Archive for March, 2009

Traveler’s Diarrhea

Diarrhea (also known as traveler’s diarrhea) is the leading cause of illness in travelers but it is usually self limiting and short-lived. Approximately 40% of affected travelers need to change their scheduled activities and approximately 20% are confined to bed. For travelers diarrhea, the most important which determines the risk is the destination of the traveler. The rate of incidence of diarrhea among travelers is about 8% in developed countries and as high as 55% or higher in parts of Africa, Central and South America, and Southeast Asia for a 2-week stay. Young people and infants are most vulnerable to get diarrhea. A recent study suggests that there is little correlation between dietary indiscretions (eating what traveler like without thinking of health problems) and the occurrence of travelers’ diarrhea.

The commonest identified pathogens for traveler’s diarrhea are entero-toxigenic Escherichia coli (ETEC) and entero-aggregative E. coli. But in some parts of the world traveler’s diarrhea like northern Africa and Southeast Asia, is due to Campylobacter infections. Other organisms found to cause traveler’s diarrhea are Salmonella, Shigella, rotavirus, and norovirus (this virus has caused numerous outbreaks on cruise ships) etc. Parasitic infections like giardiasis may cause traveler’s diarrhea some times, but other parasitic infections are uncommon causes of travelers’ diarrhea. A huge problem that is emerging in case of travelers’ diarrhea is development of antibiotic resistance among many bacterial pathogens (strains of Campylobacter are resistant to quinolones like ciprofloxacin and strains of E. coli, Shigella, and Salmonella resistant to trimethoprim + sulfamethoxazole combination).

The clinical features of traveler’s diarrhea include frequent stool and some times abdominal pain, but these symptoms disappear within few days (self limiting) even without any treatment. Treatment of traveler’s diarrhea is usually not required in maximum number of patients as it goes off by itself with a few days. The dehydration is usually mild and no aggressive rehydration is not required. If it persists or as a precaution oral rehydration salts (ORS) can be taken as required.

Prevention of Malaria and other Insect Borne Diseases during Travel

Malaria and other infectious diseases are a huge health problem among travelers. In many developed countries the cases of malaria are mainly of travelers returning from an malaria endemic area. The risk of contracting malaria depends on factors like area of travel, whether chemoprophylaxis is taken or not and the endemicity of malaria in the particular area.

The risk of contracting malaria vary if different parts of the world. Highest risk in sub-Saharan Africa and Oceania regions where it is estimated that the chance of contracting malaria is as high as 1 in 5 (1:5) to 1 in 50 (1:50) per month of stay, if chemoprophylaxis is not taken. The intermediate (malarious) areas are Indian subcontinent and in Southeast Asia where chance of contracting malaria is 1:250–1:1000 per month of stay. Low risk areas are South and Central America where the chance of contracting malaria is 1:2500–1:10,000 per month of stay.

In US more than 1000 cases of malaria are reported annually and out of these more than 90% are due to Plasmodium falciparum (most serious form of malaria and can involve brain and develop cerebral malaria). Almost all the cases are seen among travelers returning from or immigrating from Africa and Oceania.

There is worldwide increase in chloroquine- and multi drug-resistant falciparum malaria and the decision on chemoprophylaxis has become complicated. Recently there is spread of malaria due to primaquine- and chloroquine-resistant strains of Plasmodium vivax. This also has med the treatment of malaria more complicated. The case-fatality rate of falciparum malaria in the United States is 4% but the fact is only about one third of these fatal cases of malaria are diagnosed or thought of diagnosis of malaria before death.

Many studies indicate that less than 50% of the travelers follow the basic recommendations for malaria prevention. The main protective measure of malaria during travel are personal protection measures against mosquito bites (especially between dusk and dawn) and malaria chemoprophylaxis. The personal protection measures against mosquito bites include use of DEET-containing insect repellents, permethrin-impregnated bed-nets and clothing, screened sleeping accommodations, and protective clothing (the important motto of this is “sun down sleeves down” and for this traveler should use full sleeve dress). Personal protection measures against mosquito also help prevent other insect-transmitted illnesses, like dengue fever.

A new insect repellent with picaridin as active ingredient is quite efficacious and is available in the United States, but only in low-concentration formulations that require frequent reapplications. So, in regions where infections like malaria are transmitted (very high chance of transmission), DEET products (25–50%) are recommended, even for children and infants who are above 2 months of age.

CDC recommends the following anti malarial drugs for chemoprophylaxis according to region:

• Chloroquine: For Central America (north of Panama), Haiti, Dominican Republic, Iraq, Egypt, Turkey, northern Argentina, and Paraguay. Mefloquine, Doxycycline, Atovaquone + proguanil are the alternatives to Chloroquine.
• Mefloquine, Doxycycline, Atovaquone + proguanil (Malarone): Recommended for South America including Panama (except northern Argentina and Paraguay); Asia (including Southeast Asia), Africa and Oceania. Primaquine is an alternative to all the above.
• Doxycycline, Atovaquone + proguanil (Malarone): For Thai-Myanmar and Thai-Cambodian borders.

Alternative medicine: Music Therapy

Alternative medicine also known as CAM (complementary and alternative medicine) is really a good alternative for many people who are seeking some relief from their ailments. There are many systems of alternative medicines. Some of the alternative systems of medicines are aroma therapy, music therapy, herbal medicine, acupressure, ayurvedic medicine, homeopathy, chiropractic medicine, acupuncture, dance therapy, hydrotherapy, meditation, hypnosis, naturopathy, unani, yoga, hypnosis etc. to name a few of them. In United states alone it was found in one study by Eisenberg, that approximately $30 billion is spent in the year 1997 in alternative medicines by the Americans.

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General Health Advice for International Travel

According to World Tourism Organization the number of international tourist arrivals is approximately one billion every year at present and the number is increasing steadily every year. Not only are more people traveling; these days travelers are seeking more exotic and remote destinations and studies show that 50% to 75% of short-term travelers to the tropics or subtropics report some health problem during or immediately after the travel. Most of these health problems are minor and only about 5% of them require some medical attention and less than 1% require hospitalization. Among these travelers infection is a major contributor of illness but only approximately 1% of the deaths among travelers is due to infection.

The most frequent causes of death among travelers from the United States and other western countries are cardiovascular disease (49% deaths among travelers) and injuries (22% deaths) due to accidents. The age specific death rates due to cardiovascular disease are similar among travelers and non travelers but for injuries (motor vehicle, drowning, aircraft accidents etc.) it is much higher among travelers.

The health advice and recommendations for international travel are based on traveler’s destination, health status of the traveler (pregnancy, old age, any specific diseases like cardiovascular diseases, respiratory disease etc.), specific itinerary, and lifestyle during travel. Most commercial aircrafts are pressurized to 2500 m (8000 ft) above sea level (corresponding to a Pa_O2 of ~55 mmHg), travelers with serious cardiopulmonary problems, severe anemia should be evaluated before travel. those who have recently had surgery, a myocardial infarction, a cerebrovascular accident, or a deep-vein thrombosis are at high risk during flight.

Fitness of traveler is an important issue and a growing concern due to increased numbers of elderly and chronically ill individuals journeying to exotic destinations. A pre-travel health assessment is highly recommended for travelers particularly for those who are considering adventurous recreational activities, such as mountain climbing and scuba diving.

From the Centers for Disease Control and Prevention (CDC) publication Health Information for International Travel you can get detailed information regarding country-specific risks and recommendations for international travel.

The Travelers Medical Kit

A traveler should always carry travelers medical kit along with him/her (especially while traveling from a developed country to a developing country or an underdeveloped country) and it is strongly recommended by all the authorities in the field. The travelers medical kit is very much helpful in times of need.

There are many medications available in many countries of travel (often over the counter), directions for their use may not be there with the medicine or if present it is in a foreign language, the medicine may be outdated or counterfeit. For example, a recent multi-country study in Southeast Asia showed that an average of 53% (range, 21–92%) of anti-malarial drugs were counterfeit or contained inadequate amounts of active drug and can not be relied upon.

The contents of travelers medical kit may very depending on many factors and situations. The contents of travelers medical kit vary depending on the itinerary of travel, duration of stay, style of travel, and local medical facilities where you are going etc. For a short term traveler the travelers medical kit should contain an analgesic or painkiller like ibuprofen; an anti-diarrhea agent and an antibiotic for self-treatment of travelers’ diarrhea like azithromycin; a laxative, ORS or oral re-hydration salts; antihistamines (allegro or fexofanadine, cetirizine etc.); sunscreen with a SPF (skin-protection factor) of at least 30; an insecticide for clothing like permethrin; a DEET containing insect repellent (for mosquito and other insects) for the skin and some anti-malarial drugs like artesunate (acts in case of falciparum malaria which can cause cerebral malaria).

A long-stay traveler should have all the above mentioned medicines in the travelers medical kit and should add some more additional medications. A long-stay traveler should add a broad-spectrum general-purpose antibiotic like levofloxacin or azithromycin, a topical antifungal cream like miconazole, an antibacterial eye and skin ointment etc to the travelers medical kit.

A first aid kit should also be there with the travelers medical kit regardless of duration of stay. The travelers first aid kit should contain items like scissors, tweezers, a knife and bandages. Long-stay traveler should carry a once-daily dose of antibiotics is to use 3 tablets “below the waist” (bowel and bladder infections) and 6 tablets “above the waist” (skin and respiratory infections).

Loose Weight by Hoodia Gordonii

There are many weight loss products in the market. Many weight lose products like Acai berry products are very well known to the general public, thanks to its promotion by many celebrities like Oprah Winfrey. But there are many more products which are as good as Acai berry products if not better and one of such product is hoodia gordonii.

Hoodia gordonii is a leafless spiny desert plant that grows naturally South Africa and Namibia in the deserts. Hoodia gordonii was discovered by Colonel Robert Jacob Gordon (so named gordonii) in 1779 in and around Orange River. The hoodia plant was long known to the indigenous populations of Southern Africa (the Bushmen tribe) and was used for indigestion and minor infections. But to the modern men hoodia gordonii is not known for use in these ailments. It is known to the modern men as appetite suppressant. The discovery of hoodia gordonii as appetite suppressant was possible because the plant flesh was eaten by the Bushmen tribe during long hunting trips to the Kalahari Desert to suppress hunger.

The active ingredient that cause the suppression of appetite is known as P57 and it was isolated by South African Council for Scientific and Industrial Research in 1977 and patented in 1996.

While buying hoodia gordonii you should always try to get the best of unique hoodia and do not try to get it cheap because you will not get the best of is hoodia gordonii at cheap rate. So if you want to lose weight by using hoodia gordonii get the best of the product for the best result.

There are many sites that are promoting hoodia gordonii as an appetite suppressant and a weight lose products and one of the best site for hoodia gordonii is hoodiagordoniiguide.info.

Prevention of Diseases During Travel

Travelers (especially traveler from a developed country to a developing or underdeveloped country) are at high risk of contacting many diseases compare to the local population. Many of the diseases are infectious diseases and many are not related to disease agents. All the risks are due to indulgent of travelers to different activities in the place of their travel.

Travelers are at high risk of contacting an STD (sexually transmitted disease). Recent studies show that large number of travelers engage in casual sex and they can get reluctant to use condom consistently and get infected with STDs. To prevent STD all travelers should use condom during casual sex and also carry condom with them. Use of condom can also prevent spread of HIV. In USA an increasing number of travelers are diagnosed with schistosomiasis. Travelers should avoid bathing, swimming or wading in freshwater lakes, streams, or rivers in parts of tropical South America, the Caribbean, Africa, and Southeast Asia.

Prevention of travel associated injuries or injury during travel is also very important as study shows that the chances of getting injury is much higher among travelers. Common-sense precautions should be taken during travel like not riding a motor cycle without a helmet, avoiding overcrowded public transport etc. A traveler should not travel in developing countries by road after dark (especially alone), particularly in rural areas. Traveler should not go out of his/her shelter after dark and alone. Travelers are cautioned to avoid walking barefoot because of the risk of hookworm infection and Strongyloides infection and snake bites. Excessive alcohol use has been a significant factor in drowning, assaults, injuries and not to mention the chances of increased motor vehicle accidents. Excess alcohol should be avoided during travel and also excessive “tasting” of local drinks, because travelers may get a bigger “kick” due to local alcoholic drinks.

Prevention and Control of Typhoid

Theoretically typhoid is an eradicable (as smallpox) disease as Salmonella that cause enteric fever survive only in human hosts and are spread by contaminated food and water. But high prevalence of typhoid in developing countries and lack of adequate sewage disposal and water treatment make the goal of eradication of typhoid impracticable at present. So travelers from developed countries to developing country should monitor their food and water intake carefully and also get vaccinated for typhoid.

Typhoid vaccines:

At present 2 types of typhoid vaccines are commercially available: (1) Ty21a, an oral live attenuated vaccine of Salmonella Typhi (given on days 1, 3, 5, and 7, with a booster every 5 years) and (2) Vi CPS, a parenteral vaccine (given intramuscularly) consisting of purified Vi polysaccharide from the bacterial capsule (given in 1 dose, with a booster every 2 years). The older vaccine of whole cell typhoid/paratyphoid A and B vaccine (given intramuscularly) is no longer licensed due to its side effects. The minimum age for vaccination is 6 years for oral type or Ty21a and 2 years for Vi CPS. At present there is no vaccine licensed for paratyphoid. An acetone-killed whole-cell vaccine is available which is only used by the U.S. military.

Vi CPS typhoid vaccine is poorly immunogenic in children of less than 5 years of age because of T cell–independent properties. More than three new live vaccines are in clinical development and experts hope these will prove to be more efficacious and longer-lasting than previous live vaccines.

Ty21a, whole cell vaccines, and Vi CPS are all equally effective for the first year, the 3-year cumulative efficacy of the whole-cell vaccine (73%) exceeds that of both Ty21a (51%) and Vi CPS (55%). The heat killed whole cell vaccine has efficacy for 5 years, but Ty21a and Vi CPS has efficacy for 4 and 2 years, respectively. But the whole cell vaccine also has more side effects than the other two.

Data on typhoid vaccines in travelers are limited and some evidence suggests that they may be less efficacious in travelers than those for local populations in endemic areas. WHO and CDC recommend typhoid vaccination for travelers to typhoid-endemic countries like in Indian subcontinent. An analysis in the CDC found that 16% of travel associated cases occurred among persons who stayed at their travel destination for 2 weeks or more. So vaccination should be done even if the duration of stay is short in typhoid endemic areas.

Typhoid can be prevented by providing good quality drinking water to the population and sewerage disposal in a hygienic way. But these two things are difficult to achieve in developing countries and these countries harbor the disease in the community.

Health Benefits of Spa Baths

There are many benefits of spa baths and whirlpool baths. Many of the benefits are health benefits and beauty benefits. Baths have been in use since Roman times as far back as about 500 BC. Romans use hot baths as a form of relaxing, socializing and maintaining well being or maintaining good health. The practice of bath as a form or relaxing, socializing and health benefits are in use till date in some form or other.

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Diagnosis of Typhoid Fever

The clinical features of typhoid fever are nonspecific. So diagnosis of typhoid fever should be considered if a traveler returning from developing country with fever, especially from Indian subcontinent, and Latin America or in developing countries any patient with fever. Other diagnosis to be considered in case of fever and international travel are malaria, hepatitis, bacterial enteritis, dengue fever, rickettsial infections, leptospirosis, amebic liver abscesses, and acute HIV infection etc.

A positive blood culture is the only confirmatory test for diagnosis of typhoid fever and other laboratory tests are not diagnostic. There may be non specific laboratory changes like leukopenia and neutropenia in 15% to 25% of the cases of typhoid fever and also moderately elevated liver function tests and muscle enzyme levels.

The definitive diagnosis of enteric fever is done by isolation of Salmonella Typhi or Salmonella Paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions. The positive blood culture is 90% during the first week of infection and decreases to 50% by the third week. A low yield of positive result in infected patients is related to low numbers of salmonellae (less than 15 organisms/ml) and/or to recent antibiotic treatment. Bone marrow culture yield is 90% despite approximately 5 days of antibiotic therapy. Even if bone marrow culture is negative, culture of intestinal secretions (best obtained by a noninvasive duodenal string test) can give a positive result for typhoid fever. If bone marrow and intestinal secretions are cultured together, it can give more than 90% positive result anytime during Salmonella infection.

There are other serologic tests also like classic Widal test which is for “febrile agglutinins”, but none of these tests are sufficiently sensitive or specific to replace culture methods especially in developed countries. Some new tests are being developed like PCR (Polymerase chain reaction) and DNA probe assays to detect S. Typhi in blood.