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ID Travel Care physicians provide unparalleled expertise in the field of travel safety and protection. We are a vast and current resource of travel-related information. Please contact us for answers, clarifications, suggestions.

Q1. What are the risks of getting illnesses when I travel abroad?

A1. Thirty-million or more Americans travel abroad each year, 8 million to less developed countries. Over the last couple of decades, Americans are now venturing out beyond the usual tourist sites of Western Europe, Australia, and New Zealand, and are now going to what we call 'second-tier' countries in Africa, South East Asia, etc. Also, particularly in the New Jersey area, we have an enormous number of people who have come from other countries and regularly go back and visit relatives. Therefore, the amount of international travel to places where tropical illnesses are very common is quite pronounced in our area, and thus the risk of travelers returning with illnesses is enhanced.

Depending on the destination, 23% to 64% report some sort of illness after they return. The most common illnesses are traveler's diarrhea, which after a stay of two weeks in a developing country can approach about one-third of all travelers; acute respiratory infections, which are 10% to 20%; and then hepatitis A, hepatitis B, and typhoid, which are much less common.

One needs to also remember that the #1 cause of death in American travelers overseas is motor vehicle accidents. Often, the roads are not engineered to the degree that the roads are in the United States, drivers often do not obey traffic signals, and cars in use are often old and in poor repair. Because of this, there are an enormous number of accidents overseas involving Americans. Even the simple thing of having people drive on the opposite side of the road such as in the United Kingdom can be very disconcerting to travelers coming from America and can lead to pedestrian and motor vehicle accidents.

Q2. What should I pack when I go on a trip abroad?

A2. What one packs often depends upon where one is going. In traveling to Western Europe, Japan, Australia, etc., where there is a big consumer market, one would be less likely to be as compulsive about bringing everything that one would need because items such as toiletries could easily be bought overseas. However, if one is going to Africa or Asia especially to rural areas where products may not be readily available, it is incumbent on the traveler to bring with them all that they may need.

Certainly, one needs to bring all of one's prescription medicines. Buying prescription medicines overseas is fraught with hazards since drugs may be counterfeit or not manufactured to the same standards as in America.

Also, one needs to consider bringing an extra pair of contact lenses or glasses since they may not be readily replaced overseas.

If one goes to a tropical country, sunscreen is absolutely mandatory, and sunblock with SPF of at least 30 is recommended. Also, it is very important to bring a cap with a visor and to wear sunglasses to ward off strong sunshine in tropical areas. The glare in tropical countries, especially near the water, can result in corneal irritation. Therefore, sunglasses (especially polarizing ones) are important.

Mosquito repellent in tropical countries may also be very useful. Typically products containing DEET are most effective. Although DEET has somewhat of a bad reputation, there have been only 30 cases documented in the literature out of billions of users where there has been some neurotoxicity, usually in very young children where the DEET was applied over the entire body. If the DEET is applied sparingly, even in children, there usually is no risk of any long-term side effects. Generally DEET in the range of 30% to 35% is sufficient. Any higher percentage will not provide better protection but will last longer. Typically, the formulated 30% to 35% products will last four to six hours and will last longer as the percentage of the DEET increases in the mosquito repellent.

If one is going to be in a country where there is a great deal of malaria, buying permethrin to spray on mosquito netting or on clothes would be most useful, and permethrin lasts even through laundering of clothes.

Q3. What should be part of my medical kit that I bring overseas?

A3. As mentioned above, it would vary somewhat based on where one is going. The list should generally include:

1. Personal prescription medications.
2. Antimalarial medications as applicable.
3. Antidiarrheal agents such as over-the-counter Imodium.
4. Antibiotics for self-treatment of moderate-to-severe diarrhea.
5. Antihistamine.
6. Decongestant.
7. Antimotion sickness medication.
8. Mild pain medicines such as acetaminophen (Tylenol) or ibuprofen (Advil).
9. Antacids.
10. Hydrocortisone cream.

One might also consider bringing a mild sedative; perhaps a sleeping pill if one has trouble sleeping and wants to try to regulate his/her sleep cycle better. One should also remember to pack in the medical bag the address and phone numbers of hospitals, clinics, or even English-speaking doctors in areas where you are spending a prolonged amount of time. A supply of bandages including Band-Aids and Ace bandages, etc., might also be useful, particularly in adventure travel where the chances of a sprain or cut are quite high.

Q4. How do I obtain medical care abroad?

A4. If an American citizen becomes seriously ill or injured abroad, probably the first contact should be the US Consul. One needs to remember that getting any medical care abroad may not be covered by your health insurance policy. Medicare for the elderly does not cover overseas medical care, and often other policies do not cover. It is advised to check with your insurance company before going abroad. If you will be in a developing country for a long period of time, it is sometimes useful to look into getting evacuation insurance overseas.

Three organizations, which might be of some help in this regard, are:

1. International SOS with web site being This offers comprehensive 24-hour physician-backed medical and security assistance for which members pay a fee. Insurance policies including medical evacuation, repatriation, coverage, and access to international clinics that provide primary care are also available through SOS.

2. MEDEX at This again offers 24-hour access to coordinators who can help to locate appropriate medical care providers and also supplies insurance policies including medical evacuation and repatriation services.

3. International Association for Medical Assistance for Travelers at IAMAT is a nonprofit organization, which provides medical information to travelers and has as its goal to make competent medical care available to travelers worldwide. IAMAT maintains an international network of physicians, hospitals, and clinics that have agreed to treat IAMAT members in need of medical care while abroad. Membership is free although a donation to support IAMAT efforts is appreciated. Members can receive a directory of participating physicians and medical centers and have access to a variety of travel-related informational brochures by accessing IAMAT's web site.

Q5. How should I prepare for my plane flight abroad?

A5. Certainly it is becoming much more common that plane flights are delayed and security has been tightened because of terrorism alerts in the United States and abroad. Therefore, it is very important that one gets to the airport early, particularly for international flights. The flights now tend to be more crowded than they were in the past because there are fewer flights available, and also seating arrangements seem to be tighter than ever. It is very important on long intercontinental flights that you get up and walk around at least every hour. If one sits in a chair with legs bent for prolonged periods of time, it is very possible to get a blood clot in the legs, and these can be potentially life threatening if these clots migrate up to the lungs and cause what we call a pulmonary embolism. To prevent clots in the legs, it is important to walk around, increase your fluid intake, and if you have a problem with varicose veins, to use compression stockings, and even to think about taking a prophylactic dose of aspirin (either one baby aspirin or a full adult aspirin before the plane flight).

Also, it is important that a nasal decongestant spray be used if one has trouble with a cold while boarding a plane. If one cannot clear his or her nose or ears during landing or take-off, this can cause a great deal of pain in the ears and even a ruptured eardrum.

Q6. What can one do to prevent motion sickness?

A6. Motion sickness is a very individual thing. It affects only certain people and most people usually know if they have problems with motion sickness. Generally in traveling on the very large planes that go overseas, this is usually not a problem. It is more of a problem on crew ships or in small planes if you have a fly to small towns outside of the major capitals. If motion sickness is a problem, the preventive measures that can be taken is fixing your eyes on the horizon and taking medications such as Dramamine and Bonine which are available without a prescription or a scopolamine patch, which is available by prescription. The patch is usually effective for about three days. It can dry the eyes and mouth, however, and there are other side effects that need to be considered.

Q7. What should I do to try to prevent jet lag?

A7. Jet lag by definition means your body having trouble adjusting to changing time zones. The symptoms are usually insomnia, fatigue, and irritability. Flights going west to east tend to be more difficult for people to adjust to than flights going from east to west. There are a few simple things that can be done to try to prevent jet lag. The first is to decrease the amount of alcohol that one drinks on flights. Many people think that this relaxes them, but it actually leads to dehydration in an air cabin that is pressurized at a mile high and tends to be dry. Dehydration can then make the jet lag worse. If you are traveling over many time zones, scheduling a stopover for a night can cause a gradual adjustment and not make the trip quite as onerous. Also, it is useful to schedule 1 or 2 days of layover at your destination to adjust to the new time zone before scheduling business appointments. A medicine that can be taken to try to regularize the sleep patterns at night would be a sleeping pill before travel and then for two to three days later to try to get back on the schedule that you would have at home.

Q8. What do I do to prevent altitude problems?

A8. Altitude adjustment can be a significant problem whether one is going skiing in the Rockies in Colorado or going overseas. Some of the capitals in the world are at quite high altitude; for example, Mexico City and Addis Ababa, Ethiopia are 7000 to 8000 feet in altitude. Generally, going to that altitude is not so much of a problem but going beyond 10,000 feet can cause 30% to 40% of people to get acute mountain sickness including headaches, fatigue, nausea, and insomnia. As prevention, a medicine called Diamox can be taken 1 time a day and continued for about 48 hours after ascent. If one is truly in a mountain climbing expedition, it is very important that one sleep below the day's maximum ascent or stay initially at 5000 or 10,000 feet for a couple of days before ascending higher.

Q9. What about safety issues overseas?

A9. Safety has become a much bigger concern as the threat of terrorism has increased. In the last couple of years, terrorists have struck not just in third world countries but also at the heart of Europe in Madrid and London. No place can be actually said to be perfectly safe. Before going on a trip, one needs to be aware of any political unrest at your destination and to monitor news events carefully. Going to the US State Department web site will give travelers information on what to avoid in the cities or towns where they will be going. If you are going into an area which has had a travel warning from the US embassy, it is very important that you register with the local US embassy. This is quite easily done by going to and will save a time-consuming trip to the embassy at your destination. Registering dates and where you will be staying could be invaluable if there is trouble in the country and the embassy needs to evacuate American citizens quickly. Also, one needs to remember when traveling in developing countries that the per capita income is often only $100 or $200 a year, and in this setting, you may be carrying in your wallet more than most people make in a year. It would be the equivalent of perhaps carrying $30,000 or $40,000 in your pocket and walking the streets of New York City and everyone knowing that you are carrying that much money. It is very important to try to blend into the environment. Try not to check your map on a busy street corner. Try to be very careful in busy train stations or bus stations where thieves tend to congregate. If there is an area where there are true security issues, it may be useful to avoid public transportation entirely and take taxis. One should consider bringing a money belt or other hidden carrying case to wear under your clothes to keep valuables secure. These can generally be purchased at luggage stores or at AAA (Automobile Association of America) travel stores.

Q10. Is it safe for a pregnant woman to travel overseas?

A10. There are some risks associated with pregnancy and travel. Generally, women can board planes and fly up to 36 weeks of pregnancy but it is really best to travel during the second trimester. Also it is generally not a good idea to get live vaccines if you are pregnant since live vaccines can cause a mild type of illness in the recipient and this might potentially damage the fetus. Some of the live vaccines include measles, mumps, rubella, chickenpox, yellow fever, and oral polio. Also, it is generally recommended to even give the killed vaccines in the second trimester rather than in the first trimester when the parts of the baby are being formed. Malaria pills tend to be safe in pregnancy including chloroquine and probably Lariam. Malaria is a very real threat to the fetus and no malaria medicine is 100% protective, and therefore it is recommended that unless absolutely necessary, travel to malarious areas should not be undertaken by women who are pregnant.

Q11. Can I bring my young infant abroad with me?

A11. Young children have special needs for international travel. They tend to have more trouble with their ears when landing and taking off and continued breast-feeding during this time or sucking on a bottle is helpful in having children clear their ears. Motion sickness can also be a problem and scopolamine is not an option for children. Children also can get dehydrated much quicker than adults and childhood diarrhea can be a life-threatening problem, so precautions need to be taken. Also young children because of their fair skin tend to have more problems with sunburn, and if one goes to a tropical area, protection with clothes and also with sunblock is absolutely essential. There are many other specific issues related to traveling with children but are much too detailed to be covered in this introductory question and answer format.

Q12. What vaccines should I take if I am going overseas?

A12. Yellow fever is really the only required vaccine at the present time and only for certain parts of Africa and South America. If one is going to one of those areas, a specific sticker from a Yellow Fever Center is necessary. ID Care has several offices in New Jersey which are approved yellow fever vaccine centers and can give the appropriate sticker for travel. Other vaccines are more optional and not required. It depends upon where you are going and how long you are going for and whether you will be deviating from the usual tourist itineraries. Longer trips in remote areas would be riskier and more protection against vaccine-preventable diseases would generally be recommended.

Q13. What are some of the vaccines besides yellow fever that I should be thinking about getting if I am going to developing countries?

A13. Hepatitis A is probably the most useful vaccine that can be given to someone going to a developing country. The vaccine is almost 100% effective and it has a protective life span of over 30 years once the two initial doses are given. Hepatitis A is also a disease that is found in the United States and therefore the vaccine will protect against both foreign and domestic exposure to the virus. Hepatitis B is now required for all children in the United States but many of the adult population has not been vaccinated. Generally, this virus is spread only by blood or sexual contact but if one has plans for a prolonged stay overseas or may need medical assistance for chronic conditions while traveling, it certainly would be advisable to get a hepatitis B vaccine also. There is a combination vaccine called Twinrix, which is hepatitis A and hepatitis B combined in one shot. Usually hepatitis A and B vaccine together are given at zero, one, and six months but an accelerated schedule can be given if necessary. Cholera vaccine is no longer available in the United States and even where available is only partially protective, so it is not generally recommended for travelers. Meningococcal vaccine is the vaccine now being given to college students as a requirement for entry into school. There are certain parts of the world where there are yearly outbreaks of this type of very fatal meningitis, particularly in sub-Saharan Africa and in these travel areas, a meningococcal vaccine would be indicated. Rabies vaccine is rarely necessary unless a great deal of adventure travel is planned or the traveler will be working with animals in a rabies area. One needs to remember that many domestic animals in other countries are not vaccinated against rabies and therefore contact with domestic dogs and cats should be avoided in these countries. Polio is a disease that will hopefully be eliminated within the next ten years. There is a worldwide eradication effort in place for the last several years, and in the first nine months of 2005, there were only 1200 cases reported mainly in sub-Saharan Africa and India. However, two new areas with polio problems in 2005 are Yemen and Nigeria. This is an ever-changing problem of when to get polio vaccine but if you are going to Africa or to Asia, one booster shot as an adult is all that is required. One must also remember that influenza is a problem even in the summer in the tropics, in Alaska in the summer, or in going to the Southern Hemisphere in our summer, which is their winter. Vaccine is usually available in the United States till June. One can be immunized until then in the United States, or if one is in a very high-risk group, certainly a vaccine can be obtained when one arrives at your destination.

Q14. When should I start taking my vaccines?

A14. It often takes about two weeks for vaccines to begin to protect travelers and some vaccines require multiple doses before the recipient is close to being 100% protected. Therefore, before you travel abroad, you should allow at least four to six weeks to begin the process of getting your pretravel consultation. Also overseas travel is a good opportunity, particularly for adults, to update vaccines which are necessary in the United States. This would include diphtheria and tetanus vaccine which is given every ten years as a routine vaccination and a pneumonia shot which is typically given to all patients over 65 and those under 65 with chronic medical conditions. Most patients will experience mild side effects of vaccines including soreness at the injection site or perhaps slight fever. This tends to last only a short period of time. People who have severe reactions to eggs, however, should not get yellow fever, influenza, measles, mumps, and rubella because these vaccines are grown in egg yolks and might be a problem if injected into a susceptible person.

Q15. Is malaria still a problem in the world?

A15. Malaria, unfortunately, is more of a problem now than it has been in the last century. There are more than 500 million cases each year in the world and there is 1 to 3 million deaths related to malaria. It is a particular problem for pregnant females and also for young children. The worldwide eradication effort that occurred in the 1950s and 1960s to try to eliminate the mosquito vector was halted because of concerns that DDT, which was used to eliminate the vector, was causing problems with the food chain. Malaria is present in most areas of the world outside of Western Europe, North America, Japan, Australia, and New Zealand. In Africa and India, malaria is present even inside the cities, while in South East Asia in the capital cities such as Bangkok, Singapore, Hong Kong, etc., malaria is not a problem but may be an issue if one goes out to rural areas. Malaria is usually not a problem at high altitude, so it is very important that one know your itinerary in a country before deciding whether malaria prophylaxis is necessary. There are three main malaria treatments. Chloroquine is recommended only if one goes to areas where malaria is sensitive to chloroquine, which is an ever-diminishing area of the world including a few places in the Middle East and north of the Panama Canal in Central America. The rest of the world has resistant malaria and chloroquine is not effective. The main two choices for malaria prophylaxis in resistant areas are Lariam and Malarone. Which of these will be selected by your travel medicine doctor will depend on the length of your stay and whether you have any contraindications to the medicines.

Q16. What are the illnesses that I am most likely to get when I go abroad?

A16. The most common illness one is likely to get would be traveler's diarrhea. It is usually caused by bacteria, is usually sudden in onset, and typically lasts three to five days. The disease carries various names in different parts of the world including Delhi Belly, Montezuma's Revenge, etc. Usually the disease is self-limited, but if one is on a tight itinerary, it can really ruin a vacation to have a severe diarrheal illness. For this reason, it is worthwhile bringing Imodium on your trip. Also, it is our practice in our travel care clinic to give an antibiotic to travelers going to areas where they may get traveler's diarrhea. We generally do not give routine prophylaxis for traveler's diarrhea except in unusual circumstances. The antibiotic we give is only brought with the traveler for treatment of acute infections. Traveler's diarrhea usually comes from eating contaminated food and water and appropriate steps to maintain hygiene when eating and drinking is important. TB is very common in other parts of the world. There are 2 billion people in the world who have a positive skin test for TB. Having a positive skin test does not mean that you have active tuberculosis. It only means that you have been exposed and have about a 10% chance in your lifetime of developing active tuberculosis. Many travelers who go overseas for long periods of time in developing countries develop a positive skin test for tuberculosis. If one is going on a long term mission abroad either as a missionary, Peace Corps volunteer, etc., it is useful to get a skin test before one goes and then three months after returning to see if you have converted from being negative to positive. If you are a new converter, it is recommended that a prophylactic regimen of nine months of a medicine called INH be given to prevent relapse to active tuberculosis later in life. HIV is another enormous problem in certain parts of the world. It is very important for the casual traveler to remember that this disease is spread through sexual contact and through needle sticks. Needle sticks can not only be from using drugs and sharing needles but also can come from needles that are not properly cleaned in clinics and hospitals in third world countries, or come from blood transfusions where the blood has not been properly screened. It is very important also to remember that prostitutes in many countries have a very high incidence of HIV and that sexual contact with them is very hazardous and carries a high risk for transmission of HIV.

Q17. What precautions should I take with foods and drinks when I am in a developing country?

A17. In general, it is best not to eat at roadside stands or stalls in developing countries. Also, if food has been cooked and has been sitting out for much of the day, this is likely to be harboring bacteria and should be avoided. One should try to eat only food that is warm. Sometimes it is difficult to avoid salads in tropical countries where the fruits and vegetables look so enticing, but if they have been washed with local water, they are often contaminated and therefore one should try to stick to foods that have been cooked. One should not eat any fruits unless they can be peeled or washed with clean water. It is important to remember that ice is water and freezing water does not kill organisms inside and ice can transmit disease also. In most countries it is very easy to get carbonated drinks, hot tea, or a bottle of water and these are recommended even for simple things like brushing your teeth. Dairy products can be a problem, particularly if milk or cheeses have not been pasteurized. Usually, one can check to see whether dairy products have been pasteurized before consuming them. If one has significant diarrhea, it is important to remember to replace fluids so you do not become dehydrated. This is particularly important for young children who are at high risk for life-threatening dehydration. The WHO (World Health Organization) produces rehydration packets which can be mixed with clean fluids to help replete chemicals lost in diarrheal stools. However, a rough approximation of the WHO formula would be to fill a liter bottle with clean water and then add 8 capfuls of sugar and 2 of salt, mix, and then consume. An alternate formula would be one liter of clean water with 1 teaspoon of salt and 2-3 tablespoons of sugar.

Q18. What do I do to prevent mosquito bites in other countries?

A18. Mosquitoes transmit malaria and also a disease called dengue fever, which is very common in South East Asia and in Central and South America. Dengue is spread by the household mosquito and therefore is in the urban areas. Anopheles spreads malaria and is usually more prevalent in rural areas than in cities, although as mentioned in the section on malaria, in Africa and India, malaria is transmitted in cities as well as in rural areas. In general, it is a good idea to bring a mosquito repellent with DEET in it, and up to 30% to 40% is recommended. If one wants to get higher concentrations, the DEET will just last longer and not give better protection. Also, using permethrin on mosquito netting and clothes would also be helpful in warding off mosquitoes. Also, it is very important to wear long-sleeved shirts, particularly in the evening when the malaria mosquitoes tend to bite.

Q19. Is there anything specific that I need to know when I return from my trip overseas?

A19. Post-travel evaluations are sometimes useful especially where travelers have been abroad for a long period of time or where parents are adopting children who have grown up overseas. In these situations, it is important to rule out parasitic diseases and tuberculosis. Infections in returning travelers on short trips can also be a problem. One needs to remember that "common things occur commonly", and although when one returns from overseas, it is very easy to think that one has an exotic tropical disease, common illnesses such as bronchitis, sinusitis, and upper respiratory infections are often the illnesses for which patients seek attention after returning home. Other problems in returning travelers include fever, diarrhea, and skin problems. Malaria occurs in up to 40% of patients who return with fever from abroad. Many patients have upper respiratory infections, which are usually viral and occur in at least 25% or 30% of patients returning from abroad. Diarrhea is usually self-limited but about 2% of diarrhea persists for more than a month and often is due to undiagnosed pathogens. If diarrhea is prolonged, one also might think of parasitic diseases such as cryptosporidia or Giardia.

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