As a physician, I try to look after my medical problems without consulting a physician. I appreciate that you probably don’t have this ability. Part of the issue is that it is almost impossible to purchase travel insurance once you are over 70.
If I were to become seriously ill or require surgery, the best travel health insurance is probably evacuation insurance. Frankly, I don’t trust the quality of medical care in many 3rd world countries.
FIRST AID
Because of the size and space occupied by a thorough first aid kit, I am a real minimalist.
1. Bandaids. A selection of Elastoplast bandaids: roll of strip bandaids that can be cut into various widths, finger-tip bandaids, and knuckle bandaids.
2. Steri Strips. These thin strips are good if you get a cut anywhere. They can easily replace sutures.
3. Moleskin. The best blister treatment. Deal with a hot spot the instant it is felt. “Thread” blisters with a needle and thread, leaving the thread in place allowing the blister to drain but keeping the skin over top intact. Cut a doughnut in the moleskin the size of the blister and cover it with duct tape. Duct tape alone is useful at the first sign of any hot spot.
4. Pressure dressing. The simplest would be a roll of Kling or an elastic bandage.
5. Antiseptic. Iodine and mercurochrome are old-fashioned and often delay healing. Use soap and water to clean a wound. Burns and large abrasions heal fastest by keeping them moist to allow new skin formation. Simple Vaseline is best. Flamazine is good for burns.
ROUTINE VACCINATIONS
Infants and Children. Follow the recommended age-appropriate immunization schedule for Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella, Haemophilus B, Meningitis, Pneumococcal, Varicella, Rotavirus, Hepatitis A and B, Human Papillomavirus.
Measles-Mumps-Rubella. Travellers of all ages should ensure that they are up-to-date. All three viruses are highly contagious and tend to spread in places of mass gatherings, including sports events and university campuses. Many countries, once believed to have eliminated the diseases, are seeing a resurgence as a result of lower herd immunity levels due to lack of or under-vaccination.
Adults born before 1957 (USA) and 1970 (Canada) are generally considered immune to Measles and Mumps due to previous illness or a clinically asymptomatic infection. Women of childbearing age should ensure they are immune to Rubella but are advised not to get pregnant for 4 weeks following vaccination.
Tetanus-Diphtheria and Pertussis: Travellers of all ages should ensure they are up-to-date. A single injection booster containing Tetanus-Diphtheria toxoids is recommended for adults every 10 years, regardless if travelling or not. A primary series (which also protects against Pertussis –Tdap) is recommended for previously unvaccinated adults.
Polio A primary vaccination series is necessary for those not previously or only partially vaccinated. Adults who have been fully vaccinated as children should receive a Polio booster once only. If travellers have not received a Polio booster as adults, vaccination is recommended for countries where Polio is not yet eradicated: Afghanistan, Nigeria and Pakistan.
Some countries in Africa, the Middle East and Central Asia are susceptible to re-introduction of Polio. Check www.iamat.org for the latest information and make sure you are fully vaccinated. I had a polio booster when I crossed from Pakistan to Afghanistan at Torkham. My vaccination card was deep in my bag.
Pneumococcal: Vaccination is recommended for persons over 65, smokers, or those with chronic health conditions such as emphysema, asthma, lung disease, heart disease, renal disorders, immune-suppressive disorders, and organ transplant recipients, including cochlear implants. Pneumonia and ear infections can be more severe for these travellers.
Influenza: Vaccination is recommended for all travellers over 6 months of age, especially children, pregnant women, persons over 65 and those with chronic health conditions such as asthma, diabetes, lung disease, heart disease, immune-suppressive disorders, and organ transplant recipients.
Influenza viruses typically circulate from November to April in the northern hemisphere, from May to October in the southern hemisphere, and year-round in the tropics.
Hepatitis A: Vaccination is recommended for all travellers over one year. This viral infection occurs worldwide and is transmitted through contaminated food or water. The vaccine is often combined with Hepatitis B for long-term protection for both viral diseases. An HAV antibody test may be advised for persons over 40 or those born in developing countries to determine immunity. Immune globulin may be recommended for some last-minute travellers.
Hepatitis B: Vaccination is now given routinely as a childhood vaccination. The virus is transmitted through infected blood products, sexual contact, or infected items like needles or razor blades.
Vaccination is recommended for persons on working assignments in the healthcare field (dentists, physicians, nurses, laboratory technicians), for those working in close contact with the local population (teachers, aid workers, missionaries), or for travellers having sexual contact with locals. This vaccine is often combined with Hepatitis A and provides long-term protection for both viral diseases.
MEDICATIONS
I routinely carry all the below drugs. I self-treat without seeing a Dr. Most medications can be purchased without a prescription in third-world countries. I make a point of buying antibiotics in these countries. They are invariably cheaper.
1. Ibuprofen. An effective analgesic/anti-inflammatory that is well tolerated. I use much larger doses than most people often in the 800-1200mg range. Great for headaches, joint inflammation, and menstrual cramps.
2. Dimenhydrinate (Gravol). A reasonable antiemetic. Available as tablets or suppositories. Good for car and sea sickness.
3. Decongestants. For those inevitable colds, use pseudoephedrine and nasal sprays like Otrivin.
4. Combination cortisone (for rubbed inflamed skin), antifungal and antibiotic cream.
5. Antibiotics. Available only by prescription from a doctor in North America and Europe. Often no prescription is necessary elsewhere in the world.
a. Travelers Diarrhea: Advice from local physicians who know the common responsible organisms can be worthwhile. Ciprofloxacin taken early in the episode can be effective for E coli, the most common cause. Azithromycin as resistance to Cipro, is becoming more common 4. Metronidazole (for giardia or amoebic dysentery).
b. Bronchitis and pneumonia 1. Amoxil – is old-fashioned but is effective for bronchitis. 2. Azithromycin 3. Levofloxacin
6. Malaria. I don’t use prophylaxis for many reasons (see Malaria discussion) but instead carry two courses of the active and best treatment, Coartem. Available anywhere in Africa for about $10. Dose 1 twice/day for three days at first sign of fever and feeling like a bad hangover. Ideally one would like a blood smear to confirm the diagnosis, but if one is not available, take the drug. It is very safe and well tolerated and all that is lost is $10. It is essential to treat malaria as early as possible.
FOOD POISONING
Food poisoning is a common, yet distressing and sometimes life-threatening problem for millions of people throughout the world. People infected with foodborne organisms may be symptom-free or may have symptoms ranging from mild intestinal discomfort to severe dehydration and bloody diarrhea. Depending on the type of infection, people can die.
More than 250 different diseases can cause food poisoning. Food poisoning is an illness caused by eating contaminated food. Most people get better without the need for treatment.
Symptoms: The common initial symptoms are feeling sick, vomiting, diarrhea and stomach cramps.
Common foods: Foods particularly susceptible to contamination if not handled, stored or cooked properly include: raw meat and poultry, raw eggs, raw shellfish, unpasteurized milk, ‘ready to eat’ foods, such as cooked sliced meats, pâté, soft cheeses and pre-packed sandwiches.
Method of contamination: Food can become contaminated at any stage during production, processing or cooking: not cooking food thoroughly (particularly poultry, pork, burgers, sausages and kebabs), not storing food that needs to be chilled at below 5°C correctly, leaving cooked food for too long at warm temperatures, someone who is ill or who has dirty hands touching the food, occasionally by eating food that has passed its ‘use by’ date, and cross-contamination (the spread of bacteria, such as E. coli, from contaminated foods).
More than 180 countries (including popular destinations the Maldives, Mexico, and the Bahamas), have tap water that is unsafe to drink. Brushing your teeth with local tap water or washing your hands before preparing lunch could lead to illness. Giardia is common with contaminated water.
ORGANISMS 31 major known pathogens cause foodborne illnesses, Depending on the bacteria, parasite, or virus, symptoms could include a few hours to a week of diarrhea and vomiting, plus stomach cramps, fever, or body aches. The most likely culprits are raw or undercooked chicken, turkey, or meat; raw milk; raw fruits and vegetables; shellfish; and food stored in unsafe temperatures (e.g. an open-air buffet) or prepared in an unsanitary way.
Norovirus is a highly contagious virus and the common cause of self-limited gastrointestinal illness common on cruise ships. Symptoms develop within one day of ingesting norovirus.
Rotavirus is the most common cause of severe diarrhea among infants and children. It is highly contagious and typically resolves after three to nine days.
Bacterial infections usually begin 1–3 days after eating contaminated food. They cause an actual infection in your intestines due to bacteria such as salmonella, Escherichia coli (E. coli O157:H7), Campylobacter, Shigella, E. coli, Listeria, or botulism.
TREATMENT
Most people with food poisoning get better without the need for treatment. To help relieve your symptoms you should rest, drink plenty of fluids and avoid food. Drink as much water as you can, even if you can only sip it, particularly every time you pass diarrhea. Oral rehydration salts (ORSs), Pedialyte, low-sugar Gatorade and soda pop such as Pepsi or ginger ale are often satisfactory replacement fluids. Over-the-counter painkillers (ibuprofen, naproxen) for stomach cramps may help.
Antinauseants. To control vomiting, Gravol as tablets or rectal suppositories (100mg for adults) or Stemetil is much more potent and is available as tablets, sublingual tablets (under your tongue), suppositories or by injection. It is available over the counter in many third world countries but is prescription in first world countries.
Diarrhea control. Since diarrhea and vomiting are your body’s natural immune response to expel toxins, only take anti-diarrhea and anti-nausea medications such as Imodium or Lomotil, and bismuth subsalicylate (Pepto-Bismol) unless you must travel and get to a toilet might be a problem. They may prolong symptoms. Letting the diarrhea run its course may allow you to excrete the organism more effectively.
Activated Charcoal Tablets, 250 mg work wonders for traveller’s diarrhea! Instead of just keeping you from pooping (which is what Imodium does) the charcoal absorbs the bacteria in your body so you can get rid of it on your next bowel movement. Used in a stronger dose for overdoses on medication.
Antibiotics. Advice from local physicians who know the common responsible organisms can be worthwhile. By testing a sample of stool, the bacteria can be identified. Ciprofloxacin taken early in the episode can be effective for E coli, the most common cause. Azithromycin as resistance to Cipro, is becoming more common. Metronidazole treats giardia or amoebic dysentery.
MALARIA
Malaria can be a dangerous disease. It can progress rapidly, so it is important to treat as early as possible.
Routine: normal mosquito prevention: long pants, socks and tops, repellent in the evening and night, and mosquito nets.
Prophylaxis. The general advice to take prophylaxis usually comes from travel clinics advising people who will be in malarial areas for a week or a month. Most prophylaxis should generally not be taken for more than 3 months. For people living in these areas, years of prophylaxis is not a good idea. No prophylaxis works 100% and may be as low as 60% because of compliance and is irrelevant to the drug used. Some only use antimalarials in small kids because you can’t tell them how they feel.
You should always carry an active treatment, even if using prophylaxis. Most long-term travellers and people living in malarial areas take no prophylaxis and treat ASAP whenever they MIGHT have malaria symptoms. They never leave the house without Coartem. Many have had malaria 15-20 times.
1. Doxycycline. The advantage is that it can be started only a few days before needed. Take daily. Needs to be taken for 4 weeks after you have left an at-risk area. It is the typical go-to drug for backpackers as it is the cheapest. Contraindicated in children under 8 and in pregnancy. Side effects. Nausea, sun sensitivity.
2. Mefloquine (Lariam/Vibramycin). Start two weeks before entering an area with malaria and for 4 weeks after leaving. Take once a week with a full glass of water and food. May be better for long trips as taken once per week. Possibly the least effective.
Side effects. With a reputation for causing vivid dreams, the mere mention of the drug often gets a negative reaction from fellow travellers. Dizziness, headache, vivid dreams, nightmares, visual and auditory hallucinations, anxiety, depression, unusual behaviour, insomnia, and suicidal ideations may occur in as many as 25%. About 11-17% are incapacitated to some degree. Safe in pregnancy.
3. Malarone or Malanil (Atovaquone/Proguanil). Start 1-2 days before arrival. Take daily and for 7 days after risk. Well tolerated with uncommon side effects. Suitable for children. It can’t be taken for more than 90 days. It is expensive in Western countries. It is easy to find over the counter in less developed countries more cheaply. The malarone generic, Mozitech, is relatively cheap and available without prescription at pharmacies in South Africa.
Treatment: Even if using prophylaxis, you should always carry an active treatment. Most long-term travellers take no prophylaxis and are treated ASAP whenever they MIGHT have malaria symptoms. If you wake up with a bad hangover and it doesn’t go away, take the treatment as it is most likely malaria. The longer you don’t treat it, the worse it will get and often rapidly. If you catch it early, it’s not much worse than a cold. If in doubt take Coartem anyway. No harm done. No side effects. Just wasted $10, worst-case scenario. Don’t drink alcohol for at least 2 weeks or it may come back.
1. Artemether/Lumefantrine (sold under the trade name Coartem) is a combination of the two drugs taken orally. It is an effective and well-tolerated malaria treatment, providing high cure rates even in areas of multi-drug resistance. It is not used to prevent malaria. It is not available as a generic medication. Dosage. The tablets are Artemether 80mg and Lumefantrine 480mg – each equal to 4 tablets of the older formulation. Adults and children 2 months of age and older weighing 35 kilograms or more at first symptoms: 1 tablet, then 1 in 8 hours and then 1 twice a day for two days – ie. 6 tablets for the total course. Food especially fat enhances the absorption of artemether and lumefantrine, taken with food as food is tolerated.
2. Malarone. 4 tablets once/day X 3 days.
• Malaria, Courtenay BC Canada. In August 2017, I was a home and developed a high temperature, loss of appetite and felt like a bad hangover. I waited 4 days to see if things would improve. I finally went to the emergency department of my local hospital.
I had been on a 5 1/2 month overland trip from Morocco to Cape Town from November 2016 to April 2017. All countries except Morocco, Namibia and South Africa had malaria warnings. I took Mefloquine once per week starting in Morocco and continuing for the four weeks I was in Nambia and South Africa, I flew home in May 2017 and felt well until I was sick in August – three months later. I may have taken a dose a day late a few times but otherwise took the mefloquine as instructed.
At the hospital, I told the lab tech to do a malaria smear. It took 5 hours for me to see a doctor. I felt like death warmed over, I was very dehydrated. The malaria smear was positive. I received the wrong drug,
I was contacted by an infectious disease specialist who prescribed the correct drug and I quickly recovered.
It is not rare to get malaria months after stopping prophylaxis.
It is dangerous to get malaria in Western countries unfamiliar with the diagnosis and treatment. I had an IV but could not take oral fluids until I was checked by a doctor. The IV was running very slowly. I became delirious.
Malaria is a serious disease with death and serious complications common. It is especially important to treat as early as possible to prevent complications. I should have been seen much earlier – that was a major mistake on my part.
Note that I no longer take prophylaxis when travelling in high-risk malaria zones. I carry the treatment and treat any fever early and aggressively. Prophylaxis has a known failure rate, Even when taking prophylaxis, you should also carry treatment.
DENGUE FEVER (Breakbone blues)
Unlike her stealthy, malaria-spreading cousin, the female Aedes aegypti signals her approach with an exasperating drone. Her bite is far worse than her buzz. If she carries a flavivirus pathogen, her victim can be infected with dengue fever. Most infections pass without symptoms, but an unfortunate few are racked with “breakbone fever”, which causes severe joint pain, hemorrhage and, occasionally, death. The after-effects, which are poorly understood, include fatigue and cognitive impairment. Aedes is so plentiful that the United States Centres for Disease Control and Prevention reckons 100 million people fall sick with dengue.
The number of people contracting dengue has risen dramatically. In 2000 about 20,000 people died of it, but in 2024, at least 40,000 will perish. By contrast, between 2000 and 2022, deaths from malaria declined by 30%. Latin America is the worst-afflicted region, Aedes’ range has been expanding as the planet warms and Aedes will spread into large parts of southern Europe and the United States.
Bed nets, a cheap and effective way to curb malaria, do not work for dengue, since Aedes, unlike Anopheles, bite people during the day.
Singapore has long done a fine job of fighting dengue. Eliminate all standing water and spray insecticide to the predicted epicentres. Every week it releases 5m mosquitoes infected with Wolbachia bacteria. This prevents them or their offspring from transmitting the virus that causes dengue and costs about $35m a year, or $6 per resident. Trials of Wolbachia infection in Colombia have seen a 94% drop. The world’s largest wolbachia-mosquito factory is to start operations in the Brazilian city of Curitiba this year.
