Health Tips

International Travel & Heart Disease

Heart disease or cardiovascular events are the main cause of death (as well as morbidity) and medical emergencies during long international flights and during international travel. During travel heart patients need extra caution as they are more prone to suffer from complication. As the saying goes “prevention is better than cure”, the heart patient should take some extra precautions to prevent any heart problem. To do’s for heart patient during in-flight as well as during travel: Extra supplies of all the medications used for heart trouble should be kept in carry-on luggage. Along with medications a copy of a recent ECG (electrocardiogram) and the name and telephone number of the traveler’s physician at home should be kept. If heart patient is using pacemaker, these are not affected by airport security devices. Electronic telephone checks of pacemaker function cannot be transmitted by international satellites during flight, which may sometimes (rarely) give trouble to the heart patient who is traveling.

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How to Cope Depression During Holidays?

Holiday session sometimes brings depression and stress along with it, as the depression and stress related problems tend to increase during holidays sessions. The reasons of depression and stress during holidays are many and range from trying to spend perfect holiday to not able to meet certain demands of family and friends. Coping with depression and stress during holidays may not be easy.

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Health Problems After International Travel

Fever is one of the commonest health problem a traveler face after return from international travel. Other health problems that may occur after international travel are diarrhea, respiratory illnesses, and skin diseases. But there may also some problems like fatigue and emotional stress and these are usually ignored and commonly seen after long stay.

To diagnose medical and health problems of international traveler require some knowledge about geographical medicine (knowledge of diseases which are prevalent in a particular geographical area) and epidemiology and clinical presentation of infectious disorders. A geographic history of a traveler should be about exact itinerary, including dates of arrival and departure; exposure history (food indiscretions, drinking-water sources, freshwater contact, sexual activity, animal contact, insect bites etc.); location and style of travel especially urban or rural, first-class hotel accommodation or camping etc.; immunization history before traveling; and use of anti-malarial chemo-suppression.

Fever is one of the commonest medical problem after return from international travel. Though “fever from the tropics” does not always have a tropical cause, malaria should be considered first. Fever in a traveler who has returned from a malarious area should be considered a medical emergency because death from P. falciparum malaria can follow an illness of only few days. The chance of fever being of P. falciparum malaria is highest among travelers returning from Africa or Oceania and among those who become symptomatic within the 2 months after return.

Other causes of fever after return from international travel include viral hepatitis (commonly hepatitis A and E), typhoid fever, bacterial enteritis, arboviral infections like dengue fever, rickettsial infections (including tick and scrub typhus and Q fever), acute HIV infection, and amebic liver abscess.

Skin problems after international travel include pyodermas, sunburn, insect bites, skin ulcers, and cutaneous larva migrans. In those with persistent skin ulcers, a diagnosis of cutaneous leishmaniasis, mycobacterial infection (tuberculosis of skin), or fungal infection should be considered. Careful and complete inspection of the skin is important in detecting the rickettsial eschar in a patient with fever or the central breathing hole in a “boil” due to myiasis.

Emergence of Communicable Diseases due to Travel

In recent years international travel has become a threat in spreading many diseases as well as reemergence of many diseases like of cholera and others as a global health threat. As one Nobel laureate once told “The microbe that felled one child in a distant continent yesterday can reach yours today and seed a global pandemic tomorrow”. This is very true in the era of “global village” idea.

Due to international travel for commerce and recreation HIV have spread throughout the world in only a few decades and created considerable fear about the possible spread of severe acute respiratory syndrome (SARS) and avian influenza also known as “bird flu” (H5N1). HIV is a classic example of fast spread of a communicable and infectious disease due to international travel.

There are many instances where a non existent disease suddenly appear in a particular geographical area with no history of the disease before in that area, e.g. appearance of schistosomiasis in previously unaffected lakes in Africa; appearance and outbreak of dengue fever in Latin America and appearance of antibiotic resistant strains of sexually transmitted diseases (STDs) and intestinal pathogens at an alarming rate in the developing countries.

There is also serious concern about possible bioterrorism by terrorists which is a of grave concerns because of use of not only standard strains of unusual agents but mutant strains as well. Only time can tell if all international travelers’ (as well as for everybody at who remain at home and do not travel) will need to get vaccinated for diseases like anthrax and smallpox.

International and national vigil is required for prevention of spread of infectious and communicable diseases and every individual and every Govt. need to play its role in preventing spread of communicable disease from one place to the other.

Treatment of Travelers’ Diarrhea

Travelers’ who suffer from travelers’ diarrhea, approximately 20% of them become bedridden and need proper treatment (should not do self treatment if diarrhea becomes severe).

In many cases a specific diagnosis is available to guide treatment and is also not necessary. The treatment should be started based on history, stool examination and severity of dehydration. The empirical treatment regimens for travelers’ diarrhea are based on certain clinical syndromes:

(1) Clinical syndrome, watery diarrhea without fever or blood in stool and 1 or 2 unformed stools per day without distressing enteric symptoms:- the treatment is with oral fluid (preferably with ORS or oral re-hydration salt or flavored mineral water).

(2) Clinical syndrome, watery diarrhea without fever or blood in stool and 1 or 2 unformed stools per day with distressing enteric symptoms:- treatment for adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses or loperamide 4 mg initially followed by 2 mg after passage of each unformed stool, not to exceed 16 mg per day or 8 tablets and loperamide can be taken for 2 days.

(3) Clinical syndrome, watery diarrhea without fever or blood in stool, but more than 2 unformed stools per day without distressing enteric symptoms:- treatment is antibiotics plus loperamide 4 mg initially followed by 2 mg after passage of each unformed stool, not to exceed 16 mg per day. Antibiotics that are used in travelers’ diarrhea are fluoroquinolones like ciprofloxacin 750 mg single dose or 500 mg twice a day for 3 days (levofloxacin, 500 mg as a single dose or norfloxacin, 800 mg as a single dose or 400 mg two times a day for 3 days are also used effectively), azithromycin, 1000 mg as a single dose or 500 mg twice a day for 3 days, Rifaximin, 200 mg 3 times a day or 400 mg 2 times a day for 3 days (this is not recommended if case of dysentery). All the above regimens are for adults. For children azithromycin, 10 mg/kg on day 1, 5 mg/kg on days 2 and 3 if diarrhea persists (furazolidone, 7.5 mg/kg per day in four divided doses for 5 days is an effective alternative to azithromycin).

In Thailand organisms (mainly Campylobacter) causing travelers’ diarrhea are resistant to fluoroquinolones and the antibiotic of choice in Thailand is azithromycin at the same dose as given above.

(4) Clinical syndrome, passing of blood in stool (dysentery) or fever of more than 37.8° C:- Antibiotic therapy as given above.

(5) Clinical syndrome, vomiting with minimal diarrhea:- treatment for adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses.

(6) Clinical syndrome, in infants less than 2 years old:- fluid and electrolyte replacement with ORS (intravenous fluid may also be required), continue feeding (continue breast feeding if infant is breast fed). If diarrhea is with dysentery or fever, antibiotics like azithromycin will be required and dose is as given above.

(7) Clinical syndrome, diarrhea in pregnant women:- Fluids and electrolytes should be given. Consider giving attapulgite, 3 gm initially, repeat after passage of each unformed stool or every 2 hour, whichever is earlier, for a total dosage of 9 gm per day.

(8) Clinical syndrome, diarrhea despite prophylaxis with trimethoprim-sulfamethoxazole:- Fluoroquinolone (ciprofloxacin) with loperamide if no fever and no blood in stool, ciprofloxacin alone if fever or dysentery is present.

(9) Clinical syndrome, diarrhea despite prophylaxis with fluoroquinolone (ciprofloxacin):- For adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses for mild to moderate diarrhea. If severe diarrhea persists consult doctor for proper antibiotic therapy like azithromycin.

Self-Treatment of Traveler’s Diarrhea

The traveler’s diarrhea is diarrhea which is seen among traveler’s (mainly from developed country to a developing country, but can occur during travel from anywhere to other country and in on study the rate of traveler’s diarrhea was, as low as 8% per 2-week stay in industrialized countries and as high as 55% in parts of Africa, Central and South America, and Southeast Asia), that is generally short lived and self limited. Though short lived about 40% of affected individuals need to alter their scheduled activities and another 20% become bedridden for few days. The causative organisms of traveler’s diarrhea are entero-toxigenic Escherichia coli and entero-aggregative E. coli. Sometimes it may be due to Campylobacter infections, Salmonella, Shigella or rotavirus.

Traveler’s diarrhea can occur despite rigorous precautions regarding food and water during travel to a developing country, all the traveler’s should carry some medication for self-treatment with them (preferably traveler’s medical kit). Antibiotic therapy will generally reduce the duration and severity (reduce frequency of stools) of traveler’s diarrhea in moderate to severe cases. The standard antibiotic regimen for traveler’s diarrhea is 3-day course of quinolone like ciprofloxacin (single double dose of quinolone is equally effective regimen). But if you are traveling to Thailand quinolone like ciprofloxacin will not work due to resistance (in Thailand more then 90% of traveler’s diarrhea is due to Campylobacter infections which are resistant to quinolone like ciprofloxacin) and azithromycin is a better alternative in such cases. Rifaximin (a poorly absorbed rifampin derivative) is also highly effective (especially against noninvasive bacterial pathogens such as entero-toxigenic and entero-aggregative E. coli) alternative to quinolone.

The present recommendation of self-treatment of travelers’ diarrhea is for the traveler to carry three once-daily doses of an antibiotic (azithromycin or ciprofloxacin) and to use as many doses as necessary to correct the diarrhea. If there is no fever or blood in stool, loperamide can be taken in combination with the antibiotic (but never take loperamide if you have fever or blood in stool as it may prolong diarrhea).

Prevention of Traveler’s Diarrhea

Traveler’s diarrhea can be prevented if precautions are observed properly during international travel. The main preventive measures of traveler’s diarrhea are related to food and water precautions. But studies indicate that indiscretion in eating and drinking water is done by approximately 98% of traveler’s upon arrival of their destination within 72 hours. That means only a handful of cautious travelers follow the precautions for prevention of traveler’s diarrhea. No wonder that such a large percentage of travelers suffer from traveler’s diarrhea. There is a popular slogan for travelers “Boil it, cook it, peel it, or forget it!” and it is easier to remember than following it as the studies indicate.

In general a traveler should follow some precautions for prevention of traveler’s diarrhea. The food precautions are eating food when it is still hot, avoid foods that are raw, poorly cooked, or sold by street vendors etc. Water precautions include drinking only boiled or commercially bottled beverages (preferably those that are carbonated). Heating can kill organisms that cause traveler’s diarrhea (entero-toxigenic Escherichia coli, entero-aggregative E. coli, Campylobacter, Salmonella, Shigella, rotavirus, norovirus etc.), but freezing can not kill them and due to this reason ice cubes made from unpurified water should be avoided.

Prophylaxis of traveler’s diarrhea:

The most commonly used prophylaxis for traveler’s diarrhea is bismuth subsalicylate, but it is only 60% effective. In special cases (athletes, persons with a repeated history of travelers’ diarrhea, and persons with chronic diseases) a single daily dose of a quinolone or azithromycin or a once-daily rifaximin regimen during travel of more than 1 month’s duration is effective in preventing travelers’ diarrhea in 75% to 90% of cases.

Self treatment of traveler’s diarrhea:

Ideally all travelers should carry some medication for traveler’s diarrhea for self-treatment, as it can occur despite rigorous food and water precautions. An antibiotic can reduce the frequency of stools and duration of illness in moderate to severe diarrhea. The standard regimen for traveler’s diarrhea is a single daily dose of quinolone (ofloxacin, ciprofloxacin etc.) for 3 successive days. Rifaximin, a poorly absorbed rifampin derivative and is highly effective against noninvasive bacterial pathogens like entero-toxigenic E. coli and entero-aggregative E. coli. But if you acquire traveler’s diarrhea, in Thailand, where more than 90% of Campylobacter infections are quinolone resistant, azithromycin can be a good choice.

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.

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.