U.S. Agency for International Development Office of U.S. Foreign Disaster Assistance

1. U.S. Agency for International DevelopmentOffice of U.S. Foreign Disaster Assistance Staying Healthy Overseas

2. Discussion Topics • Pre and post travel health visits • Your health record • Immunizations • Essential health items to pack • Health services while abroad • Your health behavior while abroad • Diarrheal Diseases • Vector-borne diseases • Other health hazards • Shared experiences and tips

3. Pre-travel Health Care • Establish a relationship with a travel health practitioner. • “At least 6-8 weeks prior to departure.” • Immunizations for “globally availability.” • Anti-malarials & other prescription items. • Advice on other aspects of travel health. • International health clinics & resources • Maintenance checks before “hitting the road” (e.g., general health, dental, eyes).

4. International Travel Insurance • Emergency Evacuation • In-country Medical Expenses • Outpatient • Ambulance • Inpatient • Intensive Care • Dental • Other Coverages

5. Post-Travel Health Care • Continue anti-malarial medication as prescribed (usually for 4 weeks after return). • See your physician if you develop the following within 1 year: fever, chills, headache, nausea, abdominal pain, diarrhea. • Seek medical care for any other acute and/or chronic symptoms (i.e., skin conditions, neuro-psychiatric, urinary, etc.) that occur after return.

6. “Yellow Card” Vaccination record Available @ health clinics that provide international travel health care services. Leave a photocopy with Health Team Keep on hand when traveling. Your Health Record

7. Health History • Essential information to record in your “Yellow Card” or passport: • Eyeglass prescription • Emergency Contact • Blood type • Chronic medications • Allergies • Food • Insect • Drug • Seasonal

8. Which Vaccines Are Needed? • Some vaccines are recommended in any setting. • Others may vary from place to place. • Consult : • your travel health practitioner • OFDA health team • WWW.CDC.GOV Traveler’s Health

9. International Health Regulations • A certificate of cholera immunization is no longer required by any country. • 1973 amendment by World Health Assembly • A certificate of yellow fever immunization is required by many countries for travelers arriving from infected areas (e.g. Africa, South America). • Vaccine is highly efficacious. • Vaccine must be WHO-approved & administered at an approved center. • Certificate is valid for 10 years starting 10 days after vaccination.

10. Up-to-Date Routine Vaccines • Tetanus/Diphtheria • Booster every 10 years after primary series • Polio • 1 dose in adult life after primary series depending on area of travel • Measles • Based on previous vaccination history or titer.

11. Up-to-Date Routine Vaccines • Influenza • One dose each year before flu season. • Flu season varies: • USA: Nov. - March • Southern Hemisphere: April - Sept. • Tropics: Throughout the year

12. For Travel to Areas Where Sanitary Conditions are Poor • Hepatitis A • 2 doses (@ 0, 6-18 months) • Consider for any travel to a developing country

13. For Travel to Areas Where Sanitary Conditions are Poor • Typhoid • 1 dose every 2 years (injection), or 1 capsule every other day X4 doses every 5 years [Note: the oral capsule is less convenient and its effectiveness may be decreased by simultaneous administration of antibiotics and antimalarials]. For travelers staying in areas of questionable sanitation.

14. For Travel to Remote Areas or Areas w/ Special Risks • Hepatitis B • 3 doses (@ 0, 1 & 6 months) • Long-term travelers (>6mo) or ANY traveler who may have contact with blood or body fluids • Yellow Fever • 1 dose every 10 years • May be required by country of destination. Endemic in Latin America & Central Africa

15. For Travel to Remote Areas or Areas w/ Special Risks • Japanese Encephalitis • 3 doses @ 0, 7 & 30 days, booster every 2-3 years • Risk areas include all of India, the Indian Subcontinent and Western Pacific. • Risk varies by season and geographic location.

16. For Travel to Remote Areas or Areas w/ Special Risks • Meningococcal (serotypes A, C, Y, W-135) • 1 dose, booster every 3-5 years • Countries in and around the “meningitis belt” in Sub-Saharan Africa. • mostly serotypes A & C • Epidemics common during dry season (Dec - June) • Increased risk among mass gatherings/displaced populations.

17. For Travel to Remote Areas or Areas w/ Special Risks • Rabies • Prophylaxis: • pre-exposure: 4 doses @ 0, 7, 21 & 28 days • booster every 2-5 years based on titers • If bitten by an animal with known or suspected rabies: • if prior vaccination, 2 doses on days 0 & 3 • if no prior vaccination, Rabies Immune globulin followed by 5 doses (@ days 0, 3, 7, 14, 21)

18. Immunization Tips • Many vaccines require multiple doses and time to take effect -- PLAN AHEAD!! • Aim to be “globally available” • Who Pays? - Depends on hiring scheme. i.e. PSC, Direct Hire, Military • Where to get? - State Department Clinic, Travel Clinics, Private Plans. • Other types of prevention should always be practiced to prevent transmission of infectious diseases.

19. Don’t Forget • Prescription Medications • Adequate supply • Divided supply among two pieces of luggage. • **Keep in original, labeled prescription bottles** • Carry a copy of practitioner’s medical prescription. • Spare Eyeglasses/Contact lenses • Copies of important documents (e.g., Passport, Health Insurance Papers, Yellow Card) • MedEvac insurance

20. Items to Discuss with Your Travel Health Practitioner • “Allergy Kit” (i.e. Ana-Kit, Epi-Pen) • Prescription antihistamines • May not cause drowsiness. • Antibiotics for moderate and severe diarrhea. • Sterile Syringes and needles • Carry a medical certificate of explanation.

21. “Know Yourself” • Malaria Prophylaxis • Condoms • Feminine Hygiene/Vaginal Antifungal • Sunscreen (also a hat, sunglasses, etc.) • Soap • Shampoo • Other…

22. Use Common Sense • This is not “home” • Laws and Customs/Culture are different • Medical Services available are different • Many items may not be available or the quality may be questionable. • That dog or cat is probably not someone’s pet or vaccinated • Take Nothing For Granted!

23. Health Services While Abroad • Different standards may exist. • Blood supply, sterility of instruments • Payment is often required up front. • Consult the embassy for recommended facilities if needed. • Unreliable availability and quality of pharmaceuticals. • Medevac insurance is wise.

24. Taking Care of Yourself:“Accidents & injuries kill more travelers than exotic infectious diseases.” • Wear a seatbelt • Drink in moderation • Jog/walk in safe places • Be aware of your surroundings and those around you • Know your quarters - door locks, smoke detectors, balconies, emergency exits

25. STRESS • Take time to unwind • Run • Walk • Read • Radio • Play

26. Coping With Stress • Listen to your body • How do you exhibit being stressed? • How do you cope with stress? • Minimize Jet Lag • Talk with colleagues • Do you need someone else to talk to • Critical Incidence Stress Debriefing (CISD) • Stress will have an effect at both the individual and team level

27. Preventive Health Practices

28. Handwashing • Single-most important means of preventing the spread of infection • Soap & water • Before eating, return to quarters, whenever possible

29. Food Safety • Think before you eat or drink!!

30. Food • Choose fruits & vegetables that can be peeled. • Avoid unpasteurized dairy products • Avoid raw or uncooked foods except for fruits & vegetables

31. Food • Avoid food from street vendors • Piping hot food is safer • Baked goods are safer • Avoid using ice • Avoid using table condiments • Ask for restaurant recommendations

32. Fluid Intake • Avoid tap water if possible • Contaminants could include bacteria, viruses, organic chemicals, heavy metals. • Use bottled water - ensure it is sealed • If unsure of water source use bottled water for toothbrushing and washing. • Treat any drinking water that is not bottled. • Coffee, tea, beer, wine and soda are suitable choices - best to drink from original container

33. Boiling - most reliable, not always convenient. Vigorous, rolling boil for 1 minute - let cool to room temperature If at altitude (>6,562 ft [2km]) boil for 3 minutes or use chemical disinfection Portable Filter or Purification Unit May not filter out viruses. Chemical Disinfection with iodine tablets Follow manufacturer’s instructions carefully Water Treatment

34. Diarrheal Diseases • Most common health problem among travelers to developing countries. • Different causes: • Viral (rotavirus) • Bacterial (cholera, shigellosis, E. coli) • Protozoal (giardiasis) • Stress • Other • Treat according to type.

35. Categorizing Diarrhea • Mild: up to 3 loose stools per day; no fever or blood in stools. Treat w/ loperamide & diet. • Moderate: >3 loose stools per day; no fever or blood in stools. Treat w/ loperamide, antibiotics & diet. • Severe: loose, bloody stools with fever or copious, rice water stools. Avoid antidiarrheals. Treat w/antibiotics. Seek medical care. • ALL FORMS SHOULD BE TREATED WITH REHYDRATION!

36. Vectors of Disease • Mosquitoes • Ticks • Flies • Snails • Fleas, lice and mites

37. Mosquitoes • Different species transmit different diseases • malaria • yellow fever • dengue • filariasis • Japanese encephalitis • Night biters vs. day biters • Breeding areas vary by species. • Urban vs. rural

38. Malaria • 4 protozoan species: • P. falciparum • P. vivax • P. ovale • P. malariae • Transmitted by Anopheles mosquitoes. • Bite between sunset and sunrise. • Breed in sunlit streams, shaded lagoons, rice fields & marshes. • Disease is characterized by: • Fever, chills, sweats • Flu-like symptoms • P. falciparum may progress to disorientation, delirium, coma, etc.

39. Malaria • Priority: Prevention • Is malaria present? See www.cdc.gov site. • Are drug-resistant strains present? • Prophylaxis - both personal & environmental • Prescription medication • Long pants/Long-sleeved shirts • Insect Repellant • Netting treated with insecticide (i.e. Permethrin) • Awareness of possible breeding grounds • Limit night-time outdoor activity

40. Anti-malarial Prophylaxis • Chloroquine • 300 mg base/week starting 2 weeks before, for duration of stay & for 4 weeks after. • For non-chloroquine resistant areas. • Mefloquine • 250 mg/week starting 2 weeks before, for duration of stay & for 4 weeks after. • Avoid if history of seizures, psychiatric disorders or cardiac condition. • Doxycycline • 100 mg/day starting 1-2 days before, daily while there & daily for 4 weeks after.

41. Vectors • Ticks • typhus • Lyme disease • paralysis • relapsing fever

42. Vectors • Flies • diarrhea • sleeping sickness • leishmaniasis

43. Vectors • Snails • Native to fresh water • Intermediate host of schistosomiasis • Second most prevalent tropical disease

44. Vectors • Fleas, Lice, & Mites • bubonic plague • scabies • typhus • secondary infection

45. Others to Avoid • Snakes • Scorpions • Spiders • “Domestic” animals • Poisonous/Stinging plants • poison ivy • stinging nettles

46. Vector Protection • Long pants/Long-sleeved shirts • DEET (30% - 40%) or other insect repellant • Permethrin treated bed netting • Permethrin treated outer clothing, especially pants legs & waist, shirt sleeves & collars • Hard-soled, closed-toe shoes • Avoid areas of long grass, heavy brush • Avoid wading in rivers, lakes, or streams • if unavoidable, immediate and vigorous towel drying may help

47. Environment • Sun Exposure • Sunburn • Heat Exhaustion • Heat Stroke • Winter

48. Avoid sun exposure during the height of the day Wear protective, loose-fitting clothing long pants/skirt and long-sleeved shirt hat sunglasses Apply sunscreen Minimum SPF 15 (30 or higher recommended) Apply 30 minutes before exposure & reapply liberally UVA & UVB protection Sunburn

49. Exhaustion dizzy, fatigue headache pale & clammy fast, shallow breathing muscle cramps intense thirst Rehydrate Stroke Medical Emergency hot, dry, flushed skin no sweating high body temperature rapid heartbeat confusion loss of consciousness Cool Heat Exhaustion and Stroke

50. Exposure to Cold • Wear Multiple Layers - loose fitting • Proper fitting footwear • Hat and mittens - 40% of heat lost through head • Hydrate