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Health On the Road: Part 3 (of 4)

Health Tips

Compliments of: "Travel With Children" by Maureen Wheeler (Lonely Planet Publications, 155 Filbert Street, Suite 251, Oakland, CA 94607. $11.95)


INFECTIOUS DISEASES:


DIARRHEA

A change of water, food or climate can all cause the runs; diarrhea caused by contaminated food or water is more serious. Totally breast-fed babies are normally safe but despite all your precautions older children may still have a bout of mild travelers' diarrhea. A few rushed toilet trips with no other symptoms is not indicative of a serious problem. Moderate diarrhea, involving half-a-dozen loose movements in a day, is more of a nuisance. 7However, any diarrhea in babies and small children should be considered serious.

Dehydration is the main danger with any diarrhea, particularly for children where dehydration can occur quickly. Fluid replacement remains the mainstay of management. Weak black tea with a little sugar, soda water, or soft drinks allowed to go flat and diluted 50% with water are all good. With severe diarrhea a rehydrating solution is necessary to replace minerals and salts. Commercially available ORS (oral rehydration salts) is very useful; add the contents of one sachet to a liter of boiled or bottled water. In an emergency you can make up a solution of eight teaspoons of sugar to a liter of boiled water and provide salted cracker biscuits at the same time. Your children should be kept on a bland diet as they recover.

Lomotil or Imodium can be used to bring relief from the symptoms of diarrhea, although they do not actually cure the problem. Only use these drugs if absolutely necessary: when you must travel. For children it is preferable to use Imodium, but under all circumstances fluid replacement is the main message. Do not use these drugs if the child has a high fever or is severely dehydrated.

The recommended drugs (adults only) would be either norfloxacin (Noroxin) 400 mg twice daily for three days or ciprofloxacin (Ciproxin) 500 mg twice daily for three days.

The drug bismuth subsalicylate has also been used successfully. It is not available in Australia. The dosage for adults is two tablets or 30 ml. and for children it is one tablet or 10 ml. This dose can be repeated every 30 minutes to one hour, with no more than eight doses in a 24-hour period.

The drug of choice for children would be co-trimoxazole (Bactrim, Septrin, Resprim) with dosage dependent on weight. A three-day course is also given.

Ampicillin has been recommended in the past and may still be an alternative.

ANTIBIOTICS FOR DIARRHEA

Use antibiotics for the treatment of diarrhea in the following instances:

Watery diarrhea with blood and mucus. (Gut-paralyzing drugs like Imodium or Lomotil should be avoided in this situation.)

Watery diarrhea with fever and lethargy.

Persistent diarrhea for more than five days.

Severe diarrhea, if it is logistically difficult to stay in one place.

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 and ameobic.

Bacillary dysentery 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.

Ameobic 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 ameobic dysentery.

For bacillary dysentery, norfloxacin 400 mg twice daily for seven days or ciprofloxacin 500 mg twice daily for seven days are the recommended dosages.

If you're unable to find either of these drugs then a useful alternative is co-trimoxazole 160/800 mg (Bactrim, Septrim, Resprim) twice daily for seven days. this is a sulfa drug and must not be used in people with a known sulfa allergy. In the case of children the drug co-trimoxazole is a reasonable first line treatment.

For amebic dysentery, the recommended adult dosage of metronidazole (Flagyl) is one 400 mg capsule three times daily for five to seven days. Children aged between eight and 12-years-old should have half the adult dose; the dosage for younger children is one-third the adult dose.

An alternative to Flagyl is Fasigyn, taken as a two gram single daily dose for three days. For children under 12-years-old the dosage is 50 mg per kg of body weight, so if your child weighs 20 kg the dose is 1000 mg (one gram) per day. Adults should avoid alcohol during treatment and for 48 hours afterwards.

CHOLERA

Cholera vaccination is not very effective. The bacteria responsible for this disease are waterborne, so that attention to the rules of eating and drinking should protect the traveler.

Outbreaks of cholera are generally widely reported, so you can avoid such problem areas. The disease is characterized by a sudden onset of acute diarrhea with "rice water" stools, vomiting, muscular cramps, and extreme weakness. You need medical help - but treat for dehydration, which can be extreme, and if there is an appreciable delay in getting to hospital begin taking tetracycline.

The adult dose is 250 mg four times daily. For children eight to 12-years-old the dose is 25 mg per kg. of body weight four times daily. It is not recommended for children aged eight years or under nor for pregnant women. An alternative drug is ampicillin, for which the adult dose is 250 mg four times a day. Children aged eight to 12-years-old should take talk the adult dosage, children under eight-years-old one-third the adult dosage.

Remember that while antibiotics might kill the bacteria, it is a toxin produced by the bacteria which causes the massive fluid loss. Fluid replacement is by far the most important aspect of treatment.

VIRAL GASTROENTERITIS

This is caused not by bacteria but, as the name suggests, by a virus. It is characterized by stomach cramps, diarrhea, and sometimes by vomiting and/or slight fever. All you can do is rest and drink lots of fluids.

HEPATITIS

Hepatitis is a general term for inflammation of the liver. There are many causes of this condition: drugs, alcohol and infections are but a few.

The discovery of new strains has led to a virtual alphabet soup, with hepatitis A, B, C, D, E and a rumored G. These letters identify specific agents that cause viral hepatitis. Viral hepatitis is an infection of the liver, which can lead to jaundice (yellow skin), fever, lethargy and digestive problems. It can have no symptoms at all, with the infected person not knowing that they have the disease. Travelers shouldn't be too paranoid about this apparent proliferation of hepatitis strains; hep C, D, E and G are fairly rare (so far) and following the same precautions as for A and B should be all that's necessary to avoid them.

HEPATITIS A (HAV)

This is a very common disease in most countries, especially those with poor standards of sanitation. Most people in developing countries are infected as children; they often don't develop symptoms, but do develop life-long immunity. The disease poses a real threat to the traveler, as people are unlikely to have been exposed to hepatitis A in developed countries.

The symptoms are fever, chills, headache, fatigue, feelings of weakness and aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light colored feces, jaundiced skin and the whites of the eyes may turn yellow. In some cases you may feel unwell, tired, have no appetite, experience aches and pains and be jaundiced. You should seek medical advice, but in general there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods. People who have had hepatitis must forego alcohol for six months after the illness, as hepatitis attacks the liver and it needs that amount of time to recover.

The routes of transmission are via contaminated water, shellfish contaminated by sewage, or foodstuffs sold by food handlers with poor standards of hygiene.

Taking care with what you eat and drink can go a long way towards preventing this disease. But this is a very infectious virus, so if there is any risk of exposure, additional cover is highly recommended. This cover comes in two forms: Gamma-globulin and Havrix. Gamma-globulin is an injection where you are given the antibodies for hepatitis A, which provide immunity for a limited time. Havrix is a vaccine, where you develop your own antibodies, which gives lasting immunity.

HEPATITIS E (HEV)

This is a very recently discovered virus, of which little is yet known. It appears to be rather common in developing counties, generally causing mild hepatitis, although it can be very serious in pregnant women.

Care with water supplies is the only current prevention, as there are no specific vaccines for this type of hepatitis. At present it doesn't appear to be too great a risk for travelers.

The following strains are spread by contact with blood and bodily fluids:

HEPATITIS B (HBV)

This is also a very common disease, with almost 300 million chronic carriers in the world. Hepatitis B, which used to be called serum hepatitis, is spread through contact with infected blood, blood products or bodily fluids, for example through sexual contact, unsterilized needles and blood transfusions. Other risk situations include having a shave or tattoo in a local shop, or having your ears pierced. The symptoms of type B are much the same as type A except that they are more severe and may lead to irreparable liver damage or even to liver cancer. Although there is no treatment for hepatitis B, a cheap and effective vaccine is available; the only problem is that for long-lasting cover you need a six-month course. The immunization schedule requires two injections at least a month apart followed by a third dose five months after the second. Persons who should receive a hepatitis B vaccination include anyone who anticipated contact with blood or other bodily secretions, either as a health-care worker or through sexual contact with the local population, particularly those who intend to stay in the country for a long period of time.

HEPATITIS C (HCV)

This is another recently defined virus. It is a concern because it seems to lead to liver disease more rapidly than hepatitis B.

The virus is spread by contact with blood - usually via contaminated transfusions or shared needles. Avoiding these is the only means of prevention, as there is no available vaccine.

HEPATITIS D (HDV)

Often referred to as the "Delta" virus, this infection only occurs in chronic carriers of hepatitis B. It is transmitted by blood and bodily fluids. Again there is no vaccine for this virus, so avoidance is the best prevention. The risk to travelers is limited.

TYPHOID

Typhoid fever is another gut infection that travels the fecal-oral route, which means that contaminated water and food are responsible. Vaccination against typhoid is not totally effective and it is one of the most dangerous infections, so medical help must be sought.

In its early stages typhoid resembles many other illnesses: your child may feel like they have a bad cold or flu on the way, as early symptoms are a headache, a sore throat, and a fever which rises a little each day until it is around 40 degrees Celsius or more. The patient'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. There may also be vomiting, diarrhea or constipation.

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. If there are no further complications, the fever and other symptoms will slowly go during the third week. However you must get medical help before this because pneumonia (acute infection of the lungs) or peritonitis (perforated bowel) are common complications, and because typhoid is very infectious.

The fever should be treated by keeping the child cool and dehydration should also be watched for.

The drug of choice is ciprofloxacin (Ciptoxin) at a dose of one gram daily for 14 days. It is quite expensive and may not be available. The alternative, chloramphenicol, has been the mainstay treatment for years. In many countries it is still the recommended antibiotic, but there are fewer side affects with ampicillin. The adult dosage is two 250 mg capsules, four times daily. Children aged between eight and 12 years old should have half the adult dosage, younger children should have one-third the adult dose. People who are allergic to penicillin should not be given ampicillin.

WORMS

These parasites are most common in rural, tropical areas and a stool test when you return home is not a bad idea. They can be present on unwashed vegetables or in undercooked meat and you can pick them up by walking in bare feet. Infestations may not show up for some time and although they are generally not serious, they can cause severe health problems if left untreated. A stool test is necessary to pinpoint the problem and medication is often available over the counter.

Children often get worms, even at home, so it may be a good idea to carry some worm treatment and pay attention if your children complain of an "itchy bottom", are very restless while sleeping, wake up often, or go off their food. Talk to your doctor about it before you go.

TETANUS

This potentially fatal disease is found in underdeveloped tropical areas. It is difficult to treat but is preventable with immunization. Tetanus occurs when a wound becomes infected by a germ which lives in the feces of animals or people, so clean all cuts, punctures or animal bites. Tetanus is also known as lockjaw, and the first symptom may be discomfort in swallowing, or stiffening of the jaw and neck; this is followed by painful convulsions of the jaw and whole body.

RABIES

Rabies is found in many countries and is caused by a bite or scratch by an infected animal. Dogs, monkeys, cats and bats are noted carriers. Any bite, scratch or even lick from a warm-blooded, furry animal should be cleaned immediately and thoroughly. Scrub with soap and running water, and then clean with an alcohol solution. If there is any possibility that the animal is infected, medical help should be sought immediately. Even if the animal is not rabid, all bites should be treated seriously as they can become infected or can result in tetanus.

A rabies vaccination is available and should be considered in high-risk situations - if you intend to explore caves where there are bats, or work with animals. Make it clear to your children that animals are to be left alone.

MENINGOCOCCAL MENINGITIS

Sub-Saharan Africa is considered the "meningitis belt" and the meningitis season occurs at the time most people would be attempting the overland trip across the Sahara - the northern winter before the rains come. Other areas which have recurring epidemics are Mongolia, Vietnam, Brazil, the Nile Valley and Nepal.

Trekkers to rural areas of Nepal should be particularly careful, as the disease is spread through coughs and sneezes by people who may not be aware that they are carriers. Lodges in the hills where travelers spend the night are prime spots for the spread of infection.

This very serious disease attacks the brain and can be fatal. A scattered, blotchy rash, fever, severe headache, sensitivity to light and neck stiffness which prevents forward bending of the head are the first symptoms. Death can occur within a few hours, so immediate treatment is important.

TUBERCULOSIS (TB)

Although this disease is widespread in many developing countries, it is not a serious risk to travelers. Young children are more susceptible than adults and vaccination is a sensible precaution for children under 12-years-old traveling for extended periods in endemic areas. TB is commonly spread by coughing or by ingesting unpasteurized dairy products from infected cows. Milk that has been boiled is safe to drink; the fermentation of milk to make yogurt or cheese also kills the bacilli.

BILHARZIA

Bilharzia is carried in fresh water by minute worms. The larvae infect certain varieties of freshwater snails, found in rivers, streams, lakes and particularly behind dams. The worms multiply and are eventually discharged into the water surrounding the snails.

The worm enters through the skin, and the first symptom is herpes.

DIPHTHERIA

Diphtheria can be a skin infection or a more dangerous throat infection. It is spread by contaminated dust contacting the skin or by the inhalation of infected cough or sneeze droplets. Frequent washing and keeping the skin dry will help prevent skin infection. A vaccination is available to prevent the throat infection.

SEXUALLY TRANSMITTED DISEASES

Sexual contact with an infected sexual partner spreads these diseases. While abstinence is the only 100% effective prevention, using condoms is also effective. Gonorrhea and syphilis are the most common of these diseases. Sores, blisters or rashes around the genitals, discharges or pain when urinating are common symptoms. Symptoms may be less marked or not observed at all in women. Syphilis symptoms eventually disappear completely but the disease continues and can cause severe problems in later years. The treatment of ghonorrea and syphilis is by antibiotics.

There are numerous other sexually transmitted diseases, for the most of which effective treatment is available. However, there is currently no cure for AIDS.

HIV/AIDS

HIV, the Human Immunodeficiency Virus, may develop into AIDS, Acquired Immune Deficiency Syndrome. HIV is a major problem in many countries. Any exposure to blood, blood products or bodily fluids may put the individual at risk. In many developing countries transmission is predominately through heterosexual sexual activity. This is quite different from industrialized countries where transmission is mostly through contact between homosexual or bisexual males, or via contaminated needles shared by IV drug users, though heterosexual transmission is becoming more common with each passiong day. Apart from abstinence, the most effective preventative is always to practice safe sex using condoms. It is impossible to detect the HIV-positive status of an otherwise healthy-looking person without a blood test.

HIV/AIDS can also be spread through infected blood transfusions; most developing countries cannot afford to screen blood for transfusions. It can also be spread by dirty needles - vaccinations, acupuncture, tattooing and ear or nose piercing can potentially be as dangerous as intravenous drug use if the equipment is not clean. If you do need an injection, ask to see the syringe unwrapped in front of you, or better still, take a needle and syringe packed with you overseas - it is a cheap insurance package against infection with HIV.

Fear of HIV infection should never preclude treatment for serious medical conditions. Although there may be risk of infection, it is very small indeed.

(Remember to check out Parts 1, 2 and 4 of this article.)

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