NOTE: The following information was written for clients of the Barrhaven Travel Medicine Clinic and the Riverside Travel Medicine Clinic. It is supplemental information intended to complement the in-person counselling we do at these two clinics. Other travellers are advised to see us or another travel clinic and should not rely on the information here unless they have been to one of our clinics. Recommendations may vary among clinics.
MEDICAL HANDBOOK FOR TRAVELLERS
A guide if you fall ill abroad
Dog bite - see Animal bite
Malaria – see Fever
Standby malaria treatment
- Phone numbers
In all cases of illness, it is best to seek the advice of a qualified medical practitioner. This booklet is intended for those situations where you are unable to access proper medical care. It is intended for use by travellers who have been to our clinic and who will have therefore received recommendations that supplement the advice provided here.
The use of any of the drugs recommended in this booklet can potentially cause a drug interaction. If you visited our clinic prior to this trip, we would have considered this before prescribing for you. This assumes you are not taking a more recently prescribed medication.
Allergic reactions to medication can occur. Before taking a new drug, consider whether you might be allergic to it based on any prior history of medication allergy.
All medication doses given in this booklet are intended for adults. Recommended medication and doses can change over time, so verify that they are still correct at the time of use. Generic names are used with Canadian brand names placed in brackets in most cases.
Recommendations and links provided can change over time. There is a possibility that updates will be posted on our clinic website. If so, we will use the URL www.travelclinic.org/BookletUpdate
If you are above 8000 feet (2400 meters), you may be experiencing dizziness, headache, lack of appetite, poor sleep, and shortness of breath. This is altitude sickness.
What to do
You should not ascend to a higher altitude. If the symptoms are tolerable, staying at the same altitude for 1-2 days will usually allow you to acclimatize.
If we have prescribed acetazolamide (Diamox) for you and you are not already taking it, you can do so - 250 mg every twelve hours (adult dosage). This will usually help to relieve symptoms but it can take 12-24 hours to do so. This can be continued until you feel well.
If you are already taking Diamox at a preventive dose of 125 mg every 12 hours, you can increase it to 250 mg every 12 hours (adult dosage).
For those who are quite ill, especially with marked shortness of breath or neurologic symptoms (severe headache, confusion, disorientation), descent to a lower altitude is urgent and medical help should be sought. See “High altitude medical emergencies” later in this section.
Diamox can cause some odd side effects that include tingling around the mouth or in the hands, having to urinate often, and a slight change in the way some things taste. These are not serious.
Don’t use Diamox if you have an allergy to sulfa as this can sometimes be dangerous. If you do contemplate using it anyway, do so only if the situation is truly serious and you have no choice.
High altitude medical emergencies
Severe shortness of breath
This may be due to a condition known as “high altitude pulmonary edema” (HAPE). In this situation, the ill person is obviously much more short of breath than everyone else and is in significant distress. HAPE is water in the lungs. It is a medical emergency. The best treatment is to descend to a lower altitude ASAP. This is not always possible, however, if weather is bad or at night. Oxygen should be administered. A Gamow bag should be used, if available. There are medications which can provide temporary relief, making descent easier and which are potentially life-saving. If you are suffering from HAPE, you can take slow-release nifedipine. This is currently available in Canada as nifedipine XL or nifedipine ER and also under the name Adalat XL or ER. The dose is 30 mg every 12 hours (adult dosage).
Confusion, disorientation, walking erratically, severe headache
This may be due to a condition known as “high altitude cerebral edema” (HACE). In this situation, the ill person may not be able to recognize what is wrong. Others will have to take charge. HACE is water on the brain. Because there is no room to expand due to the rigidity of the skull, the brain becomes compressed by the fluid. This is a medical emergency and the best treatment is to descend to a lower altitude ASAP. This is not always possible, however, if the weather is bad or at night. Oxygen should be administered. A Gamow bag should be used, if available. There is a medication which can provide temporary relief, making descent easier and is potentially life-saving: dexamethasone (Decadron) 4 mg every 6 hours (adult dosage). If you are suffering from HACE, dexamethasone should be given to you if it is available.
In most countries rabies is a threat. A bite from a dog, cat, monkey or other animal cannot be ignored even if trivial. Rabies is a fatal disease. There is no way to know with certainty if an animal is rabid.
If you have been bitten or even scratched, wash the wound for 10 minutes with soap and water. The aim is to wash away any virus that may be there.
Seek immediate medical help. You will need to get two kinds of injections:
1. Rabies immune globulin: this is a one-time fast-acting injection which gives you immediate protection from rabies. It is given at the site of the wound.
2. Rabies vaccine: this is a series of injections, usually given in the upper arm. Typically it is 4 or 5 doses spread out over weeks.
3. If you received the rabies vaccine series before departure, you will have been told that you do not need rabies immune globulin in the event of a bite. In this case and if you are certain about that, you will need additional rabies vaccine only, two doses. At the time of writing, the schedule is: the first as soon as possible after a bite, the second dose 3 days after that. The vaccine is generally available.
A shortage of rabies immune globulin has existed internationally for many years. You may not be able to get it where you are or even in that country. Yet, you need it quickly. You will have to make inquiries about where you can access it, and set out to get it. Sometimes it is necessary to fly elsewhere or even home. If you contact us in such a situation, we may be able to assist in finding a source.
Our clinic often prescribes antibiotics to travellers, at the time of writing mainly azithromycin. We prescribe them mainly for treating severe travellers` diarrhea. Please see the section on Diarrhea.
Azithromycin can also be used for a significant chest infection – for example, if you have a bad cough, producing a fair amount of green or yellow phlegm, particularly with a fever. In this case a common way to take azithromycin 250 mg is two tablets on Day 1, and one tablet on Day 2 through Day 5 (adult dose).
In all cases, it is best that a competent medical practitioner examine you first. However if this is impossible, you may decide to self-treat.
This condition mainly occurs in women. The symptoms are burning on urination, frequent urination, getting up a lot at night to urinate and sometimes blood in the urine.
Drink an adequate amount of clean water. If the symptoms does not settle, further treatment with antibiotics may be needed. Typical ones used are trimethoprim-sulfamethoxazole (Septra DS or Bactrim DS), 1 tablet twice daily for 3-5 days; norfloxacin 400 mg twice daily for 3 days, nitrofurantoin – dose depends on brand (all adult dosages).
Ideally a urine culture would be done to prove there is an infection and to determine the best treatment. Where no medical practitioner can be accessed, some people will treat themselves if they have the right antibiotic with them. This is particularly reasonable for individuals who have already experienced several bladder infections and have no fever. Please note that azithromycin, the antibiotic we usually prescribe in case of severe diarrhea, is not a good choice for bladder infections.
If you also have fever and/or back pain, it becomes more important to consult a medical practitioner.
Respiratory infections are common in travellers. As a general rule, a cold and cough without fever and without shortness of breath will settle on its own. If you are coughing up fair amounts of yellow or green sputum and have a fever, you should consult a doctor. If this is impossible, you might treat yourself with an appropriate antibiotic if you have these. One which is sometimes carried by travellers is azithromycin 250 mg. A commonly-used schedule for this drug is 2 tablets on the first day and 1 tablet daily for 4 more days for chest infection (adult dosage). If you have been prescribed norfloxacin or ciprofloxacin for diarrhea, this antibiotic can be tried for the respiratory symptoms described here. You can email or call us for information on dosage at email@example.com.
If you need to visit a dentist, try to find one of good reputation. When working on your teeth and gums, the same considerations of sterile instruments should be given as one gives to injections. We have been unable to locate a list of
recommended dentists abroad. You might try to access the resources listed under the section below, “Doctors Abroad”, contacting one or more of these to ask for their advice on locating a reliable dentist.
If you have mild diarrhea, no medication is necessary. Continue to eat and drink as usual, following the usual advice about food and water. If you have purchased packets of oral rehydration salts from our clinic or have access to Gastrolyte, use this as per the packet instructions. Gatorade is a less perfect alternative and should be taken at half-strength (diluted half and half with drinkable water). Avoid spicy food and dairy products, until the problem has cleared.
If the diarrhea is not severe but is a nuisance, you can take loperamide (Imodium) 2 mg, as directed on the box. This will usually slow down or stop the diarrhea but can sometimes lead to constipation.
If the diarrhea is severe or if it is bloody or if there is fever, you should not take Imodium alone. It is recommended that you take an appropriate antibiotic. A prescription for this was likely given to you by our clinic staff. The antibiotic commonly prescribed for adults at this time at our clinic is azithromycin. The instructions will be on the bottle. Children usually get a prescription for azithromycin suspension, based on weight. If you take antibiotics for diarrhea, adding Imodium will stop the diarrhea even faster, usually within 24 hours, and this is generally recommended for adults but not for children.
You may have bought oral rehydration salts at our clinic. If not, they can be purchased locally at a pharmacy. Follow the instructions, adding a packet to the correct amount of clean water. Drink as much as needed to avoid dehydration. If the urine is dark, it is usually a sign that you need to be taking in more fluids. This is especially important for infants, young children and the elderly who are more easily dehydrated.
It is preferable to consult a competent physician rather than self-treat. However, this is not always feasible. If you are still having diarrhea after taking the antibiotics, you should see a doctor.
The quality of medical care can vary considerably in many countries. If you decide to seek medical attention, you should try to find a competent and reliable doctor and/or hospital. There are several things you can try:
Call the Canadian embassy or high commission in that country and ask for advice.
If there is no Canadian embassy there, the US, British or other embassy may be able to help.
IAMAT (International Association for Medical Assistance to Travellers) maintains a list of doctors and clinics in most countries. Their website is www.iamat.org. You can sign up there for free, and view recommended clinics and doctors on line. Please send them a donation.
The International Society of Travel Medicine maintains a list of travel clinics in many countries at www.istm.org. Doctors and nurses there should be able to deal with your illness or refer you on.
You should be travelling with health insurance beyond what your provincial plan covers. There is often an emergency number provided, and there is some possibility that your insurer can direct you to a recommended health facility.
The Joint Commission International accredits medical facilities around the world. You can find them at http://www.jointcommissioninternational.org/JCI-Accredited-Organizations, or google them.
Note that if you locate a physician through any of these sources but not in the town you are in, it may still be worth contacting that clinic. He/she may be able to direct you to a facility in the town you are in, or close by. You can call us as well. We may have information on a reputable clinic in your area.
There are some other issues to consider when being treated abroad.
In some places, the sterility of needles and syringes may not be guaranteed. The preferred method of giving medication is by injection in many countries, differing from our practice of using tablets. Most medication that is given by injection can also be taken as a pill, and this is preferable from a safety point of view. Try insisting on pills. If this proves impossible, insist on seeing that the syringe and needle are single-use, and being unpackaged individually. Also ask or observe if the medicine you are being given is coming from a single-dose vial. These will usually have a small flip-off cap, or come as a glass vial that must be cracked open. Multi-dose bottles can be contaminated from repeated use with multiple needles.
The need for a blood transfusion is a rare event. In some countries, blood is not screened as it is in Canada, and there is then a risk of HIV, hepatitis B and other blood-borne diseases. It is generally recommended that unless you are in a country with a known safe blood supply that you accept a transfusion only if it is absolutely necessary.
It is not unusual for travellers to experience anxiety or depression when travelling. Many people are more dependent on their usual environment than they realize. It can be difficult to talk about this particularly for those who are on an assignment of some kind, for fear of being judged or jeopardizing one’s job. If the emotional problems are serious, you should consider coming home or seeing a qualified counsellor where you are. For less worrisome situations, the following may help:
- Resist the temptation to stay by yourself. Get out and mix with others.
- Call friends and family at home, and don’t hide how you are feeling.
- Reconnect with your familiar surroundings in other ways – bring out photos of family if you have them; listen to Canadian radio on the internet.
- Keep busy.
- Be physically active. Running and other exercise produces endorphins which can improve your frame of mind.
If you are currently in a malaria zone or have been within the last 3 months, your fever could be due to malaria. Your first priority is to find out if it is. This is very important because it is the one common infection that can be fatal in a matter of days. You must locate a suitable clinic immediately, and be tested for malaria. Don’t wait even one day. A blood test will be done, and you should be getting the result on the same day. If it shows no malaria, it should be repeated in 12-24 hours, and even once more at the same interval if still negative if malaria is strongly suspected.
If you have been taking malaria pills since your arrival, prescribed by a competent travel clinic, and have not missed (or vomited up) a single tablet, it is unlikely that you have malaria but you should still check it immediately. If you have purchased your malaria medication abroad, there is a possibility that they are ineffective.
It can be difficult in a hot climate to know if you have a fever. Buy a digital thermometer, and measure.
If you are not taking malaria pills but instead have been prescribed standby treatment for malaria, see the separate section “Standby malaria treatment” below.
Excessive exposure to heat, especially with exertion, can cause several health problems. Heat exhaustion can produce fatigue, weakness, nausea, lack of appetite, and sometimes fever. Treat this by finding a cool place to rest and by drinking lots of cool fluids which replenish both the water you need and the electrolyte imbalance that may have occurred. We recommend oral rehydration salts or Gastrolyte, following the packet instructions. If Gatorade is used, it should be diluted half and half with drinkable water. Avoid caffeine and alcohol which can further dehydrate you.
An easy way to tell if you are getting enough fluid is by noticing your urine output. If you are going very infrequently or it is dark in colour, you need more (clean) water.
“Prickly heat” causes numerous red bumps on the skin which can be itchy or uncomfortable. In most cases, heat-related problems are best handled by finding a cooler shady spot, avoiding exertion for a while, avoiding outdoor activities at the hottest time of the day, drinking lots of water and eating food that has some salt such as nuts, trail mix, or anything similar that you find available. Loose-fitting cotton clothing is advisable.
Several insects commonly bite travellers to the tropics including mosquitoes, flies, fleas and bed bugs. The bites can resemble each other, making it difficult to know which insect was responsible. The itch can be controlled with calamine lotion, cool compresses, “Afterbite” if you have it available or hydrocortisone 1% cream applied to the bite (though not if infected). Moist baking soda compresses can be used. If the bite looks infected (red, swollen, tender, pus), see the section below “Skin infections”.
There are several suggested medications and products for motion sickness. These include:
1. Dimenhydrinate (Gravol). It works much better if taken about two hours before the intended boat/car/air trip. The main side effect is drowsiness.
2. Scopolamine patch (Transderm V) (recommended for adults only). This can work well but there are reports of side effects including disorientation. It is better to have tried it at home before departure.
3. Sea band. This is a bracelet with a small disc that when applied properly on the wrist can relieve or prevent motion sickness. It is important that the disc be properly placed over the proper part on the wrist as this is an acupressure point.
There is a problem of counterfeit, sometimes harmful medications being sold in some countries. Buy your medications at one of the bigger and known pharmacies in the town you are in. Locals may be aware of pharmacy reputation in their town. Look for signs of unprofessional packaging, including misspelling of words and names. Be wary if the cost is unusually low. Examine the tablets for crumbling, flaws, colour faults. Check expiry dates.
Here are a few suggestions to reduce the chances of violence or theft.
If your hotel room has a safe, this is usually the best place to keep your passport and valuables. If there is none, it is often recommended that you keep these in the hotel safe rather than leaving them in your room or carrying them around with you. Ask for a signed receipt. In some countries, you need to carry your passport with you, while in others a photocopy will do. Your country guide book may inform you about this.
Keep a copy of your passport in a separate location
Don’t wear expensive jewellery or watches.
Know the parts of town; avoid empty streets particularly at night.
You may want to register with the Canadian embassy or high commission if your stay will be longer, at https://travel.gc.ca/travelling/registration.
Keep your wallet in a deep side or zipped pocket of your pants, not in your back pocket. A money belt worn under the shirt is a safe way to carry cash. It can be worthwhile to carry a “muggers wallet” with a little cash and one or two expired credit cards or non-financial plastic cards to hand over to a mugger.
In case of loss of credit cards, keep a copy of your credit card numbers and phone numbers to call, in a separate location.
It may be worthwhile keeping some cash and one credit card separate from your wallet.
Pack a rubber doorstop and use it to secure the inside of your hotel room door when needed as an additional way to prevent intrusion.
If you have had a sexual encounter and a condom was not used, there is a significantly increased risk of acquiring a sexually-transmitted infection. We recommend that you be seen by a reliable medical clinic and have appropriate testing done even if you have no symptoms. Ask about the availability and possible need for medication to help prevent HIV after a possible exposure (HIV post-exposure prophylaxis). Upon your return home, you should be seen by your family doctor or the Sexual Health Clinic in Ottawa.
Even if prostitution is legal where you are, human trafficking, sex with a minor, and child pornography are always crimes. If you become aware of someone who is abusing a child in this way, you can call the National Human Trafficking Resource Center at 1-888-373-7888 (answered 24/7).
These are common in the tropics. You can reduce the chance of problems by keeping your skin clean and dry. Shower often whenever possible. Try to avoid scratching insect bites as this can lead to skin infections. If you have an area that appears to be infected (eg an open sore with pus and surrounding redness or yellow crusted sores), cleanse it with soap and clean water and apply an antibiotic cream such as mupirocin (Bactroban) three times a day. Cover it with a bandage or band-aid when it is likely to be exposed to dirt, uncover it when not. Infections that seem to be worsening should be seen by a doctor or nurse.
Prickly heat – see Heat problems
Standby malaria treatment
Malaria is usually prevented by using anti-mosquito measures and taking anti-malaria pills during the trip. In some cases, travellers opt to use anti-mosquito measures only but will carry a treatment dose of malaria pills. These are to be taken if there is a fever and no possibility of being seen at an acceptable medical facility within 24 hours of the fever onset. The instructions are on the bottle label. Malaria can become life-threatening quickly so one should not delay in starting the tablets in the circumstances just described.
Prevention is of course much better than trying to treat sunburn. However, if you are suffering from it, here are some suggestions:
Stay in a cool, shady place
Apply wet cool towels to the burned areas for 15 minutes at a time, refreshing them, several times a day. This helps draw heat from your skin
Taking ibuprofen (Advil) at an early stage may help relieve the fever and pain that can accompany sunburn
Take acetaminophen (Tylenol, paracetamol) or other pain medication if necessary
Antihistamines may help
Moisturizers containing aloe vera and/or soy are recommended
We suggest you list the names and phone numbers of medical practitioners, such as your family doctor, who are familiar with any illness you may have.
We suggest you list any medications you are routinely taking.