VOSH Travel Advisory -- 2000



Introduction:

During the best of times, travel to any third-world country entails risk due to poor sanitary conditions and health infrastructure. Natural disasters such as flooding enhance those risks and introduce new ones. Taking appropriate precautions can keep those risks to a minimum.

This will be the thirteenth NE VOSH mission to Central America and fortunately the worst illness, to our knowledge, suffered has been self-limited gastrointestinal illness.

We will be working this year in La Concepcion and staying in Jinotepe. Both of these towns were spared the flooding, mudslides, and other disastrous sequelae of Hurricane Mitch one year ago.


What to expect:

For those of you who were with us last year, Jinotepe is located along the Masaya-Niquinohomo-Masatepe road, about another 10 miles beyond Masatepe. La Concepcion is about 10 miles further on with the town of San Marcos, home of a campus of the University of Mobile (Alabama) in between. This is an agricultural, coffee growing region with a climate similar to Masatepe; i.e. without the overwhelming heat and humidity of the low lying cities such as Managua and Granada.

Again this year, there will be a significantly increased risk of mosquito-borne illnesses: malaria and dengue fever. Two years ago I took a straw vote regarding malaria: 50% of participants were not taking medicine. This year as was last, the choice is not really optional...

The towns in which visit will be far less urban than those we have visited in the past. In addition to dodging motorized taxis, you will need to be on the lookout for runaway ox-carts!


Summary of recommendations (detailed explanations in next section):

STRONGLY RECOMMEND:

· Diphtheria/tetanus booster: every 10 years
· Malaria prophylaxis with CHLOROQUINE
· Hepatitis A prophylaxis: either Hep A Vaccine or gamma globulin
· Hepatitis B vaccine
· Oral typhoid fever vaccine
· Mosquito repellents
· Food/drink precautions
· Container of hand-wipes
· Food/drink precautions (reviewed below)

Needed vaccinations should be obtained as soon as possible.

Please note that polio booster is not recommended; polio is not endemic in Nicaragua. Furthermore, with the exception of people sneezing on the flight down, there will be no increased risk of influenza during this mission


Detailed explanations:

Diphtheria/tetanus booster: needed every 10 years


Malaria:

Spread by the bite of specific species of mosquito infected with malaria, a protozoan.

Prophylaxis: use CHLOROQUINE; first tab one week before travel, then one tab a week for 4 weeks following return.


Typhoid fever:

Caused by a subspecies of Salmonella, a bacterium

Like cholera, obtained by ingestion of food/drink contaminated by sewage, i.e.: oral/fecal

Oral typhoid fever vaccine: one capsule every other day for 4 doses recommended
Immunity lasts 5 years


Hepatitis A:

Caused by a virus that is never fatal nor becomes chronic (unlike hep B).

Route: oral/fecal

If this will be your only "adventure-trip" only, a shot of gamma globulin, which offers protection for 1 trip only, 1 to 2 weeks before travel.

If you plan to become a "third-world hand", obtain IM hepatitis A vaccine.

Vaccination must take place more than 1 month before travel, otherwise additional gamma globulin is needed and must be used before each trip.
Hepatitis A vaccine booster in 6 to 12 months -- immunity thought to last 20 years


Hepatitis B:

Caused by a virus that can be acutely fatal or cause chronic illness that is fatal in 10-20 years.

Route: parenteral/sexual; same pattern as the HIV virus but far more virulent

Recommended for third world travelers, sexually promiscuous persons, and all health care workers.

Now offered as routine pediatric immunization

Vaccination is intramuscular; a series of three injections. Duration of protection unknown and need for boosters not fully defined.


Cholera:

A bacterium of the Vibrio family.

Route: oral/fecal

A vaccine is available but not exceptionally effective. Food/drink precautions recommended.


Dengue fever:

A virus spread by the bite of a day-biting species of mosquito. No vaccine available. Use mosquito repellents.


Leptospirosis:

Caused by a spirochete excreted in urine by animals. Enters the bodies of humans when exposed to contaminated mud or streams. Often endemic in flood regions. Prophylactic doxycycline often effective.


"Parasites"

Worms, amoebae, giardia etc transmitted when eggs or cysts in passed in feces are ingested.

Symptoms are generally subacute in nature, and will not begin until after return to US.


Traveler's diarrhea:

Assorted viruses and bacteria cause acute and subacute symptoms.


Mosquito repellents:

Popular Skin-so-Soft® is NOT effective as a mosquito repellent. I recommend using an agent with DEET.

Must use during day to minimize risk of contracting dengue fever.


VOSH MEDICAL DEPARTMENT:

This component of our organization has grown dramatically over the past several years. I am pleased to announce that this year we will have a contingent of at least 3 physicians, 2 physician assistants, and 1 nurse-practitioner. We will also have at least 3 nurses and again will run a small pharmacy. There might also be a participating ophthalmologist as well!

We will have oral antibiotics including doxycycline, penicillin, and cipro with us for your use.

We will not be able to provide any intravenous medicine or fluids nor will we be equipped to treat, other than initialize treatment of, any true emergencies. There is a small hospital in Jinotepe, which, I hope, none of us will need.

We cannot supply chloroquine; you need to initiate one week before travel.

We will have a supply of lomotil for diarrhea. If you prefer imodium, please bring your own supply.


Disclaimer:

Under no circumstances can we nor VOSH be held responsible for any problems that occur during travel.

The above discussion contains my personal recommendations, but the final decision is that of yourself and your personal physician.


Bueno viaje y buena suerte,

Stu Zipper, M.D.
Medical Director, VOSH Northeast

18 November 1999



Common sense food/drink advice (courtesy of the CDC):

"Boil it, cook it, peel it, or forget it"

•If you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water.

•Ask for drinks without ice unless the ice is made from bottled or boiled water. Avoid popsicles and flavored ices that may have been made with contaminated water.

•Eat foods that have been thoroughly cooked and that are still hot and steaming.

•Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.

•When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings.

•Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors.





Further internet information:

please read these:

CDC: Travel to Central America

CDC: Traveler's Diarrhea


Ancillary info:

CDC home page: index.htm at www.cdc.gov

CDC on travel vaccines: Vaccine Recommendations

CDC on Hepatitis A: hepatitis A

State Department advisory: Nicaragua - Consular Information Sheet

Med College Wisconsin Int'l Travel Page: MCW International Travelers Clinic

WHO (World Health Organization): WHO Division of Control of Tropical Diseases ...

Annals of Internal Medicine: Mosquitoes and Mosquito Repellents

From Moon travel books: Staying Healthy in Asia, Africa, and Latin Am...

Travel Health Online:
Travel Health Online: Nicaragua

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