Ask Gadling: You develop a serious illness while traveling

by Laurel Miller on

The very thought of acquiring a serious illness or injury while traveling strikes fear into the hearts of even the most stalwart adventurers. Speaking from personal experience, it’s terrifying to find yourself alone (or not) in dodgy accomodations, in a remote area of a developing country, with a raging fever and/or an uncontrollable case of the runs or other unsavory symptoms. Which isn’t to say the same ailments suffered in the comfort of a five-star hotel in Paris are a picnic, either. Any way you slice it, getting sick in a foreign country sucks.

And sometimes, despite taking precautions, you fall ill anyway, as I can attest. It can be a matter of circumstance (That water my guide “boiled” in a bamboo culm on a Thai Hilltribe trek? Yeah, I pretty much saw the resulting case of dysentery coming), or just bad luck. I’ve been on my own during most of my unfortunate on-the-road maladies. Between my experiences and those of fellow travelers, I’ve accumulated some wisdom over the years for dealing with sudden-onset illness in less-than-ideal circumstances.

For the purposes of this article, I’m not going to include injuries, pre-existing conditions, or focus on food poisoning, which was well-covered in a previous Ask Gadling post by Melanie. I also want to stress that we’re not medical professionals here at Gadling, myself included. For the technical stuff, I turned to Dr. John Szumowski, Clinical Fellow of University of Washington Medical Center’s Division of Allergy and Infectious Disease.

After the jump, tips on prevention, what to do when illness strikes, and how to get yourself home in the event of a full-blown medical emergency.

[Photo credit: Flickr user MoHotta18]

Before you leave home

Hit the internet
Do a bit of research on emergency medical options for a worst-case scenario. The U.S. Department of State produces a list of American doctors and hospitals in foreign countries.

If you have specific questions (about, say, where to find the best dentists in Europe), Lonely Planet’s Thorn Tree travel forum can be a useful place to get ideas (please do additional research before following any advice). Take the diagnostic-related questions directed to forum members with a heaping grain of salt, and save them for your doctor.

Get vaccinated
Check the CDC’s (Centers for Disease Control and Prevention) website to see what, if any, vaccinations you need before your trip. You can also get updates on things like outbreaks of cholera or bird flu. Be sure you allow ample time before your trip for the protective effects of vaccines to establish themselves. Dr. Szumowski also recommends the CDC’s “Survival Guide to Safe and Healthy Travel” webpage.

View more Ask Gadling: Travel Advice from an Expert or send your question to ask [at] gadling [dot] com.

Keep an immunization card on you (some countries require proof of certain vaccinations) as well as an online record, like Google Health.

All travelers should get flu and tetanus shots. If you’re a frequent world traveler, get vaccinated for hepatitis A, typhoid, and polio. Depending upon where you’re traveling, you may require a Yellow Fever or Japanese Encephalitis vaccine, or malaria prophylaxis.

I used to think a rabies vaccination was overkill until I saw a fellow traveler get seriously nipped by a puppy we were playing with in a remote village near the Myanmar border. The deathly silence that followed was sufficient motivation. Adds Dr. Szumowski, “It’s still important to remember that excellent wound-care and post-bite medical evaluation are necessary, even if a person has had prior rabies pre-exposure vaccination.” The International Society of Travel Medicine has a list of global travel medicine clinics.

I also carry an EpiPen, because you never know what could trigger anaphylaxis while you’re abroad. It also bears mentioning that you can develop a life-threatening allergy to something previously benign. A chef I know went into anaphylactic shock after tasting one of his dishes containing taro root, even though he’d been cooking with it for over 20 years.

If you get sick

Stay calm, and assess your symtoms
It’s easy to get carried away and assume the worst, but odds are your sudden fever isn’t malaria.

Try to identify the source of infection or illness

Know when to seek professional medical assistance
In general, says Dr. Szumowski, some symptoms or exposures that should prompt “expeditious” medical evaluation include:

  • high fevers (over 101ºF, especially if sustained or accompanied by shaking or drenching sweats)
  • bloody diarrhea
  • inability to keep food or liquids down in situation of significant vomiting or diarrhea
  • confusion or severe headache
  • severe cough, especially if accompanied by shortness of breath
  • animal bite or other animal-related attack

Tips for self-care

Stay hydrated
If you’re vomiting or have diarrhea, stay hydrated with (purified/bottled water), and Gatorade or other electrolyte beverages. If you absolutely have to travel, take Imodium as an anti-diarrheal.

Eat bland foods
Remember the BRAT diet for gastrointestinal upset: rice, bananas, applesauce, and toast.

Control your fever
To lower a high fever, take the recommended dosages of acetaminophen (Tylenol) or ibuprofen (Advil).

Wear ID
Wear a medical alert bracelet for serious conditions, allergies, etc., Write down your condition in your destination country’s language in both your phrasebook, and place a card in your passport.

Emergency Measures

Know when to self-diagnose
Sometimes, you find yourself in a position where you have no other option. That said, this is something you want to avoid for obvious reasons. Says Dr. Szumowski, “Self-diagnosis and treatment can be appropriate for less serious conditions such as traveler’s diarrhea, but it is important not to delay evaluation by a medical professional for more serious illness [see warning signs above]. If someone chooses to self-treat, it’s important to be aware of potential for counterfeit medications locally.”

What if the only available hospital/clinic/doctor’s office is seriously sketchy?
If you’re in a situation where the medical facility is primitive/lacking in sanitation, you’ve got a tough call on your hands.

I posed this question to Dr. Szumowski. He says, “It depends on the acuity and seriousness of the condition. In general, evaluation and treatment in a facility with adequately-trained staff and more comprehensive resources is preferable whenever possible–this may mean seeking evaluation in the capital, at a private hospital, or even returning home. Aside from limited diagnostics and medications, smaller/less-resourced facilities may have inadequate sanitary practices (e.g. reuse of equipment) and screening of blood products, raising the risk of contracting pathogens such as hepatitis C or HIV. Therefore, having evacuation insurance is advisable, especially for extended travels in the developing world.”

In other words, you may be shit out of luck. But this is why you’re reading this article–so you can be prepared for all kinds of situations! Read on.

OTC antibiotics
In many countries, you can buy OTC antibiotics, and indeed, this may be your only option, but heed Dr. Szumowski’s warning, above. Caveat emptor.

If you need to be evacuated, the U.S. government offers financial assistance and/or repatriation loans. The American Citizens Service and Crisis Management (ACS) is linked to U.S. embassies and consulates all over the globe. It’s a good idea to enroll in the U.S. Department of State’s “Smart Traveler Enrollment Program (formerly known as “Traveler Registration)” if you’re traveling for a long period of time, to a high-risk region, or doing any extreme adventure activities.

Travel prepared

Get antibiotic prescriptions (and carry copies with you) from your primary care doctor or internist, or visit a travel medicine clinic, and pack them in you travel first-aid kit (You don’t have one? REI has some great options). Some people also carry sterile latex gloves and hypodermic needles with them. If you’re diabetic or have another condition that requires injections, this makes sense, provided you have a note from your medical provider. For everyone else, this is a personal choice that comes down to, “How comfortable are you with the knowledge that you’re carrying drug paraphernalia?” If you backpack, travel in places with notoriously corrupt law enforcement, or countries like, say, Malaysia, you may want to hedge your bets.

Email yourself and family or a trusted friend copies of medical insurance, itinerary, and a list of medications, and doctors.

Consider traveler’s insurance.

If the worst happens

In the highly unlikely event you do come home with a mystery disease that isn’t responding to medical treatment, get to a specialist, asap. Depending upon where you’ve been, this may be an infectious disease or tropical medicine doctor, a dermatologist or rheumatologist who specializes in tropical medicine, etc.. You may need to travel–out of state–to find the right specialist. Find someone who has first-hand experience traveling/training or practicing in developing countries, and in diagnosing diseases not found in the U.S.. It may even be best to try and seek medical treatment in the country where you became ill (even if that means a return trip).

Unfortunately, I can speak with authority this subject, because I’m in my 22nd month of diagnostics following a trip to South America. If you do find yourself harboring a travel-related (or not) disease that defies diagnosis, you must be your own advocate. No one is more invested in your health than you are, and doctors are human. They may make mistakes, despite their best intentions. Seek not just a second, but a third opinion, from at least two different medical facilities.

And finally, don’t let anything in this article scare you and put you off travel. Odds are, you’ll come home with nothing more than great memories, and the eagerness to plan your next trip. I know I can’t wait.

[Photo credits: vaccination, Flickr user alvi2047; mosquito, Flickr user tonrulkens; toast, Flickr user snowriderguy; farmacia, Flickr user ibirque; drugs, Flickr user cavale]

Five tips to reduce your health risk while eating street food

by Laurel Miller on

It was the 18th century food writer and gastronome Jean Anthelme Brillat-Savarin who famously said, “Tell me what you eat, and I’ll tell you what you are.” For certain cultures, street food is more than just a cheap, tasty, easy way to fuel the body. It’s part of a daily ritual, a way to catch up on neighborhood or community gossip, a means of eking out a living to provide for one’s family. By eating foreign street food, you get a sense of the social fabric and gender roles of a community or culture, but what about the health risks?

Some travelers equate a love of street food with a latent wish to sightsee whilst wearing an adult diaper. They steer clear of anything sold from a vendor, or resembling fruit, vegetable, or beverage not from a bottle (although when it comes to drinking water, you should always err on the side of caution, and there is something to be said about peeling or washing produce to avoid pesticide residue, since many developing nations use chemicals banned in the U.S.). What these folks may not realize is that foodborne illnesses such as E.coli, salmonella, and listeria don’t discriminate. FDA statistics show you’re more likely to get sick from preparing food at home than from dining in a domestic restaurant.

Is street food inherently more risky than eating in a restaurant when you travel? Sometimes, and it depends. Children, the elderly, and those with compromised immune systems are certainly more at risk of getting ill, and may be best off avoiding street eats. But there are certain precautionary measures healthy travelers can take before scarfing their tacos or mystery-meat kebabs that will minimize the chances of bringing home more than just a suitcase full of sweatshop-made tchotchkes as souvenirs. Read on.

1. Is there a crowd? Just like at home, go where the locals go, as they obviously know where to find the good stuff. But high volume also means that food is being prepared fresh, rather than sitting around attracting flies and turning into something useful for waging biological warfare.

2. Are basic hygiene practices being implemented by the vendor(s)? In Mexico, I’ve frequently observed street vendors slipping clean plastic bags over plates. With every order, a new bag is used, then discarded at the end of the meal. It’s an eco-nightmare, but it’s a lot more sanitary than dunking a plate in a bucket of dingy water doubling as a petri dish. Also bear in mind that in many parts of the world, the left hand performs double-duty as toilet paper. I can’t say it enough: Look at the sanitation practices before ordering.

You’ll often find co-workers whose sole responsibility is to handle money, to avoid cross-contaminating food (this isn’t always the case, however, so sometimes you’ll just have to–literally–suck it up). Once, when I accidentally handed my money to the wrong guy, he turned his hand upside-down to avoid contact with my filthy coins.

3. Is the stand or cart clean and well-maintained? Is hot food kept hot or cooked to order, and is cold food cold? Is purified water or ice used for beverages and frozen treats?

4. Are the ingredients fresh? If you’ve got eyes, a nose, and some tastebuds, you can figure this out for yourself. I look at the condiments and garnishes to determine if I want to eat at a given stand or cart. If I see crusty bowls of salsa, dessicated limes, slimy herbs, or flies congregated on any raw foods I might potentially eat, I’m out of there.

Stick to local specialties. One of the greatest joys of travel is eating regional ingredients or dishes. It also stands to reason that ordering seafood in an inland desert is a calculated risk. Raw protein products (egg, meat, poultry, fish, fresh cheeses) in general are to be avoided in the Third World. What about dishes like ceviche, where the acid in the citrus juice denatures (breaks down proteins, killing some potential pathogens in the process) the fish? It’s still risky, because technically it’s an uncooked food, and only application of heat over 145 degrees can totally annihilate anything potentially deadly lurking in fish. Again, use good judgment based on freshness of ingredients and basic sanitation, but remember that you can’t eliminate all risk.

If you’re in a coastal region, it pays to do a bit of homework on the cleanliness of the local fresh and ocean water supplies; algae blooms or cholera outbreaks will be widely reported. Try to avoid eating raw river fish or seafood, or river fish/seafood from just offshore; remember that many developing island nations and coastal regions use high tide as their toilet. If you’re eating pork in the Third World, always make sure it’s well-cooked. While trichinosis has effectively been eradicated from our domestic industrial pork supply, the disease is prevalent in other parts of the world. And not to get too graphic, but you’ll often find pigs in rural parts of the developing world lurking around latrines, searching for a snack.

Fresh ingredients don’t necessarily mean great food, but it helps. Delicious street food is ulimately a reflection of the loving care that goes into its preparation. Are the carnitas slightly crispy on the outside, with an interior succulent with greasy goodness? Is the masa in the tamales moist, with a sweet, earthy corn flavor? Are the noodles slightly toothsome, the herbs fresh and bright-tasting, the broth fragrant and piping hot? These things matter.

5. Use hand sanitizer before eating, take probiotics with live active cultures prophylactically, and pack a broad-spectrum gastrointestinal antibiotic and Imodium, just in case. I’m just sayin’.

For more information on food safety, go to this page on the USDA website.

Traveler’s Diarrhea: Getting it, fixing it, and preventing it

by Erik McLaughlin on

Traveler’s diarrhea is an unpleasant but common problem for a lot of travelers. No matter who you are or where you’ve been, chances are you’ve already experienced this unfortunate situation. (Notice you never seen Indiana Jones or James Bond suffering on their trips, though.) To keep yourself out of trouble on the road, there are a few simple things to remember to make your bout with the nasty bug a little less rough.

Rehydrate

Probably the most important thing to remember with a diarrheal illness is the need to rehydrate. Your body is losing large amounts of water in the stools. In addition to the water, valuable electrolytes such as salt, sugar, potassium, and bicarbonate are also being passed out. This is where diarrhea becomes a problem; The person becomes dehydrated and gets an imbalance in their electrolytes, sometimes requiring hospitalization for IV (intravenous) fluids.

Replacing lost water is the most important intervention one can make. But how much water should you drink and replace? A good rule of thumb, for healthy people without prior medical problems, is to determine how much water is needed based on weight.

Here’s a quick chart for daily water requirements based on weight:

  • 50 lbs or 22kg 1.5 liters/day
  • 100 lbs or 45 kg 2 liters/day
  • 150 lbs or 68 kg 2.4 liters/day
  • 200lbs or 90 kg 2.9 liters/day
  • 250lbs or 113 kg 3.3 liters.day

Remember, this is just the basic requirement of fluid for an average day; if you’re having some losses, say through several days of diarrhea, you’ll need to drink more than this! Sometimes even double your daily requirements are needed to recover. It is also important to note that some medical conditions could be made worse by aggressive re-hydration, such as heart failure or electrolyte issues. Always check with your primary health care provider to determine what is right for you!

If you are making the effort to rehydrate, make sure you’re getting the most out of your efforts. I always say, “work smarter not harder.” Simple sugar in your water helps re-hydration, which allows the water molecules to pass through the lining of the intestines easier. This means the water goes from the bowels to the bloodstream (where it is needed) faster! Sports drinks take great advantage of this fact and use a lot of tasty sugar in their drinks. Salt and potassium are the other two important things your water should contain. Most sports drinks contain everything you need, for re-hydration.

You can also make your own “sports drink” if you need too. Make sure your water is clean and drinkable first, then add 2 pinches of salt, 2 pinches of sugar and a squirt of fruit juice. Maybe not as tasty as store-bought, but works just as well! Powdered electrolyte packets are also available and I always carry a few when I travel.

Making it stop

My general rule is to let a case of Montezuma revenge, Delhi belly, or what ever you call it, run its course. Let it flow, keep well hydrated and ride it out. Loperamide (Immodium, Diareze) is a medicine that slows peristalsis, the mechanism that moves feces through the intestines. This medicine can generally “plug up” a person with profuse, watery diarrhea. Sometimes, the nature of the trip may prohibit frequent bathroom breaks. (Think bus travel, business meetings, walking tours, etc.) Loperamide is a wonderful medicine for this, but not in all cases, and should be used sparingly.

Blood in the diarrhea means that the bacteria is actually damaging the lining of the intestines. This is a need for antibiotics. This is also not a time to take a medicine that traps this bacteria in the intestines! You want that damaging bacteria out of your body, as quickly as possible.

A bland diet such as a BRAT (bananas, rice, apples, toast) often helps “cool off” an angry belly. A few days of eating this should help alleviate the frequency of stools. Dairy products should also be avoided if possible. The enzymes that digest lactose are destroyed when diarrhea occurs. The lactose ends up sitting in the intestine and osmotically draws more fluid from the body into the bowel, bringing on more diarrhea. After a few days, the enzymes are re-formed and you can go back to that cheese.

Bugs

Escherichia Coli is the bacteria name to know or “E. Coli” to his friends. Studies have shown that the vast majority of traveler’s diarrhea is due to E. Coli. A few other bacteria such as Campylobacter Jejuni, Salmonella and Shigella can also frequently occur, depending on geographic location. Viruses are another common cause of diarrhea, as well. The Norwalk virus seems to get a lot of attention, especially on cruise ships.

Cholera is a world famous bacteria that as caused several global pandemics.

Most of the deaths due to cholera are from profound dehydration and depletion of electrolytes. This is the source of the WHO ORS (Oral Re-hydration Solution) program.

Some adventure travelers may encounter some parasites such as Giardia or E. Histolytica.

Prevention

I always use the term “common sense travel.” This is basically all the things your mother told you to do as a kid, such as:

Wash your hands before you eat! This little habit can reduce chances of diarrheal infection by more than half.

Don’t eat at a place that looks dirty. I know, the road side stands have the best food, and they can often be safer than a normal restaurant. Travel health is all about risk management. You know that eating at this place may make you a little sick, but it is worth the chance? This is an individual choice.

Make sure your food is properly cooked and not raw. Extra caution should be taken with shellfish and sea food.

Lastly, we all know about bottled water. Local water may not be the healthiest stuff. Ice is another thing to think of; chances are it is made with local tap water, too. Fruits and veggies should all be washed, hopefully with clean water or avoided.

The use of antibiotics as prophylaxis (doing something to prevent illness) is a controversial matter. The nature of the trip and medical history are things to be considered when decideing whether or not to use them. Honeymoons, business trips and athletic competitions are instances that can be derailed by a simple case of diarrhea. Also, people who travel with low immune status are candidates for such prophylaxis.

Some studies have shown that bismuth subsalicylate (Pepto Bismol) is effective in prevention of traveler’s diarrhea and is a good option as well. Generally, I avoid recommending prophylactic antibiotics for most travelers.

Antibiotics

Should you take them? This seems to be the main question when it comes to traveler’s diarrhea. I believe that there are certain instances when taking antibiotics for travel-acquired diarrhea makes sense, with the presence of blood in the stool being the most important. Presence of fever is another indication of more severe infection, as is abdominal cramping. Realizing that most people don’t have quick access to health care when they travel, I do think it is wise to carry a dose of antibiotics in case of invasive or severe diarrhea. Speak with your health care provider about this working for you. Some choices include a quinolone such as Cipro or TMP/SMX (Bactrim). There are instances of increasing antibiotic resistance and other options may be needed.

Getting sick while traveling is something everybody wants to avoid. The natural adventurous spirit of travel means that more risks are taken, especially when it comes to eating. Hopefully this will help people feel a little more comfortable if they have to deal with this problem.

Resources:

Always check with your primary health care provider to determine what is right for you!