International Travel Health Guide 2006-2007

763 Pages·2006·11.454 MB·English

by  Stuart R. Rose, MD, FACEP, and Jay S. Keystone, MD, MSc(CTM), FRCPC (Auth.)

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INTERNATIONALTRAVEL HEALTH GUIDE ISBN-13: 9-7803-2304-0501
ISBN-10: 0-323-04050-0
Copyright ©2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge,changes in practice,treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered,to verify the recommended
dose or formula,the method and duration of administration,and contraindications. It is the responsi-
bility of the practitioner,relying on their own experience and knowledge of the patient,to make diag-
noses,to determine dosages and the best treatment for each individual patient,and to take all appro-
priate safety precautions. To the fullest extent of the law,neither the Publisher nor the Authors assume
any liability for any injury and/or damage to persons or property arising out of or related to any use of
the material contained in this book.
Acquisitions Editor:Tom Hartman
EditorialAssistant:Dennis DiClaudio
Publishing Services Manager:Frank Polizzano
Project Manager:Jeff Gunning
Design Direction:Nancy Sharkey
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife Waltraud, my sons John and Justin, and my stepson Nick.
Stuart Rose
I dedicate this book to my children, Danielle (and Amos), Kathryn,
Jen (and Sara), David, and Kevin, and to my first granddaughter Lylah . . . may you
always maintain your love of travel . . . and may your travels always be in good health.
Jay Keystone
Preface
The International Travel Health Guideis unique. It is the only travel health book in the
United States to be published annually. Until this guide became available, travelers had
no concise source of updated travel health advice and information.
I wrote the first edition of the International Travel Health Guidesout of sheer frustra-
tion. In counseling my patients who traveled, I often didn’t have enough time to tell
them how to prepare for their trip or how to stay healthy abroad. Even when I did
spend additional time reviewing the risks, how much, I wondered, did they remember
later on?
I knew I couldn’t recommend reading an entire textbook on tropical medicine for
my patients who traveled, and travel books that gave health advice often didn’t cover
the necessary information in sufficient detail. Furthermore, all of these books are soon
outdated—with important information possibly misleading. If only I could give my
patients a book that summarizes the latest advice . . . and so in 1989, the first edition
of the International Travel Health Guidewas born.
This 13th edition of the Health Guide continues to focus on those topics that are the
most important, the most common, or the most interesting to a great many travelers, es-
pecially those going to less developed countries. The Health Guidecontains the very
latest medical information on diseases and their prevention. This information is pre-
sented in an easy-to-understand, concise format. And if the Health Guide doesn’t pro-
vide the information you need, it tells you where to find it.
Perhaps the most unique feature of the International Travel Health Guideis the
World Medical Guide section. This section gives you quick reference to disease risks in
over 200 countries worldwide.
The 13th edition of theInternational Travel Health Guideis co-authored with Dr. Jay
Keystone from the University of Toronto. Dr. Keystone is a leading authority in travel
medicine, especially in the fields of malaria and parasitic diseases. For several aspects of
this project, Dr. Keystone and I were fortunate to have the expert assistance of our
medical advisers: Dr. Phyllis Kozarsky from Emory University (Travel and Pregnancy,
AIDS/HIV, Trip Preparation); Dr. Bradley Connor, President, International Society of
Travel Medicine (Hepatitis); Dr. Peter Hackett, University of Colorado Health Science
Center (Altitude Illness); and Dr. Doug Quarry, Medical Director, International SOS
(Travel Assistance, Emergency Medical Transport, Medical Care Abroad). We thank
them for their advice.
Stuart R. Rose
Jay S. Keystone
vii
Acknowledgments
I wish to express my appreciation to all of those in the travel medicine community who
have told me over the years how much they have relied on the International Travel
Health Guideto help them counsel travelers.
I especially wish to thank Tom Hartman and his team at Elsevier for now introduc-
ing the International Travel Health Guideto a wider audience—the millions of everyday
travelers who need access to accurate, concise, up-to-date information on safe travel.
Stuart Rose
I would like to thank Lori Kalata for her superb editing, excellent suggestions, and in-
credible, logical approach to problem solving.
Jay Keystone
ix
About the Authors
Stuart R. Rose, MD, FACEP
Dr. Rose is a graduate of Columbia University College
of Physicians and Surgeons. He is board certified in
internal medicine and emergency medicine and
Assistant Clinical Professor of Emergency Medicine,
Tufts University School of Medicine. Dr. Rose is
Founder and President of Travel Medicine, Inc.
Jay S. Keystone, MD, MSc(CTM), FRCPC
Dr. Keystone is Professor of Medicine, Department of
Medicine, and Immediate Past President, Medical
Alumni Association at the University of Toronto. He
also is a senior staff physician (and former director) of
the Centre for Travel and Tropical Medicine at Toronto
General Hospital.
Dr. Keystone received his medical degree from the
University of Toronto Faculty of Medicine in 1969. He
completed his internship at Toronto General Hospital
and his residency at Sunnybrook Hospital, Toronto, as
well as at the University of Michigan Medical Center,
Ann Arbor. He received his Master’s Degree in Clinical Tropical Medicine at the
London School of Hygiene and Tropical Medicine. He has carried out his field work in
sub-Saharan Africa, South America, and India. He is a past president of the International
Society of Travel Medicine, the clinical division of the American Society of Tropical
Medicine, and The Canadian Society of International Health.
Dr. Keystone has more than 150 scientific publications to his credit and is the senior
author of a recently published textbook on travel medicine.
His claim to fame is being the first and last attending physician to make rounds at
Toronto General Hospital on rollerblades.
xi
D
CHAPTER 1
Overview of
Travelers’ Health
KEY POINTS:
(cid:2) Health risks vary accord- (cid:2) Fewer than 1% of travel- (cid:2) Education, combined
ing to destination, itiner- ers required hospital ad- with common sense, can
ary, and medical history of mission abroad. prevent most illness or
the traveler. (cid:2) Accidents and injuries injury during travel.
(cid:2) As many as 70% of cause most deaths in trav- (cid:2) All individuals traveling
travelers report an illness elers younger than age 55, frequently, or planning an
or impairment during their and most are preventable. extended trip abroad,
trip. Most self-reported (cid:2) Cardiovascular disease is should have a pre-travel
health problems are minor. the cause of most deaths in evaluation, preferably in a
older travelers. travel clinic.
The Risk of Illness While Traveling
How risky is foreign travel? People tend to exaggerate unlikely dangers such as terror-
ism or the potential for transmission of Ebola virus, and disregard or minimize more
common perils such as motor vehicle accidents and malaria. Disasters, like the
Indonesian earthquake and resultant tsunami of December 2004, killed thousands of
tourists, but such catastrophic events are often unpredictable. Large disasters often di-
vert attention from the simple day-to-day precautions that travelers can take to stay
healthy and safe.
The chances of acquiring certain diseases, or of having an accident, depend largely
on where you travel and what you do while traveling. Out of 30 million Americans who
go abroad each year, approximately 8 million go to less developed countries where the
incidences of tropical and infectious diseases are often high. Almost 7 million U.S. citi-
zens travel to countries where there is risk of malaria. Surveys of travelers show that:
• There is a 60% to 70% possibility of illness when traveling in less developed countries
for up to 90 days (median trip duration—19 days). Most of these illnesses are minor.
• There is a 5% to 8% chance you will seek medical care while traveling in a develop-
ing country.
• Your chance of being hospitalized will be less than 1%.
• The most common reported illnesses are: diarrhea (34%); a respiratory disease
(26%); a skin disorder (8%); acute mountain sickness (6%); motion sickness (5%);
an accident and injury (5%); an illness with fever (3%).
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Health and International Travel
• On return home, there is a 26% chance that you will have a bout of diarrhea, a respi-
ratory illness, a skin problem, or a fever related to your trip.
Your individual risk, however, may vary considerably. For example, if visiting the
Indian subcontinent, (and particularly friends and relatives) your risk of typhoid fever
may be as high as 18 times greater than for any other geographic region. Other variables
that can affect your health include (1) the duration of your trip; (2) your use (or nonuse)
of preventive antimalarial drugs; (3) your use of prevention measures against insect
bites; (4) your vaccination status; (5) your risk-taking (or avoidance) behavior; and (6)
your underlying health status.
Bear in mind, though, that traveling is usually good for one’s physical and emotional
health. Aside from seeking holiday pleasures, some people travel to improve their
lifestyle, perhaps to change harmful personal habits, “get in shape”—or temporarily
(perhaps permanently) leave a stressful job, a bad relationship, a harsh climate, or other
adverse life events.
Prevention of Illness
Preventing illness abroad involves learning as much as possible about the countries you
will be visiting, consulting with a travel medicine provider to receive immunizations and
medications and taking the necessary clothing, equipment, or devices (such as a water
filter or mosquito net) to deal with local health conditions and climate. Your own health
status should also be evaluated.
Most travel-related diseases can be prevented. Hepatitis, meningitis, yellow fever, and
rabies are some of the diseases that can be prevented by vaccination. Chemoprophylaxis,
combined with protective measures against mosquito bites, can prevent virtually all cases
of malaria, as well as many other insect-transmitted diseases. Sexually transmitted dis-
eases, including HIV, can be avoided with behavior modification.
Types of Illnesses
Diarrhea (see Chapter 6) This is the most common malady affecting travelers. There is a
35% to 60% chance that you will acquire travelers’ diarrhea during a month-long trip to
a less developed country. Adhering to safe food and drink practices can reduce your risk
(but most travelers have trouble sticking to the guidelines). Prompt treatment with an-
tibiotics and loperamide quickly resolves most cases of travelers’ diarrhea.
Malaria (see Chapter 7) This mosquito-transmitted illness, which can be fatal, is the
most important parasitic disease to avoid overseas. Malaria is a serious health problem
in many tropical and subtropical countries. Check your itinerary carefully to assess your
risk of exposure.
Hepatitis (see Chapter 12) The viruses hepatitis A and hepatitis B pose a serious risk for
travelers. Although both are rarely fatal, hepatitis A can ruin a carefully planned vaca-
tion and result in weeks or months of disability; contracting hepatitis B can have serious
long-term consequences. You can prevent hepatitis A with the appropriate vaccine and
hepatitis B with vaccination and/or limiting your exposure to potentially contaminated
4
Overview of Travelers’ Health
blood and secretions. Although there are no vaccines against hepatitis C and E,
Chapter 12 outlines measures you can take to reduce your risk of these illnesses.
Other Illnesses Colds and respiratory infections, skin rashes, ear infections, sunburn,
sprains, contusions, and superficial injuries account for the majority of less serious
problems.
Fatalities During Travel
Although it is quite possible you will have some type of minor illness while abroad, the
chance that your illness will be fatal is reassuringly small. In 1984, out of 30 million trav-
elers overseas, just 1,298 deaths were recorded. Mortality abroad is due mainly to heart
Figure 1.1 Monthly Incidence Rates of Health Problems During Stays in Developing Countries
100% 100 000
30–80%
Any health problem:
Travelers’ diarrhea
used medication or felt ill
Felt subjectively ill
ETEC* diarrhea 30–60% 10 000
Consulted physician
abroad or back home
Malaria (no chemoprophylaxis
Stayed in bed
West Africa)
Acute febrile respiratory tract infection
1% 1 000
Incapacity of work after return
Hepatitis A
Dengue infection (SE Asia)
Animal bites with rabies risk
0.1% 100
Hepatitis B (expatriates)
Gonorrhea Air evacuation
Typhoid (India, N, NW Africa, Peru)
Died in high altitude trekking
HIV infection 0.01% 10
Typhoid (other areas)
0.001% 1 Died abroad (average)
Legionella infection
Cholera
0.0001%
Meningococcal disease
*ETEC (cid:2)Enterotoxigenic E. coli. ETEC is usually responsible for 30–60% of all cases of travelers’ diarrhea.
5
Health and International Travel
attacks, motor vehicle accidents, and other injuries. Cardiovascular disease causes about
50% of all deaths abroad, but most of these occur in older travelers. Cardiovascular death
rates, however, are not increased by travel. Other points include the following:
• Injuries are the most common cause of death in younger travelers. Fatal injuries are
mostly due to motor vehicle accidents or drowning.
• The number of accidental deaths in 15- to 44-year-old travelers is higher by a factor
of 2 to 3 as compared with rates among the same age group back at home in the
United States or Canada. “Excess mortality” abroad, therefore, is mainly due to acci-
dental injuries.
• Infections cause fewer than 4% of deaths abroad.
ACCIDENTS AND TRAVEL
Accidents are the leading cause of death among travelers younger than the age of 55.
Death rates from motor vehicle accidents, according to The Association for Safe
International Road Travel, are 20 to 80 times higher in some countries than in the
Table 1.1 Reported Deaths of U.S. Citizens Abroad by Cause of Death*
Vehicle-related accidents 569
Homicide 287
Drowning 213
Other accidents 207
Suicide 204
Air accident 74
Drug-related 60
Natural disaster 42
Terrorist action 51
Train accident 11
Maritime accident 10
Under investigation 1
Unknown 1
*From October 1, 2002 to December 31, 2004.
NOTE: This chart does not represent a statistically complete account of U.S. citizen deaths abroad. The chart depicts
only deaths that were reported to the Department of State for which it was possible to establish that death was not
due to natural causes. Most U.S. citizens who die abroad are resident abroad. Also, it is difficult to establish how
many deaths go unreported to the Department of State. Note also that deaths attributed to “Terrorist action” do not
include deaths of U.S. military and government personnel in Iraq.
6
Overview of Travelers’ Health
United States, illustrating one reason why “excess mortality” abroad is primarily
injury related. The majority of deaths in younger travelers are from motor vehicle
and motorcycle accidents, and drowning; air crashes (usually nonscheduled carries),
suicides/homicides, burns, and electrocution are less frequent causes.
Each year, an estimated 750 Americans die of injuries on foreign roads, and at least
25,000 are injured. One study has revealed that many road accidents involving tourists
do not involve a collision between two vehicles but are often due to loss of driver con-
trol caused by fatigue, alcohol intoxication, unfamiliar road conditions, or other factors.
In many developing countries, vehicles are in disrepair; drivers are inexperienced; roads
are not well maintained; and common-sense rules of the road are disregarded.
The Bethesda, Maryland-based Association for Safe International Road Travel
(ASIRT; Tel: [phone]; website: www.asirt.org) can provide a report on road
safety conditions in 70 foreign countries. Their road travel reports also contain informa-
tion about seasonal hazards; city, rural, and interstate traffic; and the most dangerous
roads in various countries. ASIRT currently cites Egypt, Kenya, India, South Korea,
Turkey, and Morocco as some of the most dangerous countries. (ASIRT, a nonprofit or-
ganization, requests a small donation in exchange for the information it provides.)
Preventing Traffic Accidents and Injuries
If you follow the recommendations below, you will decrease your chances of having an
accident or being injured while driving overseas.
• Always wear a seat belt (if one is present).
• Bring a car seat for infants, and place them in the back seat.
Table 1.2 Global Road Toll Fact Sheet
1.7 million people die annually on roads worldwide.
30 million people are injured annually on roads worldwide.
Road crashes are the single greatest cause of premature death and injury in men
ages 15-45.
Road crashes are the fifth leading cause of death in women.
Twenty percent of fatal accidents in developing countries involve children younger
than the age of 15.
Road accidents will soon become the third greatest health burden worldwide.
More than 80% of all road deaths and serious injuries occur in developing countries in
Africa, Asia, Latin America, and the Middle East.
More than 40% of the accidents occur in countries in the Asian-Pacific region.
Road accidents cost developing countries 100 billion U.S. dollars annually.
From the Association for Safe International Road Travel, www.asirt.org. Used with permission.
7
Health and International Travel