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U.S. Department of Health and Human Services

Inspections, Compliance, Enforcement, and Criminal Investigations

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Inspections

EXHIBIT 4A

 
 
 

EXHIBIT 4A
Health Care Tips for International Travelers

 
  1. Long Trips

    Exercise --To avoid circulatory problems in your legs, stand up and walk for several minutes every hour or so. This may be inconvenient, but isn’t your health worth it?

    Eating and Drinking -- Drink plenty of liquids. Avoid overindulgence. Drinking excessive amounts of alcohol and eating too much can result in gastrointestinal problems, poor sleep pattern adjustment, and altered moods.

    Jet Lag --In order to minimize the fatigue often associated with changes in time zone, eat normally and try to get a good initial night’s sleep at your destination.

  2. Food and Drink

    Beverages
    In developing countries, water sources may be contaminated. Avoid tap water in all forms to avoid disease. Beware of confident assertions of water quality; local standards and testing may not be up to our standards.


    Avoid:
    Tap water by the glass or in mixed drinks.
    Ice that was made with tap water.
    Tap water used when brushing your teeth. Even a small quantity of infected
    water can make you sick.


    Safe Beverages:
    Boiled water--five minutes of boiling is adequate except at high altitudes where water should be boiled for ten minutes.
    Hot beverages--relatively safe even if full boiling is not assured.
    Bottled water--carbonated water may be preferable to ensure that it was just opened and not filled at the tap.
    Bottled or canned beverages--soft drinks, beer, wine.
    Treated water--commercial iodine or chlorine tablets provide substantial protection if added to tap water and allowed to stand according to the directions.

    Food
    In developing countries, the most important foods to avoid are raw vegetables. Fruits and vegetables that grow near to the ground are likely to be contaminated by the same organisms as the tap water: amoebas and other parasites, hepatitis virus, etc.


    Avoid:
    Raw vegetables including salads--rinsing them in water is not adequate.
    Fruits, especially those that do not have a thick outer covering.
    Rare or raw meat or fish.
    Dairy products from small independent vendors.
    Avoid food of any kind that has been left out in the sun, especially soups,
    custards, creams, and mayonnaise.


    Safe Foods:
    Cooked fruits and vegetables.
    Fruits with a thick covering (citrus fruits, bananas, and melons).
    Meat or fish that is thoroughly cooked (pork and lamb should be well done; beef
    medium).
    Dairy products from large commercial dairies.

  3. Diarrhea
    Many travelers get diarrhea while abroad. A normal case would include two to four watery stools per day, with cramping for several days. Occasionally, the symptoms begin with nausea and vomiting, low-grade fever, and frequent stools, with symptoms subsiding in four to twelve hours. Bloody diarrhea, severe abdominal pain, high fever, or dehydration call for prompt, expert medical attention.

    Avoiding Diarrhea
    The best way to avoid diarrhea is to avoid tap water, ice, salads, and foods that have been left out in the sun.

    Treatment of Diarrhea
    No matter how careful you are about choosing safe foods and beverages, you may develop diarrhea since some microbes are passed by personal contact. The most common cause of tourists’ diarrhea can be treated with Pepto-Bismol or a similar product. Effective drugs that control the frequency of diarrhea include Lomotil (diphenoxyiate), lmodium (loperamide), and Kaopectate. If you have any of the following warning signals, find medical help.

    Warning Signals:

    • Severe abdominal cramps
    • Severe abdominal pain
    • High fever
    • Blood or mucus in your stool
    • Severe dehydration

     

    Consulting local pharmacists or others can lead to misfortune; many drugs sold in developing countries contain ingredients that are impure or toxic. Entero-Vioform is a drug widely distributed abroad for treatment of diarrhea, but this drug has been linked to neurological complications--do not use this drug under any circumstance. Unless you are an expert at reading medical components in the language of the country, do not buy any product without consulting a competent doctor.

    If you are going to be more than 48 hours away from any medical care, consult your physician in advance about prescriptions you might need to take with you.

    Treatment of Dehydration
    Maintenance of adequate fluid intake is essential to prevent dehydration. Oral intake of fluid and salts must be continued in spite of vomiting or diarrhea.

    The following solutions are recommended:

    1. Fruit juice (canned or boiled) or bottled sugar-soft drinks alternating with
    2. Water (boiled) 8 oz., with the following:
      baking soda--1/4 tsp.
      table sugar--1/2 tsp.
      table salt--1 pinch
      No-Salt (potassium salt)--1 pinch

     

    Medical Follow-up of Diarrhea
    Upon returning home, you may want to consult with your physician about the advisability of having a stool examination.

  4. Diseases Spread by Respiratory Routes
    Many diseases including influenza, tuberculosis, and diphtheria are spread by respiratory droplets released when infected individuals sneeze, cough, or talk. Diphtheria and influenza can be prevented or altered by immunization. Tuberculosis must be monitored by periodic skin tests. Consult your physician about testing and immunization.
  5. Mosquito Borne Diseases

    Avoiding Mosquitoes
    Mosquito Repellent--Take an ample supply of a liquid mosquito repellent with at least 30% of the active ingredient Diethyltoluamide (DEET).
    Long sleeves and long pants--Wear protective clothing at dusk when malaria mosquitoes often bite.
    Mosquito netting--Use this at night if available. Tuck it around the mattress, and then spray with insecticide inside the netting.

    Malaria
    Malaria is transmitted through the bite of some mosquitoes. It is not common in urban areas or altitudes above 3000 feet. Malaria is characterized by high fever and chills. You may get the disease any time after the first week of contact, even years later. Most malaria attacks occur while you are in the area, or within a few weeks thereafter.

    Prevention: If you enter an area with malaria mosquitoes even briefly, you must take a weekly pill(s). Chlorquine (Aralen) and sulfadoxine-primethamine (Fansidar) are the drugs of choice. Treatment should be started one week prior to exposure and continued six weeks afterward. You should consult your physician.

    Yellow Fever
    Yellow fever is a viral disease that can be prevented by immunization. The disease is characterized by fever and severe gastrointestinal problems and is often fatal. Anyone entering a region with yellow fever should have a yellow fever immunization, even if the country has no entry requirement.

    Dengue
    This viral disease causes severe fever, muscle aches, and fatigue, but is rarely fatal. At this time it can not be prevented by medicine or immunization. Use of insect repellent and mosquito netting is the best preventative.

    Japanese B Encephalitis
    This virus causes high fever and brain infection initially manifested as decreased alertness and confusion. Immunization is recommended in areas of active transmission.

  6. Swimming

    Fresh Water

    In South America, Africa, and Asia, many fresh water ponds are infested with a parasite which enters the body through the skin and causes a chronic disease called schistosomiasis. Do not swim in fresh water unless a reliable source assures you there is no schistosomiasis.

    Chlorinated Pools and Salt Water
    Chlorinated pools and salt water are generally safe from infectious diseases.

  7. Altitude
    Even healthy athletic individuals may become ill at altitudes over 10,000 feet. Young children are especially at risk. Common symptoms are headache, shortness of breath and fatigue. If you are going to high altitudes, you should rest during the first 12-24 hours there in order to adjust to the decreased oxygen content of the air. You may also wish to consult your physician about obtaining some acetazolamide (Diamox). Individuals with chronic heart and lung disorders should consult a physician before traveling to altitudes over 3000 feet.
  8. Medical Assistance Abroad
    The International Health Care Service can provide you with the names of English speaking doctors prior to your departure. The United States embassies can often recommend physicians; the cooperativeness of the embassy and the quality of their recommendations is variable.
  9. Immunizations
    Immunizations build up your immune defenses against specific diseases. Required immunizations enable a traveler to enter a country. Many immunizations are not required, but are quite useful for protecting your health and are therefore recommended. There are 19 immunizations the traveler should consider. An asterisk (*) marks those given to most travelers to the developing world. You should get your immunizations six weeks prior to departure for optimal effectiveness. Adequate (but less than optimal) protection can usually be given on shorter notice.
    1. Smallpox--this disease no longer exists. Since serious side effects can result from the immunization, it should never be given. If some country still requires this shot for entry, a letter of contraindication from a physician may be acceptable to waive the requirement.
    2. Yellow Fever--This often fatal disease, carried by mosquitoes, can be prevented by a safe live virus. It is imperative that anyone entering a yellow fever zone receive this immunization. Booster Frequency: 10 years.

    3. Cholera--This severe diarrheal illness, transmitted by infected water almost never occurs in North American travelers. Also, the vaccine is relatively ineffective. However, many countries require this shot if you enter from a cholera infected country. In certain instances, it is practical to have this shot in advance in order to avoid being detained at borders.
    4. *Tetanus--This disease is caused by infected wounds and occurs all over the world. Everyone should be current on tetanus shots regardless of travel.
      Booster Frequency: 10 years.
    5. *Diphtheria--Although this respiratory disease has been largely eradicated in the United States, it is very common in developing countries. Travelers should be current on their immunization. Booster Frequency: 10 years.
    6. *Polio--Polio is a viral disease that causes paralysis and death. It is widespread over the developing world. It is transmitted by human stool, especially via water. Booster Frequency: 5 years.
    7. *Gama Globulin--Gama Globulin protects against Hepatitis A, an illness common among travelers. Gamma Globulin will protect the recipient from most symptoms. Booster Frequency: 3 months (small dose--2cc) or 6 months (large dose--5cc).
    8. *Typhoid--This bacterial disease causes fever and gastrointestinal disease. The immunization provides partial protection and may be recommended for certain travelers and certain locations. Booster Frequency: 3 years.
    9. Measles--This viral disease is epidemic in Central Africa. The vaccine is recommended for those areas if the traveler has not already had either the disease or vaccine.

      The following are indicated only for individual travelers because as dictated by medical history or the unusual nature of the trip.
    10. Plague
    11. Rabies
    12. Meningococcus
    13. Influenza
    14. Pneumococcus
    15. Mumps
    16. Rubella
    17. Hepatitis B
    18. Japanese B encephalitis
    19. Hemophilus
  10. Travel Health Kit
    Do not plan to buy medicines abroad. Take an ample supply of any prescription medication with you. Try to take any medications that you might need with you. Keep them in their original packaging to avoid confusing border guards. You may want to carry medications and treatments for the following symptoms or problems:

     

    • Common Cold
    • Constipation
    • Cuts, scratches, burns
    • Diarrhea
    • Heartburn or indigestion
    • Insomnia
    • Motion sickness
    • Allergies
    • Nasal congestion
    • Pain or fever
    • Sore throat
    • Malaria prevention
    • Protection against insects
    • Sun screen

    Ask your pharmacist for recommendations.

  11. Return to North America
    Upon returning to North America, some travelers should have a physical examination including blood tests and stool analysis. The need for specific tests will depend on where you went, how long you stayed, and what you did. Consult with your physician before you go and schedule an appointment for your return if advisable.