PROBLEMS-can result from contact with people, plants, insects, or animals. Even minor problems should be taken care of immediately to guard against secondary infection.

If you are participating in adventure travel or spending extensive time in rural areas, ask local people, guides, or other contacts about precautions needed to avoid any poisonous plants or animals.

Rashes and other skin inflammations (contact dermatitis) can be caused by a wide variety of products used for cleaning or personal hygiene. If you suspect that a product you are using might be the problem, stop using it and try one with milder or fewer ingredients.

Prevent blisters by wearing soft cotton socks and sturdy, comfortable shoes. Don't bring new shoes on your trip and expect to break them in while traveling; make sure they fit well before you leave. If you have a blister, don't open it. This leaves damaged skin exposed to bacterial infection. Pad the area with soft, dry gauze and keep it clean. If it opens on its own, treat it as you would any other minor abrasion.

Clean minor cuts or abrasions thoroughly by scrubbing gently with soap and boiled, bottled, or purified water or povidone iodine solution to remove bacteria and debris, then rinse. Coat the area with antibiotic ointment and keep it covered with a clean, dry bandage until it begins to heal.

To relieve the pain of minor burns, apply cool, wet compresses to the area and take oral anti-inflammatory drugs such as aspirin or ibuprofen. Don't apply ice—this can damage already traumatized skin tissue.

Fungal infections such as "athlete's foot" and "jock itch" are more likely to occur in warm, moist climates. Bring an antifungal skin cream, ointment, or powder for these problems and apply according to package instructions; keep the affected area clean and dry.

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If you have a history of allergic reactions, take precautions to avoid allergens and make sure to bring a medication that works for your symptoms. If you have severe allergies, wear a medical alert tag and carry an epi-pen in case of anaphylactic reaction.

Consider bringing antihistamines (such as Benadryl), which decrease the allergic response in most people. A topical ointment with hydrocortisone to relieve itching is also helpful.

TETANUS- is an acute neuromuscular disease caused by organisms found worldwide in dust and soil, especially where there is animal waste. These organisms can infect a wound or other damaged tissue and create toxins that affect the nervous system.

Symptoms include muscle rigidity and spasms, usually starting with "lockjaw." Severe cases can be fatal. Although it is highly preventable with vaccination, tetanus is a common disease in developing countries where the vaccine is not widely utilized.

All persons should complete a primary series of diphtheria, tetanus, and acellular pertussis vaccine. DTaP is used for children ages 6 years and younger; Tdap and/or Td is used for persons ages 7 years and older. A booster dose of Tdap is routinely given at age 11-12 years and to persons 11 years and older who have not yet received 1 dose of Tdap. Td boosters are given every 10 years. If you receive a wound, you may need a dose of tetanus-containing vaccine depending on how many doses you have received previously and when your last booster dose was given.

Additional illnesses that may be contracted from physical contact: anthrax, brucellosis, diphtheria, Ebola, Lassa fever, leptospirosis, pertussis, schistosomiasis, and tuberculosis

RETURNING FROM TRAVEL

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Keep in mind that some exposures you experienced during travel can produce symptoms months after travel. If you develop any illness after travel, it is important to inform your health care provider that you traveled, where and when you traveled, the types of exposures you had when traveling, and the time line of your symptoms.

TREATING WATER 

Travelers who are camping, hiking, or staying in remote areas may need to disinfect their drinking water. Several methods can be used.

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Heat- Most germs die quickly at high temperatures. Water that has been boiled for 1 minute is safe to drink after it has cooled. Urban travelers may choose an immersion coil for boiling water (a plug adapter and current converter might be necessary). If no other method of water disinfection is available, very hot tap water may be safe to drink if it has been in the tank for a while.

Filtering- A variety of filters are available from camping stores. Most have filter sizes between 0.1 and 0.4 microns, which will remove bacteria from water but will not remove viruses. New “hollow fiber” technology can remove viruses as well. “Reverse osmosis” filters remove bacteria and viruses and can also remove salt from water, which is important for ocean voyagers. The quality control of filters varies, and it is recommended that all drinking water be boiled if possible. In areas where it is not practical to boil all drinking water, a good quality filter with a pore size of 0.2 microns will help minimize the risk of pathogens. The filtered water should then be treated chemically as well.

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Chemicals- Tablets or packets of powder can be bought at camping stores to disinfect water (Globaline, Potable-Aqua, Coghlan's). These usually combine chemical disinfectants (such as chlorine or iodine) with a substance that makes the water clear and improves its taste. Follow the instructions on the package closely—you may need to wait several hours until all the germs are killed. If you did not pack enough tablets with you and need to rely on local supplies, it is helpful to know that Chlorine’s germicidal activity varies greatly with temperature and other factors; thus it is less reliable than

iodine. Most diarrheal pathogens are susceptible to being killed by iodine, which can be used to disinfect water, leafy vegetables, and fruits. Add 5 drops of 2% iodine to 1 liter of water and let stand for 30 minutes. For those travelers who wish to avoid the taste and smell of iodine in their disinfected water, vitamin C (ascorbic acid) can be added to the water after the iodine has been in contact with the water for 30 minutes or more.

Add about 50 mg of vitamin C to a liter of water and shake briefly to eliminate the iodine taste and odor. Travelers who have thyroid problems or iodine allergies or who are pregnant should NOT use iodine for water purification. 

Ultraviolet (UV) Light- Portable units that deliver a measured dose of UV light are an effective way to disinfect small quantities of clear water. However, this technique is less effective in cloudy water since germs may be shielded from the light by small particles.

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Solar Radiation- In an emergency situation, water can be disinfected with sunlight.

Water in a clear plastic bottle, preferably lying on a reflective surface (such as aluminum foil), will be safe to drink after a minimum of 6 hours in bright sunlight. This technique does not work on cloudy water.

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VACCINES

Vaccines are often necessary to keep you healthy both inside and outside of the USA. All travelers should have the basic vaccines that are necessary for admission to schools. However, travelers often require special vaccines to help protect them in the area they are traveling to.

Copies of all vaccine records should be brought with you for your Travel Consult appointment. Using these records, your medical history, and your travel itinerary, you will be informed of vaccines recommended, and in some cases, required, for your travel.

Information about the vaccines, side effects and dosing schedules can be found on the CDC “Vaccine Information Sheet” for each vaccine. http://www.cdc.gov/vaccines/pubs/vis/default.htm Please review this information so that you can ask any questions you might have.

Other Resources: Other Helpful Resource Sites: ■U.S. State Department Travel Site: Information about topics such as safety and security in destinations, passports, visas, and entry/exit requirements ■U.S. Customs and Border Protection: Information about what you can and cannot bring back from your trip abroad ■U.S. Embassies: Helpful in-country contacts during your travel ■Transportation Security Administration (TSA): Information about flying ■CIA World Factbook: Interesting background information about countries around the world