CHAPTER 1

Overview of Travelers’ Health

Key Points:

The Risk of Illness While Traveling

How risky is foreign travel? People tend to exaggerate unlikely dangers such as terrorism or the potential for transmission of Ebola virus, and disregard or minimize more common perils such as motor vehicle accidents and malaria. Disasters, like the Indonesian tsunami of December 2004, killed thousands of tourists, but such catastrophic events are infrequent and unpredictable. Large disasters often divert attention from the simple day-to-day precautions that travelers can take to stay healthy and safe.

The chances of acquiring certain diseases, or of having an accident, depend largely on where you travel and what you do while traveling. Out of 30 million Americans who go abroad each year, approximately 8 million go to less developed countries where the incidences of tropical and infectious diseases are often high. Almost 7 million U.S. citizens travel to countries where there is risk of malaria. Surveys of travelers show that:

• There is a 60% to 70% possibility of illness when traveling in less developed countries for up to 90 days (median trip duration—19 days). Most of these illnesses are minor.

• There is a 5% to 8% chance you will seek medical care while traveling in a developing country.

• Your chance of being hospitalized will be less than 1%.

• The most common reported illnesses are: diarrhea (34%); a respiratory disease (26%); a skin disorder (8%); acute mountain sickness (6%); motion sickness (5%); an accident and injury (5%); an illness with fever (3%).

• On return home, there is about a 25% chance that you will have a bout of diarrhea, a respiratory illness, a skin problem, or a fever related to your trip.

Your individual risk, however, may vary considerably. For example, if visiting the Indian subcontinent, (and particularly friends and relatives) your risk of typhoid fever may be 18 times greater than for any other geographic region. Other variables that can affect your health include (1) the duration of your trip; (2) your use (or nonuse) of preventive antimalarial drugs; (3) your use of prevention measures against insect bites; (4) your vaccination status; (5) your risk-taking (or avoidance) behavior; and (6) your underlying health status.

Bear in mind, though, that traveling is usually good for one’s physical and emotional health. Aside from seeking holiday pleasures, some people travel to improve their lifestyle, perhaps to change harmful personal habits, “get in shape”—or temporarily (perhaps permanently) leave a stressful job, a bad relationship, a harsh climate, or other adverse life events.

Prevention of Illness

Preventing illness abroad involves learning as much as possible about the countries you will be visiting, consulting with a travel medicine provider to receive immunizations and medications and taking the necessary clothing, equipment, or devices (such as a water filter or mosquito net) to deal with local health conditions and climate. Your own health status should also be evaluated.

Most travel-related diseases can be prevented. Hepatitis, meningitis, yellow fever, and rabies are some of the many diseases that can be prevented by vaccination. Chemoprophylaxis, combined with protective measures against mosquito bites, can prevent virtually all cases of malaria, as well as many other insect-transmitted diseases, such as dengue fever and Japanese encephalitis. Sexually transmitted diseases, including HIV, can be avoided with behavior modification.

Types of Illnesses

Diarrhea (see Chapter 6) This is the most common malady affecting travelers. There is a 35% to 60% chance that you will acquire travelers’ diarrhea during a month-long trip to a less developed country. Adhering to safe food and drink practices can reduce your risk (but most travelers have trouble sticking to the guidelines). Prompt treatment with antibiotics and loperamide quickly resolves most cases of travelers’ diarrhea.

Malaria (see Chapter 7) This mosquito-transmitted illness, which can be fatal, is the most important parasitic disease to avoid overseas. Malaria is a serious health problem in many tropical and subtropical countries. Check your itinerary carefully to assess your risk of exposure.

Hepatitis (see Chapter 12) The viruses hepatitis A and hepatitis B pose potential risks for some travelers. Although both are rarely fatal, hepatitis A can ruin a carefully planned vacation and result in weeks or months of disability; contracting hepatitis B can have serious long-term consequences, including cirrhosis of the liver and liver cancer. You can prevent both hepatitis A and hepatitis B with vaccination. Although there are no vaccines against hepatitis C and E, Chapter 12 outlines measures you can take to reduce your risk of these illnesses.

Other Illnesses Colds and respiratory infections, skin rashes, ear infections, sunburn, sprains, contusions, and superficial injuries account for the majority of less serious problems.

Figure 1.1 Monthly Incidence Rate of Health Problems During Stays in Developing Countries

*ETEC - Entrotoxigenic E. coli. ETEC is usually responsible for 30 - 50% of all cases of travelers' diarrhea.

ACCIDENTS AND FATALITIES DURING TRAVEL

Although it is quite possible you will have some type of minor illness while abroad, the chance that your illness will be fatal is reassuringly small. Approximately 6,000 Americans die outside of the U.S. each year. The majority of these are long-term residents of a foreign country. The U. S. Department of State assists with the return of remains for approximately 2,000 Americans annually. Mortality abroad is due mainly to heart attacks, motor vehicle accidents, drownings, and other injuries. Cardiovascular disease causes about 50% of all deaths abroad, but most of these occur in older travelers. Cardiovascular death rates are not significantly increased by travel. Other points include the following:

• Injuries are the most common cause of death in younger travelers. Fatal injuries are mostly due to motor vehicle accidents and drownings. Air crashes (usually nonscheduled carries), suicides/homicides, burns, and electrocution are less frequent causes.

• The number of accidental deaths in 15- to 44-year-old travelers is higher by a factor of 2 to 3 as compared with rates among the same age group back at home in the United States or Canada. “Excess mortality” abroad, therefore, is mainly due to accidental injuries—not cardiovascular disease.

• Infections cause fewer than 4% of deaths abroad.

Accidents are the leading cause of death among travelers younger than the age of 55. Death rates from motor vehicle accidents, according to The Association for Safe International Road Travel, are 20 to 80 times higher in some countries than in the United States, illustrating one reason why “excess mortality” abroad is primarily injury related.

Table 1.1 Reported Deaths of U.S. Citizens Abroad by Cause of Death

*From October 1, 2002 to December 31, 2004
NOTE: This chart does not represent a statistically complete account of U.S. citizen deaths abroad. The chart depicts only deaths that were reported to the Department of State for which it was possible to establish that death was not due to natural causes. Most U.S. citizens who die abroad are resident abroad. Also, it is difficult to establish how many deaths go unreported to the Department of State. Note also that deaths attributed to "terrorist action" do not include deaths of U.S. military and government personnel in Iraq.

Studies have revealed that many road accidents involving tourists do not involve a collision between two vehicles but are due to loss of driver control caused by fatigue, alcohol or drug intoxication, unfamiliar road conditions, or other factors. In addition, in most developing countries vehicles are often in disrepair; roads poorly maintained; and common-sense rules of the road disregarded.

The Bethesda, Maryland-based Association for Safe International Road Travel (ASIRT; Tel: 301-983-5252; website: www.asirt.org) can provide a report on road safety conditions in 70 foreign countries. Their road travel reports also contain information about seasonal hazards; city, rural, and interstate traffic; and the most dangerous roads in various countries. ASIRT currently cites Egypt, Kenya, India, South Korea, Turkey, and Morocco as some of the most dangerous countries. (ASIRT, a nonprofit organization, requests a small donation in exchange for the information it provides.)

Preventing Traffic Accidents and Injuries

If you follow the recommendations below, you will decrease your chances of having an accident or being injured while driving overseas.

• Always wear a seat belt. Do not rent a vehicle without seat belts.

• Bring a car seat for infants, and place them in the back seat.

• Consider hiring a qualified guide or driver. This is essential in many countries, e.g., India.

• Do not be afraid to tell your driver to slow down or use more caution.

• Rent a larger rather than a smaller vehicle.

• Know the meaning of all international road sign symbols.

• Note that in some countries road signs are almost totally lacking—or the signs may be in the local language.

• Be sure you have collision/liability insurance.

• Know that a driver approaching a traffic circle must yield the right of way to those already in the circle.

• This traffic rule, like many others, may not be followed. Many drivers overseas just “drive with their horn.”

• Know the route to your destination. Study road maps (if available) thoroughly in advance of your trip.

Other advice for improving your road safety:

• Drive defensively.

• Keep a well-stocked first aid kit in your car and know how to use it.

• Travel in convoy with other cars.

• Do not travel alone in a vehicle.

• Have a communications system that covers where you are traveling.

• Report your progress to someone who knows your route plan and agree with them what action they will take if you do not make contact at a scheduled time.

• Plan how you will get emergency service in response to an accident.

• Plan how you will get medical treatment in case of an accident.

Table 1.2 Global Road Toll Fact Sheet

From the Association for Safe International Road Travel, www.asirt.org. Used with permission

The two most important rules to follow are:

• Do not drive at night in rural areas.

• Do not ride a motorcycle, moped, or bicycle (even if you are experienced).

PERSONAL SAFETY GUIDELINES

Although you can’t escape the remote possibility that you simply may find yourself “in the wrong place at the wrong time,” you can take steps to enhance your personal safety while traveling: plan your trip carefully, be reasonably cautious, obey common-sense rules of behavior, and don’t panic! Remember that the vast majority of travelers arrive home unscathed.

The following guidelines will be helpful in ensuring your travel safety:

• Carefully select swimming areas. Don’t swim alone, while intoxicated, or at night.

• Avoid small, nonscheduled airlines in less developed countries.

• Don’t travel by road at night outside urban areas. If you are out at night, stay in a group.

• Don’t go out alone on beaches at night.

• Don’t hitchhike or pick up hitchhikers.

• Don’t sleep in your car or RV at the roadside at night.

• Camp only in legal campsites.

• If you are drinking alcohol, don’t relax by sitting on the railing of your hotel balcony. Falls and serious injuries often occur this way.

• Review hotel fire safety rules. Locate nearest exits.

• If possible, book a room between the second and seventh floors—high enough to prevent easy entrance by an intruder and low enough for fire equipment to reach.

• Lock your hotel room at all times.

• Keep valuables and travel documents in your room (in-room safe) or hotel safe.

• Avoid countries or regions where there is drug-related violence and drug trafficking. Avoid excursions into remote areas of certain countries such as Mexico, Colombia, or Peru, where you might be mistaken for a drug agent or a rival drug dealer.

• Never purchase, transport, or use illegal drugs.

• Don’t accept drinks or rides from a stranger you have just met.

• Familiarize yourself with the local laws and customs of the countries to which you are traveling and abide by them. Know the laws about exchanging money and deal only with authorized agents when you exchange money or purchase art or antiques.

• Put identifying markings on your luggage. Don’t, however, put your home address or telephone number on your luggage tags. Instead, put a business card in the tag, or a use a P.O. box address and a business, mobile telephone, or third- party telephone number for contact.

• Do not put all your valuables in luggage you check; e.g., jewelry, cameras, watches. Besides your luggage possibly being lost, there is, unfortunately, increasing theft occurring during security searches of checked luggage. The best course is not to travel with any item of significant value.

There are numerous publications that provide specific advice on personal safety and security. Suggested titles include The Safe Travel Book—A Guide for the International Traveler by Peter Savage (Lexington Books: 800-462-6420) and The Security Minute; How to Be Safe in the Streets, at Home, and Abroad So You Can Save Your Life! by Robert L. Siciliano (Safety Zone Press: 800-438-6223).

CORPORATE SECURITY

Risk Management Companies

In times of geopolitical turmoil and terrorist activity, corporate interests are often targeted and advising corporations on matters of safety and security has become increasingly important. The companies listed below provide a variety of services that include the following: crisis management and contingency planning; hostage-release negotiation; counter-terrorism education/training; defensive driving training; executive protection; travel advisories and warnings; country-specific political analyses and risk assessments.

International SOS Assistance, Inc.
3600 Horizon Boulevard, Suite 300
Trevose, PA 19053
215-942-8000 or 1-800-523-8930
http://www.internationalsos.com/

iJET Travel Risk Management
910F Bestgate Road
Annapolis, MD 21401
410-573-3860
http://www.ijet.com

Kroll International
900 Third Ave., 8th floor
New York, NY 10022
800-212-593-1000
http://www.krollworldwide.com

State Department Security Advisories

You can obtain in-depth advice about specific security issues in any country by contacting the Regional Security Officer (RSO) at the embassy of the country to which you will be traveling. Here is the procedure:

• Contact the Department of State at 202-647-4000 and ask to be connected to the Country Desk covering the destination country.

• Request the name and overseas telephone number of the Regional Security Officer (RSO) stationed at the embassy. The State Department maintains a listing of Key Officers at each embassy.

• Telephone the RSO during embassy business hours in the destination country. Inquiries often include questions about:

• The safest taxi cab/route to take from the airport

• Street crime or terrorism problems

• Neighborhoods to avoid

• Recent incidents involving tourists or corporate executives

• Safety of public transportation

OSAC 

The Overseas Security Advisory Council (OSAC) was established in 1985 by the U.S. Department of State to foster the exchange of security-related information between the U.S. Government and American private sector operating abroad. Administered by the Bureau of Diplomatic Security, OSAC has developed into a successful joint venture for effective security cooperation. Through OSAC, the American private sector, including colleges and universities, is provided timely information on which to make informed corporate decisions on how best to protect their investment, facilities, and personnel abroad.

BUREAU OF CONSULAR AFFAIRS

How the Government Can Help

The website of the Bureau of Consular Affairs (www.travel.state.gov) is an extensive and convenient source of information that lists passport and visa requirements, foreign country entry requirements, a listing of embassies and consulates overseas, and emergency services for U.S. citizens abroad. The Bureau of Consular Affairs also issues consular information sheets,  travel warnings, and public announcements on more than 200 countries.

• Consular information sheets include the location and telephone number of the embassy and each consulate, information on health conditions, political disturbances, currency, entry regulations, and crime and security activities in each country.

• Public announcements disseminate information about terrorist threats and other relatively short-term and/or trans-national conditions posing significant risks to the security of travelers.

• Travel warnings list countries the State Department believes should be avoided, except for essential travel. Some travel authorities believe, believe, however, that the travel warnings are often alarmist and damage tourism to a particular country.

Emergency Services to U.S. Citizens Abroad

The Office of American Citizens Services and Crisis Management (ACS) serves Americans traveling or residing abroad. Services provided by ACS include help with the following:

• Arrest/detention of an American citizen abroad

• Robbery of a citizen abroad

• Death of an American citizen abroad

• American citizen missing abroad; welfare and whereabouts inquiries

• Legal services; document issuance; help with financial emergencies

• Disaster assistance

• Crises abroad that involve a U.S. citizen

• Medical emergencies. If emergency medical transport or an air ambulance is needed, the OCS may refer you (or the people helping you) to an assistance company. The U.S. government won’t pay the costs of transport, but the OCS can facilitate transfer of funds. Working with the embassy or consulate, the OCS will help coordinate stretcher transport on a commercial airliner to bring a sick traveler home to the United States. In event of death, they will assist with returning the remains.

• Contacting the Office of Overseas Citizens Services directly Consular duty personnel are available for emergency assistance 24 hours a day, 7 days a week, at embassies, consulates, and consular agencies overseas and in Washington, D.C.  To contact the Office of Overseas Citizens Services in the U.S. call 1-888-407-4747 (during business hours) or 202-647-5225 (after hours).  Contact information for U.S. embassies, consulates, and consular agencies overseas is on the Internet site. Overseas Citizens Services Telephone Assistance—888-407-4747 (From Canada and overseas: 202-501-4444).

TRAVEL HEALTH INFORMATION

Almost all health problems related to travel are either preventable or can be minimized, but most travelers are often unaware of just what those risks may be. A travel clinic can be an excellent source for this information, but time constraints limit the amount of advice a practitioner can dispense in one or two office visits. And if the clinic hands out printed material, how much will you read or remember? And is the information you are given sufficient? It is often essential that you do additional pre-departure reading and data gathering. The Internet can provide the most current information, if you know where to find it, but books that are updated on a regular basis are also good references (and can be brought along on your trip, as well). However, it’s possible that no single resource, printed or electronic, will provide all the information that you may need, so numerous resources are listed in this chapter. Be aware that these sources of information may not always be in agreement. For example, the Centers for Disease Control and Prevention (CDC) recommends that malaria prophylaxis be taken in all malarious areas, whereas many travel clinics and other information sources usually advise that low-risk, short-term travelers may rely instead on insect bite-prevention measures, or carry standby malaria treatment medication. And some literature in travel medicine advises that children with diarrhea not be treated with quinolone antibiotics, when in fact this treatment may be preferred. NOTE: Information is sometimes available from retail travel agents, tour operators, and airlines and other common carriers, but the quality of this information varies and may be unreliable.

Travel Health Information from the CDC

CDC's Traveler's Health website - http://wwwn.cdc.gov/travel

Go to the website of the Centers for Disease Control and Prevention (CDC) to obtain a vast amount of travel health advice and information, such as disease outbreaks, vaccination requirements, destination risks, and much more. You can also download for free chapters from Health Information for International Travel (the Yellow Book. The Yellow Book is published every two years by the CDC as a reference for those who advise international travelers of health risks, but it is also useful for travelers who are not medical professionals. The book can also be purchased online (softcover) for $24.95 at http://www.amazon.com/ or at Elsevier Inc. at their website http://www.us.elsevierhealth.com/product.jsp?isbn=9780323048859.

Additional Online Travel Health Information

United States

• Shoreland, Inc.—www.tripprep.com

• Travel Medicine, Inc.—www.travmed.com

• MDtravelhealth—www.mdtravelhealth.com

Canada

• HEALTH CANADA—http://www.phac-aspc.gc.ca/tmp-pmv

United Kingdom

• The Travel Doctor—www.traveldoctor.co.uk

• MASTA (The Medical Advisory Society to Travellers)-http://www.masta.org

• National Travel Health Network & Centre (NaTHNaC)—http://www.nathnac.org/

The National Travel Health Network and Centre, NaTHNaC, was created to promote clinical standards in travel medicine by improving the quality of travel health advice available to GP practices and other health care providers. The Outbreak Surveillance reports are especially useful and much more comprehensive and up-to-date than those of WHO.

• Fit fort Travel—http://www.fitfortravel.scot.nhs.uk/

"fitfortravel" is a public access website provided by the NHS (Scotland). It gives travel health information for people travelling abroad from the UK. The website is compiled by a team of experts from the Travel Health division at Health Protection Scotland (HPS). This is the only site the Health Guide could find that has malaria maps of all endemic areas.

Australia

The Australian Government's travel advisory and consular assistance service.

• http://www.smartraveller.gov.au/index.html

Europe

• Fit For Travel-http://www.fit-for-travel.de/en

TRAVEL CLINICS

Before you depart you’ll want to consult with your health-care provider if you have medical problems, are traveling to a less-developed country (where there is often the risk of tropical and infectious diseases), or planning an extended trip abroad. Specialized immunizations and prophylactic medications may be recommended or required. Although your own doctor may be able to administer some routine immunizations, most physicians’ offices don’t stock specialized vaccines, such as typhoid, rabies, or meningitis, and they are not authorized to stock and administer yellow fever vaccine, or issue the International Certificate of Vaccination. (Public health departments can administer yellow fever vaccines.) More importantly, your health-care provider may not have the expertise or resources to advise you about safe travel, or what to do if you get sick abroad. There are more than 220 different countries with evolving and varying disease-risk patterns, and providing travelers with accurate health information can be complex and time consuming. Most physicians are not prepared, or willing, to give this type of consultation.

Fortunately, the specialty of travel medicine has expanded rapidly over the past 15 years and there are now many physicians and nurse practitioners that either specialize in this field, or have added it to their regular practice. Although no specialty board certification is required to practice travel medicine, most travel medicine practitioners have received further training under the auspices of the International Society of Travel Medicine (www.istm.org) and/or the American Society of Tropical Medicine and Hygiene (www.astmh.org). Both of these organizations have developed specialty examinations that award a Certificate of Knowledge.

More information on the practice of travel medicine is found here.

Types of Travel Clinics Travel clinics vary in their ranges of services and professional staffing. Sometimes a medical facility is dedicated solely to this specialty, but often a travel clinic is from a doctor’s private practice, an ambulatory care clinic, an HMO or group practice, an occupational health clinic, or the infectious disease department of a university teaching hospital. These clinics, unlike regular physician’s offices, are almost all tied into Internet and electronic databases that provide them with updated travel/health information and conditions worldwide.

Travel clinics supervised by physicians trained in infectious and/or tropical diseases are usually better able to counsel travelers with special needs, or who have returned from abroad with a suspected or undiagnosed tropical or infectious disease. Such clinics are often, but not invariably, associated with a university hospital or a medical school.

Finding a Travel Clinic

If you need to locate a travel clinic, visit one of the websites listed below. They have extensive listings, but no one website lists all clinics currently operational. The ISTM, ASTM&H, and Travel Medicine, Inc., websites also list travel clinics in many countries worldwide. This can be helpful if a travel/tropical disease specialist needs to be contacted for an illness occurring abroad.

Travel Clinics in the United States & Canada

• Travel Medicine, Inc.   (www.travmed.com)

• Shoreland, Inc., Travel Health Online  (www.tripprep.com)

• International Society of Travel Medicine (ISTM) (www.istm.org)

• American Society of Tropical Medicine and Hygiene (ASTM&H) (www.astmh.org)

• HEALTH CANADA  (http://www.phac-aspc.gc.ca/tmp-pmv/travel/clinic_e.html)

Travel Clinics in the United Kingdom

• The Travel Doctor   (http://www.traveldoctor.co.uk/clinics.htm)

• MASTA   (http://www.masta.org)

Finding Hospitals and Doctors Overseas

The International Association for Medical Assistance to Travellers (IAMAT) publishes a booklet listing English-speaking physicians and healthcare facilities worldwide. IAMAT also provides information on tropical diseases such as malaria and schistosomiasis. IAMAT is a tax-free foundation, and there is no charge for their publications; a donation, however, is requested. IAMAT, 417 Center Street, Lewiston, NY 14092; 716-754brr4883. In Canada: 40 Regal Road, Guelph, Ontario, N1K 1B5; 519-836-0102.

The Destinations section on www.travmed.com has listings of hospitals and physicians for every country.

Chapter 16 of this book will tell you how to locate medical care abroad (see link below).

Hotels and resorts can refer you to a local English-speaking doctor.

Most U.S. and Canadian embassies and consulates maintain lists of physicians and medical facilities for distribution to travelers needing medical care. The inclusion of a specific physician or medical facility does not constitute a recommendation and the Department of State assumes no responsibility or liability for the professional ability or reputation of, or the quality of services provided by, the medical professionals, medical facilities, or air ambulance services whose names appear on such lists. See U.S. Embassies and Consulates websites to access medical lists for specific countries. Lists are normally found under the American. Citizens Services section of the embassy website.  Note: These lists are not always well-maintained or updated. The U.S. Department of State has not established a standard form or protocol for identifying medical in each country.

Travel insurance policies with assistance. Companies such as the International SOS (http://www.internationalsos.comand Medex (http://www.medexassist.com) provide policyholders with access to an extensive network of doctors and hospitals worldwide. Physician referrals and monitoring of hospital care are parts of the assistance package provided.

Obviously, in many emergencies, such as a heart attack, stroke, or serious motor vehicle accident, you won't be able to choose which facility you're transported to. (And in many locations there won't be alternative choices.) This is why travel medical insurance that has an "assistance" feature is so important; the assistance hotline center can monitor your medical care and decide if immediate evacuation to a more advanced medical facility, even in another country, is indicated.

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 TRAVEL MEDICINE PUBLICATIONS

Travelers’ Health Publications

International Travel Health Guide by Stuart R. Rose, MD, FACEP and Jay Keystone, MD (Elsevier, 2006. Paperback). This is the print edition of  content on this website. The International Travel Health Guide is also available at amazon.com.

Travel Medicine, edited by Jay Keystone, M.D., et al. (Mosby 2007) The standard textbook in the field of travel medicine, with contributions from over 70 internationally recognized experts. Available at amazon.com.

Travel Medicine Advisor—A comprehensive source of travel health information from an online database with bimonthly newsletter updates in both print and electronic formats. Editor: Frank Bia, MD, MPH; American Health Consultants, Atlanta, GA; 800-688-2421—(www.ahcpub.com).

The Travel and Tropical Medicine Manual, edited by Elaine C. Jong, M.D. and Russell McMullen, M.D. (WB Saunders, 2007. Paperback). A comprehensive source of information on tropical medicine and travel-related infectious diseases.

Traveler's Health—How to Stay Healthy Abroad by Dr. Richard Dawood (Random House, 2002). A well-known source of travel health information compiled primarily by British experts. Available on amazon.com.

Health Information for International Travel (The CDC’s “Yellow Book”). This is a travel medicine reference manual published biannually. The paperback version of the Yellow Book can be ordered from the publisher at http://www.us.elsevierhealth.com/. Chapters from the book can be downloaded at no charge from the CDC website. The Yellow Book is written primarily for healthcare providers, but travelers will also find it useful.

Wilderness Medicine and First-Aid

Wilderness Medicine - Management of Wilderness and Environmental Emergencies, 2003. Paul S. Auerbach, M.D., editor (Mosby, 2001) The primary reference for anyone seriously involved in outdoor and medicine.

A Comprehensive Guide to Wilderness and Travel Medicine by Eric A. Weiss, M.D. (Adventure Medical Kits; 800-324-3517). Also available on amazon.com.

The Pocket Doctor: A Passport to Healthy Travel by Stephen Bezruchka, MD. Provides the traveler with a quick reference for avoiding-and treating-travel-related illness and injuries.

Underwater Medicine/Decompression Chambers

For a guide to hyperbaric and decompression chamber facilities worldwide, contact the Undersea and Hyperbaric Medical Society, 9650 Rockville Pike, Bethesda, MD; 301-571-1817.

High Altitude Illness

Medicine for Mountaineering & Other Wilderness Activities, by James A. Wilkerson (Paperback, 2001). Available from Amazon.com.

Internet-based altitude illness information: www.high-altitude-medicine.com. This website also contains a listing of numerous publications on mountaineering medicine, altitude illness, wilderness medicine, and first-aid.

Travel Medicine Databases

During the past decade, there have been dramatic increases in the amount of travel health information available electronically, either via the Internet or distributed on PC disks or CD-ROMs. The advantage of these systems lies in their ability to provide updated, organized, itinerary-specific information in a format that can be printed out for the traveler. This is of great help in pre-travel counseling and trip preparation. In addition, some systems can also alert overseas travelers via e-mail about evolving emergency conditions—be they medical or safety/security related. Other systems allow a company to check on an employee’s whereabouts and current status—a feature especially used by corporate medical and security departments tracking overseas employees who may be at risk.

TRAVEL CARE—International SOS Assistance, Inc., 3600 Horizon Boulevard, Suite 300, Trevose, PA 19053; 215-942-8000 or 1-800-523-8930. Website: www.internationalsos.com (or www.travelcare.com for a free demonstration).

Online travel health program designed for the medical professional conducting pre-travel medical consultations. TRAVEL CARE’s sophisticated but easy-to-use databases help the practitioner decide on appropriate vaccinations and malaria prophylaxis and also evaluate current health risks for any itinerary. Detailed country reports and advisories include comprehensive medical and disease-risk information, as well as nonmedical information—such as safety and security issues, cultural tips, and types of electrical plugs (including photos). Updated health and security advisories can be sent by e-mail to the overseas traveler. The “Traveler Locator Service” from the International SOS consolidates a company’s airline booking data into one database and allows company executives to search this data online to track employee travel. These searches can be current, prospective or historic, with data searched by continent, country, city, hotel, flight number, or country risk rating.

TRAVAX-Shoreland, Inc., 2401 N. Mayfair Road, Suite 309, Milwaukee, WI 53226; 800-433-5256; 414-290-1900; e-mail: sales@shoreland.com; Internet: www.shoreland.com. Basic travel health recommendations, including country-by-country disease-risk information, vaccine recommendations, and current disease outbreak alerts. Disease-by-disease fact sheets. Very detailed malaria, yellow fever, and cholera risk maps by country. Health-related entry requirements. Detailed country profiles, including geography and climate. Crime, security, and other associated information. Contact information for U.S., Australian, and Canadian embassies and consulates. List of Internet URLs for U.S. State Department resources. Itinerary maker feature considers order of travel and presents summary recommendations for entire itinerary. Printout for each country can be customized to allow physician-added comments and allows deletion of sections not of use to an individual patient.

Travax EnCompass, an expanded (detailed overseas medical facility data) wholly Internet-based version, is available to corporations under a licensing agreement.

CATIS-Computerized-Assisted Travel Information System (CATIS). Dr. David Lawee; Travel Information & Supplies; PO Box 41003, 2795 Bathurst St. Toronto, Ontario, Canada M6B 4J6. Tel/fax: 416-785-6219.

Content: Country-by-country vaccine recommendations, plus disease risk information both textual or illustrated with colored maps. Brief disease and vaccine fact sheets. Comparison maps for the CDC, WHO, CATMAT; malaria recommendations. Itinerary maker feature requires responses to a multiscreen detailed questionnaire even if patient and itinerary are uncomplicated. Requires patient to have detailed knowledge of in-country itinerary. Printout generated accounting for traveler health status. Printed prescription for malaria prophylaxis with calculation of dosage, number of tablets required, and schedule of administration. No country background or emergency contact information.

Kidney Dialysis Abroad

Global Dialysis is a resources for both renal patients and medical professionals. Their  directory lists over 14,000 centers in 154 countries, making it the largest database of dialysis centers available in the world.

Dialysis at Sea Cruises  They are largest provider of dialysis services aboard cruise ships. Tel: 800-544-7604; Website: http://www.dialysisatsea.com/about.aspx