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Dysentery
This serious illness is caused by contaminated food or water and is
characterized by severe diarrhea, often with blood or mucus in the
stool.
There are two kinds of dysentery. Bacillary dysentery(shigellosis) is
characterized by a high fever and rapid onset; headache, vomiting and
stomach pains are also symptoms. It generally does not last longer than
a week, but it is highly contagious.
Amebic dysentery is often more gradual in the onset of symptoms, with
cramping abdominal pain and vomiting less likely; fever may not be
present. It is not a self-limiting disease: it will persist until
treated and can recur and cause long-term health problems.
A stool test is necessary to diagnose
which kind of dysentery you have, so you should seek medical help
urgently. In case of an emergency the drugs norfloxacin or ciprofloxacin
can be used as presumptive treatment for bacillary dysentery, and
metronidazole (Flagyl) for amebic dysentery.
Typhoid Fever
Typhoid fever is an acute bacterial disease caused by Salmonella typhi.
Typhoid germs are passed in the feces and, to some extent, the urine of
infected people. The germs are spread by eating or drinking water or
food contaminated by feces (or urine) from the infected individual.
Symptoms generally appear one to three weeks after exposure. In its
early stages typhoid resembles many other illnesses, and often sufferers
may feel like they have a bad cold or flu on the way. The onset of
typhoid fever is normally gradual, with fever, malaise, chills,
headache, generalized aches in the muscles and joints, tiredness, loss
of appetite, and sore throat. Abdominal pain and distension may occur.
Vomiting, which may occur toward the end of the first week, is not
usually severe. Diarrhea is infrequent; constipation occurs more often
than diarrhea.
A fever develops which rises a little each day until it is around 104
degrees Fahrenheit or more. The person s pulse is often slow relative to
the degree of fever present and gets slower as the fever rises, unlike a
normal fever where the pulse increases.
In the second week, the high fever and slow pulse continue and a few
pink spots may appear on the body. Trembling, delirium, weakness, weight
loss and dehydration are other symptoms. "Pea soup" diarrhea may occur.
Abdominal pain and distension may be increased. If there are no further
complications, the fever and other symptoms will slowly diminish during
the third week. However, typhoid is a very dangerous infection and an
infected individual must get medical help as soon as possible, because
pneumonia or peritonitis (perforated bowel) are common complications.
Diagnosis comes from isolation of Salmonella typhi from the blood or
stool of an infected person.
The best protection is to avoid consuming food or water that may be
contaminated. For foreign travelers, drinking only boiled water or
carbonated beverages and eating only cooked food, lowers the risk of
infection.
The fever should be treated by keeping the victim cool, and dehydration
should also be watched for. Treatment is with ampicillin,
chloramphenicol, Bactrim, or Cipro, depend ing upon the clinical
circumstances. Chloramphenicol is the most effective drug for treatment
of the acute illness, if the organism is not resistant. If hospital
facilities are not close by, consider starting treatment with Cipro.
Ampicillin and amoxicillin are effective alternatives.
Fatalities are less than 1 percent with antibiotic treatment. Even after
effective treatment, you may continue to carry typhoid bacteria in your
intestinal tract, which can be passed to close contacts such as family
members. Follow-up testing is very important. Relapses are common, and
the frequency of relapse does not appear to have been changed
dramatically by antibiotic therapy.
Vaccines are available that afford significant protection. Currently
available vaccines have been shown to protect 70% - 90% of the
recipients. Therefore, even vaccinated travelers should be cautious in
selecting their food and water.
The oral vaccine consists of 4 capsules containing live attenuated
bacteria. They are taken every other day for seven days. The oral
vaccine is effective for travelers to infected areas for five years. The
entire 4 doses should be repeated every 5 years if the person is at
continued risk. Reactions are rare and include nausea, vomiting,
abdominal cramps, and skin rash.
The injectable vaccine consists of a primary series of two shots, spaced
at least 4 weeks apart. A booster dose given every 3 years provides
continued protection for repeated exposure. If there is insufficient
time for two doses a month apart, an accelerated schedule of three shots
a week apart may be administered. The accelerated schedule may be less
effective.
CDC recommends a typhoid vaccination for those travelers who are going
off the usual tourist itineraries, traveling to smaller cities and rural
areas, or staying for six weeks or more. Typhoid vaccination is not
required for international travel.
HIV / AIDS
Acquired Immune Deficiency Syndrome (AIDS) is caused by infection with
the Human Immunodeficiency Virus (HIV). HIV destroys the body s immune
system, which means that the body can no longer successfully fight
against certain infections and some forms of cancer.
AIDS is a global problem. It is estimated that more than six to eight
million people are now infected with the HIV virus. Sex workers are
frequently infected: the proportion infected exceeds 80% in many parts
of the world, and the current stated average population infection rate
in Africa is one in 40.
Human immunodeficiency virus (HIV) which causes acquired
immunodeficiency syndrome or AIDS is found primarily in blood, semen,
and vaginal secretions of an infected person. HIV is spread by sexual
contact with an infected person, by needle-sharing among injecting drug
users, and through transfusions of infected blood and blood clotting
factors. Babies born to HIV-infected mothers may have the disease.
In the United States blood is screened for HIV antibodies, but this
screening may not take place in all countries. Scientific studies have
revealed no evidence that HIV is transmitted by air, food, water,
insects, inanimate objects, or casual contact. Even though HIV
antibodies are normally detected on a test within 6 months after
infection, the period between infection and development of disease
symptoms (incubation period) may be 10 years or longer. Treatment has
prolonged the survival of some HIV infected persons, but there is no
known cure or vaccine available.
AIDS is found throughout the world. The risk to a traveler depends on
whether the traveler will be involved in sexual or needle-sharing
contact with a person who is infected with HIV. Receipt of unscreened
blood for transfusion poses a risk for HIV infection.
Most everyday activities pose no risk of HIV transmission. Normal social
contact, swimming in public pools, eating in restaurants and using
public toilets are not dangerous. There is no scientific evidence to
suggest that mosquitoes transmit HIV.
Avoiding casual unprotected sexual contacts is the best solution. Other
than this, condoms are a reasonable barrier. However, if petroleum
lubricants are used, condoms are liable to break as petroleum products
attack latex. Also, locally produced condoms can often be poor quality
and are not recommended.
Never use needles or syringes that have been used by others. When
receiving medical attention, always insist that unused, disposable
equipment or fully sterilized material is used. If you do need an
injection, ask to see the syringe unwrapped in front of you, or better
still take a needle and syringe pack with you overseas - it is a cheap
insurance package against infection with HIV. Never use another person s
razor or toothbrush. Don t have parts of your body pierced, or allow
yourself to be tattooed.
HIV/AIDS can be spread through infected blood transfusions. Most
developing countries cannot afford to screen blood for transfusions.
No effective vaccine has been developed for HIV.
CHOLERA
Cholera is an acute intestinal diarrheal disease caused by a bacterium
-- Vibrio cholerae, which is found in water contaminated by sewage.
Cholera occurs both sporadically and in large, abrupt epidemics.
An epidemic of cholera started in South America in 1991, and has swept
through Central and South America since then. Cholera cases were first
recognized in Peru in the last week of January 1991. The majority of
cases have been reported from Peru, Ecuador, Colombia, Guatemala, and
Mexico. Cholera has been reported in coastal cities and inland areas of
most of these countries. Cholera has also been reported in Cuzco in Peru
and in the Galapagos Islands of Ecuador. Other countries to report cases
include Argentina, Belize, Bolivia, Brazil, Chile, Costa Rica, El
Salvador, French Guiana, Guyana, Honduras, Nicaragua, Panama, Suriname,
and Venezuela. Bolivia has reported cases as well. Cholera has been
reported from five states in Brazil. Several municipalities near the
mouth of the Amazon River have been affected. Cholera has been reported
in a small number of US residents traveling to Peru and Ecuador.
The risk of infection to the US traveler is very low, especially those
that are following the usual tourist itineraries and staying in standard
accommodations. Cholera germs account for only a small percentage of all
cases of travelers diarrhea. Very few Western travelers ever get
seriously ill from cholera. In fact, the disease is reported in only 1
in 500,000 returning travelers. Most illness occurs in native people who
are malnourished and who ingest large amounts of bacteria from heavily
contaminated water. Travelers should consider the vaccine if they have
any problems with their stomach, such as anti-acid therapy, ulcers, or
if they will be living in less than sanitary conditions in areas of high
cholera activity.
Predicting how long the epidemic in Latin America will last is
difficult. The cholera epidemic in Africa has lasted more than 20 years.
In areas with inadequate sanitation, a cholera epidemic cannot be
stopped immediately, and there are no signs that the epidemic in the
Americas will end soon.
Latin American countries that have not yet reported cases are still at
risk for cholera in the coming months and years. Major improvements in
sewage and water treatment systems are needed in many of these countries
to prevent future epidemic cholera.
The clinical picture of cholera varies widely. The illness in healthy
tourists is usually very mild because they rarely ingest the heavily
contaminated water necessary to trigger the disease. Severe cases
usually strike only the indigenous population. 1 in 20 infected persons
gets severe disease. The cholera germs grow in the small intestine and
produce an intestinal toxin that can cause a massive outpouring of water
and salt into the gut. The toxin does not cause physical damage to the
intestinal wall.
There is an abrupt onset of voluminous watery diarrhea, dehydration,
vomiting, and muscle cramps. The onset of the diarrhea is painless and
explosive, and several liters of fluid may be lost every hour. The rapid
loss of salt and water in the stools can cause severe, life-threatening
dehydration. The frequent, watery stools soon lose all fecal appearance
and odor ("rice water stools"). The diarrhea is not bloody and there is
no fever. Vomiting generally occurs but is not associated with
nausea.Without treatment, death can occur within hours. Death from
dehydration can occur in up to 50% of untreated cases.Cholera must be
distinguished from other causes of travelers diarrhea caused by E.
coli, Shigella, Salmonella, viruses, and parasites. The lack of blood,
mucus, or pus in the stools of cholera victims is a distinguishing
feature.
Managing the effects of dehydration is the mainstay of treatment. If you
can drink sufficient fluids, you can prevent serious dehydration. Oral
rehydration solutions are essential, and their prompt use has saved many
lives. (The World Health Organization rehydration formula is prepared by
adding one packet to one liter of safe drinking water. Individuals
should drink 6 to 8 ounces, or more, after every loose stool.) If the
diarrhea is very profuse and exceeds what individuals can drink, or if
they are vomiting and can t drink, hospitalization and intravenous
therapy will be necessary.
If there is an appreciable delay in getting to a hospital, then
tetracycline should be taken. The adult dose is 250 mg four times daily.
It is not recommended for children aged eight years or under, nor for
pregnant women, because tetracycline stains the developing teeth of
fetuses and children. An alternative drug is Ampicillin. While
antibiotics might kill the bacteria, it is the toxin produced by the
bacteria which causes the massive fluid loss. Fluid replacement is by
far the most important aspect of treatment. In the hospital, antibiotics
such as Furoxone, tetracycline, Cipro, or Bactrim will shorten the
duration of illness and are important adjuncts to hydration therapy.
Travelers to cholera infected areas should follow the standard food and
water precautions of eating only thoroughly cooked food, peeling their
own fruit, and drinking either boiled water, bottled carbonated water,
or bottled carbonated soft drinks.
Following these simple rules, will help you avoid most food and water
borne diseases:
*Drink only water that you have boiled or treated with chlorine or
iodine.
Other safe beverages include tea and coffee made with boiled water and
carbonated, bottled beverages with no ice.
*Eat only foods that have been thoroughly cooked and are still hot, or
fruit
that you have peeled yourself.
*Avoid undercooked or raw fish or shellfish, including ceviche.
*Make sure all vegetables are cooked.
*Avoid all salads.
*Avoid foods and beverages from street vendors.
*A simple rule of thumb -- Boil it, cook it, peel it, or forget it.
The available vaccine is only 50% effective in reducing the illness, and
is not recommended routinely for travelers. The primary series is
normally two injections with booster doses given every 6 months for
persons who remain at high risk. Cholera vaccine is not recommended for
infants under 6 months old, or for pregnant women.
If you are exposed, the vast majority of cholera germs that you ingest
will be destroyed in your stomach by gastric acid. The cholera vaccine
offers little protection and is no longer officially recommended by the
World Health Organization. The antibodies produced by the vaccine have
little effect upon the germs in your intestine. Marginal benefit from
vaccination may occur in those travelers with (1) low-protective gastric
acid levels (e.g., people taking anti-ulcer drugs) and (2) those on
long-term assignment in high-risk areas where there is poor sanitation
and the possibility of exposure to heavily contaminated water.
Otherwise, the only indication for the vaccine is to satisfy the entry
requirements of certain countries.
Poliomyelitis (polio)
Poliomyelitis is a highly contagious infection caused by poliovirus,
which is transmitted from person to person through exposure to fecal
material or respiratory secretions containing the virus. The incubation
period ranges from nine to twelve days. Most poliovirus infections are
asymptomatic.
Initial symptoms, when they occur, are similar to those of other viral
infections and may include fever, headache, muscle aches, malaise,
nausea, vomiting, and sore throat. In roughly one in a thousand cases,
poliovirus attacks the spinal cord or brainstem, leading to paralysis in
various parts of the body, most often the legs.
Polio mainly affects children under three years of age.
All children should receive four doses of inactivated polio vaccine at
ages 2 months, 4 months, 6-18 months, and 4-6 years. An accelerated
immunization schedule is recommended for children who have not completed
their polio immunizations and who may be traveling to places where polio
still occurs.
Adults who will be traveling to an area where polio is reported and who
have never been immunized or whose immunization status is unknown should
be given a total of three doses of inactivated polio vaccine separated
by at least 4 weeks from each other. Adults who completed the full
childhood series of polio immunizations but never had a booster as an
adult may be given a single dose of inactivated polio vaccine before
entering a polio-endemic area.
Inactivated polio vaccine has essentially replaced oral polio vaccine in
the United States because the latter may cause paralytic poliomyelitis,
though this is rare. Oral polio vaccine is recommended only for
unvaccinated children who will be traveling in less than four weeks to
an area where polio is endemic and for mass vaccination campaigns to
control polio outbreaks.
In 2000, there were fewer than 3500 reported polio cases worldwide. Tens
of thousands more children are infected with the virus; while they do
not suffer paralysis, they can infect other children.
Polio has been eradicated in the Americas, except for a small outbreak
in the Dominican Republic and Haiti in late 2000 which appears to have
been controlled. In October 2000, the World Health Organization
certified that the Western Pacific region, which includes large parts of
Southeast Asia as well as the Pacific Islands, was polio-free. In
Europe, only Turkey continues to report a small number of cases.
Poliovirus transmission continues to occur in the Indian subcontinent
and sub-Saharan Africa, as well as certain countries in the Middle
East.Travelers to countries where poliomyelitis is epidemic or endemic
are considered to be at increased risk of poliomyelitis and should be
fully immunized.
In general, travelers to developing countries (excluding countries in
Latin America) should be considered to be at increased risk of exposure
to wild poliovirus.
Unvaccinated, or partially vaccinated travelers should complete a
primary series with the vaccine that is appropriate to their age and
previous immunization status.
Persons who have previously received a primary series may need
additional doses of a polio vaccine before traveling to areas with an
increased risk of exposure to wild poliovirus.
MALARIA
Malaria is a serious parasitic infection that is transmitted to humans
through the bite of an infected Anopheles mosquito. These mosquitoes are
present in almost all countries in the tropics and subtropics. Anopheles
mosquitoes bite during evening and nighttime hours, from dusk to dawn.
Both personal protection measures and anti malarial drugs are
recommended for travelers who have exposure during evening and nighttime
hours in malaria risk areas.
Symptoms of malaria include fever, chills, headache, muscle ache, and
malaise. Early stages of malaria may resemble the onset of flu.
Travelers who become ill with a fever during or after travel in a
malaria risk area should seek prompt medical attention and should inform
their physician of their recent travel history. Neither the traveler nor
the physician should assume that the traveler has the flu or some other
disease without doing a laboratory test to determine if the symptoms are
caused by malaria.
Travelers can still get malaria despite the use of preventive measure.
Malaria symptoms can develop as early as 7 days after being bitten by an
infected mosquito or as late as several months after departure from a
malarious area, after anti malarial drugs have been discontinued.
Malaria can be treated effectively in its early stages, but delaying
treatment can have serious consequences. If left untreated, malaria can
cause anemia, kidney failure, coma, and death. In spite of all
protective measures, travelers occasionally develop malaria. Therefore,
while traveling and up to one year after returning home, travelers
should seek medical evaluation for any flu-like symptoms.
Malaria transmission occurs primarily between dusk and dawn. The risk of
malaria depends on the traveler s itinerary, the duration of travel, and
the place where the traveler will spend the evenings and nights.
Protective measures include remaining in well-screened areas, using
mosquito nets, and wearing protective clothes that cover most of the
body. Insect repellent should be used on exposed skin. The most
effective repellents contain DEET. The effect should last for about 4
hours. Travelers should use pyrethroid-containing flying insect spray in
living and sleeping areas during evening and nighttime hours. Permethrin
(Permanone) may be sprayed on clothing for protection against
mosquitoes. When used according to directions, Permethrin will repel
insects from clothing for several weeks.
Travelers at risk for malaria should take Mefloquine tablets to prevent
the disease. Mefloquine should be taken one week before leaving, weekly
while in the malarious area, and weekly for 4 weeks after leaving the
malarious area. Chemoprophylaxis may also include Fansidar drugs
depending on the area to be visited and the absence or existence of
resistant strains of malaria.
Malaria occurs in large areas of Central and South America, Hispaniola,
sub -Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle
East, and Oceana. The risk of exposure is less in urban areas and during
the daytime, and greater in rural areas and during the evening and
nighttime hours. The risk of acquiring malaria is greater in Africa
since travelers to Africa tend to spend considerable time, including
evening and nighttime hours, in rural areas where malaria risk is
highest.
Chloroquine/mefloquine-sensitive malaria occurs in: Mexico, Central
America, far north Argentina, Paraguay, Egypt, Turkey, Syria, Lebanon,
Iraq, Saudi Arabia, Kuwait, United Arab Emirates, Quatar, Bahrain.
Chloroquine/melfoquine-resistant P. falciparum malaria occurs in:
Brazil, Peru, Equador, Columbia, Venezuela, Guyana, Surinam, French
Guiana, Bolivia, throughout sub-Saharan, West, Central, East, and
southern Africa, including Madagascar, in Yemen, Oman, Iran,
Afghanistan, all of South Asia, all of Southeast Asia including
Indonesia, Philippines, and southern China.
Resistance to both chloroquine and Fansidar is widespread in Thailand,
Burma, Cambodia, and the Amazon basin area of South America, and
resistance has also been reported in sub-Saharan Africa. Resistance to
mefloquine has been confirmed in Thailand along the borders with
Cambodia and Burma.
Worms
Worms are parasites common in rural, tropical areas.
They can be present on unwashed vegetables or in undercooked meat and
you can pick them up through your skin by walking in bare feet.
Infestations may not show up for some time, and although they are
generally not serious, if left untreated they can cause severe health
problems.A stool test is necessary to pinpoint the problem and
medication is often available over the counter.
Tetanus
Tetanus, also known as lockjaw, is an infection caused by wounds
contaminated by Clostridia bacteria, a germ which lives in the feces of
animals and people. It occurs worldwide.
It is important to clean all cuts, punctures or animal bites.
The first symptom of the disease may be discomfort in swallowing or
stiffening of the jaw and neck; this is followed by painful convulsions
of the jaw and whole body, and death.
The disease is preventable with a vaccination, and then a booster given
every 10 years.
Hepatitis A
Hepatitis A is an enterically transmitted viral disease, highly endemic
throughout the developing world, where standards of sanitation are poor.
In developing countries, hepatitis A virus (HAV) is usually acquired
during childhood. Most frequently the children either are asymptomatic
or they develop mild infections, resulting in the development of
life-long immunity.
Transmission may occur by direct person-to-person contact, from
contaminated water, ice, or shellfish harvested from sewage-contaminated
water, or from fruits, vegetables or other foods which are eaten
uncooked, but which may become contaminated during handling.
Symptoms include fatigue, fever, loss of appetite, nausea, dark urine,
jaundice, vomiting, aches and pains, and light stools. No specific
therapy is available.
For travelers to developing countries, risk of infection increases with
the duration of travel, and is highest for those who live in or visit
rural areas, trek in back country, or frequently eat or drink in
settings of poor sanitation.
Travelers are at high risk for Hepatitis A, especially if travel plans
include visiting rural areas and extensive travel in the countryside,
frequent close contact with local persons, or eating in settings of poor
sanitation.
A study has shown that many cases of travel-related hepatitis A occur in
travelers to developing countries with "standard" itineraries,
accommodations, and food consumption behaviors.
In developing countries, travelers should minimize their exposure to
hepatitis A and other enteric diseases by avoiding potentially
contaminated water or food. Travelers should avoid drinking water (or
beverages with ice) of unknown purity and eating uncooked shellfish or
uncooked fruits or vegetables that are not peeled or prepared by the
traveler.
Hepatitis A virus is inactivated by boiling or cooking to 185°F or 85°
C for 1 minute, therefore eating thoroughly cooked foods and drinking
only treated water serve as general precautions. Cooked foods may serve
as vehicles for disease if they are contaminated after cooking. Adequate
chlorination of water as recommended in the U.S. will inactivate HAV.
This is a very infectious virus, so if there is risk of exposure,
injection with gammaglobulin (IG) or vaccination with Havrix -- the
hepatitis A vaccine currently licensed for use in the US -- is
recommended. Gammaglobulin is an injection of antibodies to hepatitis A,
providing immunity for a limited time. Havrix is a vaccine which causes
the traveler to develop his or her own antibodies, giving long-lasting
immunity.
Hepatitis A vaccine is recommended for persons who plan to travel
repeatedly or reside for long periods of time in intermediate or high
risk areas. Immune globulin should be used for travelers under 2 years
of age, and is recommended for any person who desires only short term
protection.
CDC recommends hepatitis A vaccine or IG for protection against
hepatitis A. For travelers over 18 years of age, hepatitis A vaccine
should be given in a two dose series with the second dose administered
6-12 months after the first. For children and adolescents (2-18 years),
a three dose series of hepatitis A vaccine is recommended; the second
dose is given 1 month after the first dose and the third dose 6-12
months after the first dose.
Travelers can be considered to be protected four weeks after receiving
the initial vaccine dose. IG should also be given if vaccine is
administered less than four weeks before travel. The vaccine series must
be completed for long-term protection.
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