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Risks of travel, benefits of a specialist consult

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PREVENTIVE COUNSELING

In addition, travelers going abroad should be advised on measures to avoid diarrhea, insectvector diseases, accidents, excessive exposure to the sun, altitude sickness, and other risks their itineraries may expose them to.

Avoiding traveler’s diarrhea

Traveler’s diarrhea is by far the most common health problem experienced abroad. It is prevalent in Mexico, where 20 million visits by Americans occur each year. A quarter to half of visitors to developing countries contract traveler’s diarrhea and, on average, lose 2 to 3 days of their business trip or vacation.3,10 The disease therefore imposes not only discomfort but also financial losses on travelers, especially business travelers.

Though many pathogens may be responsible, the most common one is Escherichia coli, usually transmitted by human fecal contamination of food or drink. Preventive measures against E coli are the same as for other foodborne and waterborne infections, such as hepatitis A, cholera, and typhoid fever.

The rule for avoiding traveler’s diarrhea may be summarized by the CDC-coined phrase, “boil it, cook it, peel it, or forget it.” Simple, written advice is most likely to be followed. 6 Thorough boiling or cooking kills bacteria in contaminated food, and food should be served steaming hot. Travelers should only eat foods they know have been well cooked, declining cold dishes like salsa or casseroles. They should avoid tap water for brushing teeth or in the form of ice cubes and should stick to drinking bottled beverages, preferably carbonated ones. No matter how appetizing a salad looks, travelers should avoid eating fresh fruits and vegetables unless they are sure that they were peeled under sanitary conditions. Simply eating at a high-priced restaurant is not a guarantee of uncontaminated food. Before meals or any hand-to-mouth contact, hands should be washed in soap and water or with sanitizers.

Travelers to remote areas may wish to acquire filtering devices, chlorine, or iodine for treating water. A combination of filtering and iodine treatment is most effective.

While this advice is undoubtedly wise, the evidence shows that, in practice, most travelers fail to take all precautions, and the benefits of this counseling have been difficult to demonstrate.11 Therefore, physicians should prescribe drugs for prophylaxis and self-treatment of traveler’s diarrhea during travel.

Bismuth subsalicylate (Pepto-Bismol) taken as two tablets or 2 oz of liquid 4 times a day while traveling may reduce the risk of diarrhea by one half, though it should be avoided by patients with contraindications to aspirin.3,6

Self-treating traveler’s diarrhea

Proper hydration is crucial, since dehydration can worsen and prolong symptoms.

Ciprofloxacin (Cipro) 500 mg orally two times daily for 3 to 5 days is effective.

Azithromycin (Zithromax) 500 mg daily for 3 to 5 days may be better in some areas of Southeast Asia, where fluoroquinolone-resistant bacteria are prevalent.

Rifaximin (Xifaxan), a nonsystemic antibiotic, is another option. The dosage is 200 mg three times a day for 3 days.

Avoiding insect bites

Malaria, yellow fever, tickborne encephalitis, and dengue fever are all transmitted by insect bites. Often the best protection is to avoid being bitten.

Bites can be avoided by using insect repellants containing diethyltoluamide (DEET) or picardin. If the traveler is going to be out in the sun, he or she should apply sunscreen first, then DEET on top of that. Anopheles, which transmits malaria, is a night-biting mosquito and may be avoided by staying in screened areas at dusk and dawn and by using bed netting. Permethrin, an insecticide, can be applied to clothing and mosquito netting.

Other things to avoid

Accidents are the second most common cause of death in travelers (after cardiovascular disease), accounting for as many as one-third of deaths.9 Several studies indicate road accidents are the major cause of accidental death, but also significant are drowning and air crashes. Travelers should be advised that transportation in developing countries is often more dangerous than at home. Seaside vacationers should be aware of the dangers of riptides and other threats to swimmers and should obey warnings posted at beaches.

Sexually transmitted diseases. When appropriate, physicians should warn travelers about the dangers of contracting HIV and other sexually transmitted diseases, especially in sub-Saharan Africa.

Sunburn, dehydration. Travelers should regularly use sunscreen and should remain hydrated.

Crimes against and involving tourists are a serious threat in many places, including some popular destinations. All of the 100,000 young people traveling to Mexico each year for spring break should read the US Department of State warnings against crime and possible arrest in that country.12 Travelers who are victims of crimes in foreign countries should contact their national consulate as soon as possible. The US Department of State issues advisories on countries where there is danger to travelers because of political turmoil, crime, or other causes.13

Motion sickness and jet lag can be ameliorated by proper hydration, avoiding caffeine, and using a scopolamine patch or dimenhydrinate (Dramamine).1

When traveling to wilderness areas

Wilderness and expedition medicine is a complex subset of travel medicine.14 All travelers need to understand the risks of whatever activities they undertake.

Mountain climbers and skiers have to contend with altitude sickness and frostbite. Scuba divers have the risks of decompression sickness, barotrauma, and hazardous marine life. Travelers on expeditions may have to deal with predatory animals, exotic parasites, and ethnic or political violence. People who participate in these activities should do so only when they are properly certified and educated in the associated health risks.

Ordinary tourists should enjoy safe adventures with well-established tour agencies and venues and should be cautioned against activities that expose them to dangers they may not be prepared to confront.

Insurance, evacuation, and emergency care

Health insurance often does not pay for preventive travel medicine. Unfortunately, cost can be a factor in immunizations and other health care. The cost of most travelers’ medications and vaccinations is generally comparable to that of other immunizations. The exceptions are two specialized vaccines—ie, for Japanese encephalitis ($1,000 or more for a full course) and for rabies, which can cost considerably more. Pricing by different providers can vary widely.

Travelers, especially those who are pregnant, elderly, disabled, or immunocompromised or who have preexisting diseases, need to review their insurance policies to make certain that care in foreign countries is covered. If not, evacuation insurance can be purchased at a relatively modest cost.

Pretravel counseling and immunization are legitimate expenses for business travelers. Visitors to developing countries and other remote areas should research which emergency medical facilities are available (Table 3).

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