1999 NE VOSH Travel Advisory
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. Enhanced precautions this year can keep those risks to a minimum.

We will be working in Masatepe and staying in Granada. Both of those towns were spared the flooding, mudslides, and other disastrous sequelae of Hurricane Mitch. The greater devastation was towards the northern region of Nicaragua. The worst disease outbreaks will be confined to those areas but there will be pockets and smaller outbreaks throughout Central America as displaced, homeless refugees export certain illnesses with them. Specific illnesses such as leptospirosis should be confined only to the devastated
regions.

Joe D'Amico's VOSH group will see more direct damage in San Juan del Sur.


What to expect:

You can expect to see some added pathos. You might see patches of devastation: roads and bridges washed out; communities destroyed. I would imagine that there will be many more displaced homeless refugees in Granada with a significant rise in begging. My contacts have not reported any increase in crime. There will be a significantly increased risk of mosquito-borne illnesses: malaria and dengue fever. Last year I took a straw vote
regarding malaria: 50% of participants were not taking medicine. This year the choice is not really optional... You will hear of outbreaks of leptospirosis, typhoid fever, and cholera elsewhere in the country.

Granada has, or at least had, a relatively safe municipal water supply.

At the clinic, your patients will have increased incidence of conjunctivitis, skin rashes, and diarrhea. And they will still need eyeglasses and bless you when you are done...


Summary of recommendations (detailed explanations in next section):

strongly recommend:

Diptheria/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.


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, ie: 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 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.
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.
   

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 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.


What I can and cannot supply:

    I will have oral antibiotics including doxycycline, penicillin, and cipro with me for your use.
    I will not be able to provide any intravenous medicine or fluids nor will I be equipped to treat, other than initialize treatment of, any true emergencies.
    I cannot supply choroquine; you need to initiate one week before travel.
    I will have a supply of lomotil for diarrhea. If you prefer imodium, please bring your own supply.


Disclaimer:

Under no circumstances can I or 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



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

CDC on travel vaccines

CDC on Hepatitis A

State Department advisory on Nicaragua

Med College Wisconsin Int'l Travel Page

WHO (World Health Org.) Control of Tropical Diseases

Annals of Internal Medicine: Mosquitoes and Mosquito Repellents

Moon travel books: Staying Healthy in Asia, Africa, and Latin America

Be careful out there.

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

CDC on travel vaccines

CDC on Hepatitis A

State Department advisory on Nicaragua

Med College Wisconsin Int'l Travel Page

WHO (World Health Org.) Control of Tropical Diseases

Annals of Internal Medicine: Mosquitoes and Mosquito Repellents

Moon travel books: Staying Healthy in Asia, Africa, and Latin America

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