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- General Medical Information
- Medical Care Abroad
- Pregnant Women Traveling Abroad
- W.H.O. Blood Transfusion Guidelines
- Risks from Food & Drinks
- Environmental Effects
- Anthrax-Contaminated
- Sexually Transmitted Diseases
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- Traveler's Medical Kit
- Motion Sickness
- Children Traveling Abroad
- Disabled Travelers
- Traveler's Diarrhea
- Animal-Associated Hazards
- Goatskin Handicrafts
- Swimming Precautions
- Post-Travel Period
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Questions & Answers
for International Travelers
Among the international medical issues addressed by
travel med staff and the traveler are:
1. General medical information.
2. What should I pack when I
go on a trip abroad?
3. What should be part of my
medical kit that I bring overseas?
4. How do I obtain medical care
abroad?
5. How should I prepare for
my plane flight abroad?
6. What can one do to prevent
motion sickness?
7. What should I do to try to
prevent jet lag?
8. What do I do to prevent altitude
problems?
9. What about safety issues
overseas?
10. Is it safe for a pregnant
woman to travel overseas?
11. Can I bring my young infant
abroad with me?
12. What vaccines should I
take if I am going overseas?
13. What are some of the vaccines
besides yellow fever that I should be
thinking about getting if I
am going to developing countries?
14. When should I start taking
my vaccines?
15. Is malaria still a problem
in the world?
16. What are the illnesses
that I am most likely to get when I go abroad?
17. What precautions should
I take with foods and drinks when I am in
a developing country?
18. What do I do to prevent
mosquito bites in other countries?
19. Is there anything specific
that I need to know when I return from
my trip overseas?
GENERAL MEDICAL INFORMATION:
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.
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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.
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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.
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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 www.internationalsos.com.
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 www.medexassist.com. 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 www.iamat.org. 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.
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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.
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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.
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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.
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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.
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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 https://travelregistration.state.gov
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.
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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.
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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.
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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.
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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.
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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.
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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 your have any contraindications to the medicines.
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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
medicine 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.
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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.
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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.
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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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