If you are traveling in remote or inaccessible areas, review your health care needs before you leave. Be sure you understand how to treat water and prepare foods to avoid illness. Whether trekking the alps in Austria or the sands of the Kalahari, always carry your important first aid supplies and know how to respond in the event of an illness or accident.

Food and Water Precautions:

Food:
Raw and improperly cooked food allows bacteria (Salmonella) to grow and release enterotoxins that are harmful to humans. Food can also harbor parasitic organisms (Giardia lamblia) and viruses (hepatitis A). Since all of these pathogens are heat sensitive, travelers should eat only hot, well-cooked foods. When traveling in developing countries or areas you suspect to have poor sanitation, please follow the guidelines listed below.

Choose these Foods:

• Well-cooked meat, fish, rice, and vegetables (always make sure that the center of the item is thoroughly cooked)
• Fresh baked goods - breads, rolls, unfilled pastries
• Cooked fruits, vegetables, and nuts with intact skins and shells (peel the skins yourself or soak in mild chlorine solution of 1/2 teaspoon chlorine bleach to a quart of water for 15 minutes and air dry on clean surface)

Avoid these Foods:

• Dairy products (e.g., ice cream, milk, cheese, baked goods with creamy fillings)
• Raw fruits, vegetables, and leafy salads not cleaned by you
• Raw or uncooked meat, fish, shellfish
• Foods left standing at room temperature (e.g., buffet foods, cold meat platters)
• Foods prepared by street vendors

Water:
Water-containing beverages are also major sources of enteric pathogens. Travelers planning extended trips in developing countries should check with the U.S. Consulate about the safety of the local water and available alternatives. Please follow the guidelines listed below if you are traveling to underdeveloped countries.

Boiling is the most reliable way to treat contaminated water.

• For water of uncertain purity, heat vigorously until boiling occurs for one minute.
• For additional safety after the boiling point is reached, keep the water covered and hot for several minutes.

When it is not feasible to boil water, iodine and chlorine chemical treatments provide significant protection against viral and waterborne disease.

• Tincture of Iodine - Use a 2% solution, add 5 drops per quart or liter of clear water, double the dosage for cloudy water and let stand for 30 minutes. Cloudy water should be strained through a clean cloth to remove sediment and then treated with heat or iodine. Very cold water also requires a double dosage and needs prolonged contact time. Let stand for up to several hours before use.
  
• Chlorine Bleach - Use a 4-6% concentrate, add 2 drops per quart or liter of clear water, double the dosage for cloudy or very cold water. Let stand for 30 minutes and allow prolonged standing time for very cold water.
  
• Note: Chlorine treatment alone, may not kill some enteric viruses and parasitic organisms.

Choose these Beverages:

• Hot beverages, (e.g., tea and coffee made from boiled water)
• Canned or bottled beverages (e.g., soft drinks, juices, beer, wine, mineral water )
• Local water that has been purified by you or that you know has been adequately treated.

Avoid these Beverages:

• The local water (water from the local water system or well resources)
• Ice cubes made with local water
• All dairy products (especially unpasteurized milk)

Water Tips

• Use a straw and drink directly from a can or bottle when glassware appears unclean. Be sure to clean and dry any drinking surfaces before contacting them with your mouth.
• Where water may be contaminated, do not brush your teeth or take medications with the local tap water. Instead, use boiled or bottled water.
• Alcohol in punches and other mixed drinks does not reliably kill bacteria and parasites.
• Do not swim in pools unless adequately chlorinated. Avoid swimming or wading in fresh water lakes and streams. Bodies of still, non-moving water may be infested with parasitic organisms
• Contact lens wearers should wash their hands with purified water before touching their lenses.

Traveler's Diarrhea:
Approximately one third of all travelers to developing countries suffer from traveler's diarrhea (TD). Infectious bacteria, parasites, and viruses are the primary causes of TD. Normally, TD is a self-limited illness that causes 3 to 4 days of watery diarrhea. Common symptoms associated with TD include abdominal cramps, nausea, headache, and a low-grade fever. Rarely is the condition life-threatening.

Following the Food and Water Precautions listed above can greatly decrease the likelihood of developing TD. However, even meticulous attention to food and water consumption does not guarantee that you will be symptom-free. Travel from industrial countries to developing countries may cause sudden changes in the types of microorganisms that inhabit one's gastrointestinal tract. As a result, TD may occur to rid the digestive system of harmful agents.

Treatment for Diarrhea:
Take Pepto-Bismol or Imodium to help reduce cramping and control diarrhea. Follow the label directions and do not take these medications for more than 3 to 5 days.

• Avoid solid foods and dairy products for 24 hours.
• Do not take doses of Pepto-Bismol and antibiotics at the same time. Bismuth subsalicylate, the main component of Pepto-Bismol, may significantly decrease the absorption of the antibiotic.
• Use Pepto-Bismol with caution if you are taking aspirin or are sensitive to aspirin.

Travelers suffering from TD must make a concerted effort to avoid dehydration. Fluid and electrolyte levels can be maintained by drinking plenty of safe liquids and eating salted crackers.

• The World Health Organization Oral Rehydration Solution (ORS) is an effective way of treating and preventing dehydration. ORS packets for 1-L solutions are available over-the-counter in many developing countries.
• Adding Gatorade powder or other fluid replacement salts to treated water and drinking at least 8 ounces per hour is also effective.
• Alcohol and caffeine-containing beverages should be avoided when suffering from TD.

Schistosomiasis
Schistosomiasis is an infection that can be acquired from swimming in fresh water in certain parts of the world. The countries where Schistosomiasis is most common include Brazil, Egypt and most of sub-Saharan Africa, Southern China, the Philippines, and Southeast Asia. A flatworm (fluke) that uses specific fresh water snails as an intermediate host, causes the infection. Infected snails release large number of larvae that are capable of penetrating unbroken skin of human hosts. Even brief exposures to contaminated water can result in infection. Travelers are advised not to bathe, swim or wade in fresh water in areas that are known to have this problem. Salt-water swimming is safe.

Symptoms usually occur 2-3 weeks after exposure, but most acute infections are symptomatic. Acute symptoms may include fever, lack of appetite, abdominal pain, weakness, diarrhea, nausea and cough. Chronic infection can cause disease of the lungs, liver, intestine and bladder. Occasionally, people develop an itchy feeling immediately upon leaving the contaminated water.

There is no practical way for the traveler to recognize infected water. It is best to just avoid fresh water in countries where Schistosomiasis exists. In such areas, heating water to 122F for 5 minutes or chlorinating water will make it safe for bathing. If water is left to stand for three days, the larvae will die in that time period and the water will be safe for washing.

Aquatic Hazards: Helpful Hints
If schistosomiasis is present, water must be treated before bathing: a) heat to 122 F x 5 minutes; b) Iodize or chlorinate; c) or let water stand for 3 days

Do not swim in pools unless adequately chlorinated (A Portable Chlorine Tester is available)

Prevention of swimmers' ear: combine equal parts of Vinegar (5 percent Acetic Acid), Isopropyl Alcohol in sterile bottle with dropper; only for external ear canal. Do not use if blood of fluid is coming from ear or if you suspect ruptured eardrum.

If you suspect decompression sickness: Breath 100 percent oxygen, even if you fell well, go to the nearest medical facility then call Diver's Alert Network (DAN) at (919) 684-8111 for nearest available decompressing chamber location and phone number (U.S. Only)

Insect and Animal Protection:

Mosquitoes: Mosquitoes are most active during dusk and dawn, on cloudy days, and in shaded areas. Avoiding outdoor activity during these periods will reduce the risk of being bitten. Wear long-sleeved shirts (tucked in), long pants, hats, and apply a permethrin containing repellent to clothing. Follow the guidelines listed below for applying insect repellents.

Ticks: When traveling in tick infested areas, pants should be tucked into socks and boots should be worn. Light colored clothing facilitates tick detection. Permethrin and DEET containing repellents also provide tick protection. During activity and at the end of the day, travelers should inspect themselves for ticks. Early removal of attached ticks may prevent infection.

Insect Repellents Guidelines:

• Apply permethrin-containing repellents to clothing sparingly. One application will last through 5 washings or 6 months in clothes that are not washed.
• Apply DEET containing repellents sparingly to any exposed skin. Choose repellents that contain 20-35% DEET. Avoid high concentration DEET repellents since they may cause adverse skin reactions.
• Avoid inhaling repellents and wash your hands after application. Do not apply repellents to wounds or broken skin.
• If a reaction to insect repellents occurs, wash the treated skin and call a physician. Take the repellent container to the physician.
• Note: Insect repellents do not protect against bees and spiders.

Other Insects: Always wear shoes to protect against hookworm, fungus, jigger, and fleas.

Snakes: Snakes are most active at night and during warm weather. When traveling in snake-infested areas, wear long pants and boots. If walking at night, use a flashlight. Attempts to kill or harm snakes should be avoided.

Scorpions: Scorpions are nocturnal feeders that avoid high-intensity light. Their stings result in painful localized reactions that can cause paralysis and convulsions but are rarely fatal.

• Be sure to shake out and inspect your shoes before putting them on. Snakes and scorpions tend to rest in shoes and clothing.

Wild Animals: Animals rarely attack humans without provocation. Avoid contact with wild animals and do not attempt to corner or capture them. Rabid animals normally show abnormal eye movements, excess salivation, staggering gait, and convulsions. Rabid animals will also approach humans.

Heat Illness:
When traveling to tropical countries and hot climate areas, avoid prolonged periods in the sun. During the first few days of travel and especially during peak tanning hours (11 am to 2 PM), expose yourself to the sun in periods of 10-30 minutes.

• Always wear a sunscreen with a sun protection factor (SPF) of at least 15. The higher the SPF rating, the greater the protection. Apply sunscreen to skin, lips, ears, and around the eyes. Do not use a sunscreen containing PABA if you are sensitive to benzocaine, sulfonamides, or aniline dyes.
• Perform strenuous physical activity only during the cooler parts of the day (i.e., early morning and late afternoon).
• If physical activity can not be postponed in hot weather, the traveler must drink more than thirst dictates. Drinking 400 to 500 ml of safe water before exertion is advised. To avoid dehydration and heat illness, consume a cup or more (300 ml) for every 20 minutes of activity.
• Wear white or light-colored cotton clothing and a wide brimmed hat to minimize heat absorption.

Heat Exhaustion and Heat Stroke: Both conditions result from overexposure to heat. Water and electrolyte loss from exercise in hot weather is a common cause of heat exhaustion. Common symptoms include excessive sweating, nausea, confusion, thirst, elevated temperature, and fatigue.

If you suspect heat exhaustion:

• Stop all activity and seek a cool, sheltered location (away from direct sunlight).
• Loosen any restrictive clothing.
• To lower body temperature, immersion in ice water or cold tap water are the most effective measures.
• Alternatively, the traveler can be wetted down with cold water and fanned.
• If alert, the traveler must replenish depleted fluid levels. Cold, purified water and fluid replacement beverages are adequate. A target intake of 1 to 2 L over 2 to 4 hours is reasonable.
• The traveler should continue to rest for the next 24 hours and force fluids.
• If symptoms persist, a physician should be contacted immediately.

Heat stroke is a true medical emergency and results from extreme elevations of body temperature. As a result, the body systems are overwhelmed by heat and impaired functioning results. Common signals include temperatures greater than 106 F, red, hot, dry skin, and altered consciousness.

High-Altitude Sickness:
Rapid ascents to altitudes above 8000 feet (2400 m) may cause acute mountain sickness ((AMS).

Symptoms Include:

• Headache, feeling "hung over"
• Lack of appetite
• Nausea
• Trouble sleeping
• Shortness of breath
• Excessive fatigue
• Swelling of the hands, face, and ankles

These symptoms may begin at the time of ascent, but most often occur 6-48 hours after climbing. With the avoidance of strenuous exertion, symptoms usually subside in one to seven days while staying at the same altitude.

More severe conditions of pulmonary edema (fluid in the lungs) and cerebral edema (swelling of the brain) may occur at altitudes above 8000 feet. Symptoms may include fatigue, shortness of breath, cough, headache, loss of coordination, and confusion. These symptoms usually occur during the 2nd to 4th days of climbing to altitudes greater than 8000 feet. Both conditions require immediate medical attention.

Prevention:

• Staging: Spend two to five days at an intermediate altitude, 6600 ft (2000 m).
• Slow Ascent: Above 9900 ft (3000 m), ascend only 1000 ft (300 m) per day. It is also important to rest for 24 hours on day three or four after attaining altitude. Avoid strenuous overexertion for the first few days at altitude. Rapid ascent by car or plane is very risky.
• Diet and Liquids: Be sure to drink plenty of safe liquids while increasing altitude. Eat a normal diet that is low in salt.
• Acetazolamide (Diamox) and Dexamethasone are two prescription drugs your physician can prescribe to prevent AMS.

Treatment:

• If mild AMS occurs, ascent must be halted so that acclimatization can improve. Acclimatization can take from 12 hours to 3 or 4 days.
• If symptoms worsen despite an extra 24 hours of acclimatization, descent is required. Descend as far as necessary for improvement.

Sexually Transmitted Diseases (STDs):
The use of latex condoms during vaginal, anal, and oral sex is strongly recommended when the status of a partner with regard to HIV and STDs is unknown. Be sure to purchase condoms before leaving the United States and include them in your Traveler's Medical Kit.

• Condoms manufactured abroad may have higher breakage rates. Natural membrane condoms (lamb cecum) should be avoided since they do not prevent viral transmission during sexual intercourse.
• Oil based lubricants (i.e., mineral oil, petroleum jelly, massage oils, body lotions) should also be avoided since they can weaken condoms and lead to a higher breakage rate. Use water-based lubricants instead.
• Do not use condoms beyond the expiration dates printed on the wrapper.
• Condoms should be stored in a cool, dry place out of direct sunlight. Extreme temperatures can make latex brittle or gummy and lower their effectiveness.
• Although condoms provide considerable protection against STDs, they are not perfect. The only sure method for avoiding STDs is abstinence. If unprotected sex does occur with an unknown partner while traveling, contact your physician upon return.

Travelers should not use intravenous drugs or share needles. Tattoos, acupuncture treatments, and injections for medical or dental procedures are very risky because the equipment used may not be sterile.

Avoid the use of locally-produced immune globulin and blood-clotting factors in countries where the blood supply is not routinely tested for communicable diseases. If a blood transfusion is necessary, contact the nearest American Consulate for advice.

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