Preparation for Foreign Dive Travel: Considerations for Local and Exotic Destinations

Modern divers travel to all corners of the globe, and in doing so may encounter extraordinary health risks. These include uncommon bacterial and viral infections, tropical parasite infestations, marine animal envenomations, and exotic or contaminated food poisoning. According to Dr. Stuart Rose, who publishes the superb International Travel Health Guide each year (Travel Medicine, Inc., [800] 872-8633), factors which determine the risk of illness for a traveler overseas include the countries visited, the length of the trip, the use of prophylactic medications, personal protection against insect bites (DEET-containing insect repellent, permethrin-containing clothing spray or solution, mosquito netting around the bed), vaccinations received, health status, and personal behavior. In many foreign countries, sophisticated medical care is remote, or unavailable. Therefore, it is important for every traveling diver to anticipate likely health hazards and be prepared to act swiftly in the event of an illness or injury.

Preparation for foreign travel includes sufficient physical and dental examinations to identify treatable problems before undertaking the journey, obtaining appropriate immunizations, determining the need for any particular drug prophylaxis (e.g., against malaria), assembling a proper medical kit, and identifying medical resources along the route of travel and at the dive destination.

If you have not had a dental examination within the past six months, visit your dentist and complete any remedial dental work necessary to correct carious teeth, gum infection, eroding caps or crowns, and faulty dental appliances. Nothing ruins a trip faster than a toothache, and a dentist may be nowhere near the dive site. Have your doctor write prescriptions for all essential drugs you will be carrying so you may procure replacement drugs if your supply becomes exhausted or is lost. It doesn’t hurt to carry a letter from your physician as well, stating your medication list with doses. It’s also a good idea to carry a spare pair of glasses or contact lenses. Always take along a copy of your prescription in case you need to have new glasses made.

Medical emblems (e.g., bracelets) or wallet cards can prove extremely useful, particularly if you become incapacitated and cannot communicate your personal medical information with precision. Medic Alert, (800) 825-3785, is the best-known program, with body-worn emblems that are inscribed with a person’s most critical medical facts, as well as a telephone link to a 24-hour Emergency Response Center where more information can be obtained. The Life- Fax Emergency Medical Response System, (800) 962-8620, offers a wallet card which allows the card carrier to link to a central database and initiate an immediate fax of personal medical information to any location.

Be certain to identify the location of the nearest hyperbaric chamber facility, either by contacting the Divers Alert Network (DAN), (919) 684-2948, or the Undersea and Hyperbaric Medical Society, (301) 942-2980. The International Association for Medical Assistance to Travelers (IAMAT), (716) 754-4883, can provide you with a booklet listing English-speaking physicians and health clinics worldwide. In a crisis overseas for which you need translation, call the AT&T Language Line, (800) 628-8486.

When carrying medications, keep them marked clearly, and keep each drug in a separate container. Use the original labeled container if possible, so that customs inspection is less onerous. Do not carry narcotics or controlled drugs (e.g., sleeping pills) unless medically necessary. If you must carry needles or syringes, carry a letter from your physician stating the medical necessity.

Immunizations are critical in the prevention of disease. When yellow fever and/or cholera immunization is required to enter a country, you must carry a validated certificate of vaccination (“yellow card”), which can be obtained only at an authorized Yellow Fever Vaccination Center, usually a travel medicine clinic or Health Department immunization clinic. Failure to secure validation at an authorized city, county, or state health department renders the certificate invalid and may force a traveler to be revaccinated or quarantined. The form (stock number 017-001-004405) is available from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.

You should list all immunizations, current medications, and critical prescriptions (e.g., eyeglasses) on the card. To determine which immunizations are necessary for travel to a particular country, call the Centers for Disease Control (CDC) Travelers’ Health Hotline, (404) 332-4559 automated voice or (404) 332-4565 fax. The voice line provides malaria advisories, immunization schedules, disease risk and prevention information by region of the world, and disease outbreak bulletins. The fax line allows retrieval of hard copy. A detailed, updated list of required immunizations by country may be obtained in the annual publication Health Information for International Travel (Centers for Disease Control, 1600 Clifton Road NE, Atlanta, GA 30333; or U.S. Govt. Printing Office, Washington, DC 20402 — HHS Pub. No. [CDC] 85-8280). In this monograph, specific vaccinations (cholera, yellow fever) are listed as “required by country” in three categories: 1) vaccination certificate required of travelers from arriving countries; 2) vaccination certificate required of travelers arriving from infected areas; and 3) vaccination certificate required of travelers arriving from a country of which any part is infected. malaria risk by country is also noted. General rules and standards for vaccination are discussed, including special topics such as vaccination during pregnancy, vaccination of persons with altered immunocompetence (ability to fight infections), and vaccination of persons with severe febrile (fever) illnesses.

Depending upon where you will be traveling and your prior history of immunizations, you may be a candidate for vaccination against the following diseases: yellow fever, cholera, hepatitis A, hepatitis B, tetanus/diphtheria, typhoid fever, meningococcal meningitis, Japanese encephalitis, polio, measles, measles/mumps/rubella, rabies, tuberculosis, tick-borne encephalitis, plague, influenza, and pneumococcal pneumonia.

It is extremely important to plan immunizations as far in advance of an expedition as possible, since some vaccines interact in a way that diminishes effectiveness. For instance, yellow fever and cholera vaccines need to be given either on the same day or at least three weeks apart.

Take the time to gather records of which immunizations you have received and when they were given. This will prevent the uncertainty of trying to remember how long ago you were vaccinated in case you suffer a wound or possible exposure to a disease.

TETANUS

Any traveler who will be away from medical care for more than 48 hours should have adequate tetanus immunization. The recommendations are as follows:

• A person previously immunized should receive a booster dose of tetanus toxoid if his last dose was not administered within the past 10 years. If there is a good chance that the traveler will suffer an injury during the trip, he should take a booster if the last dose was not administered within the past five years.

• Nonimmunized individuals should become immunized with a series of three injections (over three to six months).

• Low-risk (for tetanus infection) wounds are those that are recent (less than six hours old), simple (linear), superficial (less than a half-inch [1.3 cm] deep), cut with a sharp edge (knife or glass), without signs of infection, and free of contamination from dirt, soil, or bodily secretions. High-risk wounds are those that are old (more than six hours), crushed or gouged, deep (greater than a half-inch deep), burns, frostbite, with signs of infection, and contaminated. If a person suffers a wound, the standard recommendations listed in the sidebar below apply.

POLIOVIRUS, DIPHTHERIA, PERTUSSIS (WHOOPING COUGH), MEASLES,MUMPS, RUBELLA (GERMAN MEASLES), CHICKEN POX, HAEMOPHILUS b

Immunization against poliomyelitis, diphtheria, pertussis, measles, mumps, and rubella should be obtained prior to travel. These are routinely administered during childhood in the United States. Because of the incidence of these infectious diseases in developing countries, such immunizations are mandatory prior to travel. Immunizations against Haemophilus type b (causes middle ear infections and meningitis) and the virus that causes chicken pox are available, and should be considered under recommendation from your physician. Polio is still common in developing nations. Unimmunized adults (older than 18 years) should receive a series of three injections of the inactivated (virus) Salk vaccine, not the oral (Sabin) vaccine, which is recommended for children. Persons under the age of 18 years who have never been immunized should receive three doses of oral polio vaccine one month apart. Persons who travel to high-risk areas who were immunized as children should receive one booster dose of oral polio vaccine.

CHOLERA

Cholera is an intestinal infection that can reach epidemic proportions. It is caused by the microorganism Vibrio cholerae, which induces painful diarrhea and extreme fluid losses through the gastrointestinal tract. A person whose stomach contains normal gastric acid is not at much risk for acquiring cholera. Most countries do not require immunization. However, some countries require cholera immunization for travelers entering from a territory that still reports the disease. Two injections are administered one week apart, and partial immunity (the vaccine is not extremely efficacious) is acquired after a six-day waiting period. In special cases (high-risk, by virtue of living in unsanitary conditions or having insufficient gastric acid), an additional booster injection may be required a month after the primary series. The vaccine is good for six months, so frequent booster shots are necessary. Infants should not be immunized. The vaccine appears to provide 50 percent effectiveness in reduction of the disease. To be maximally effective, cholera and yellow fever vaccines should be administered at the same time or at least three weeks apart.

YELLOW FEVER

Yellow fever is acquired in tropical Africa and South America, where victims may suffer the bite of the Aedes aegypti mosquito (urban environment) or other mosquitoes (jungle environment). Immunization is effective to prevent the disease. A single injection is administered, and immunity is acquired after a 10-day waiting period. The vaccine is good for 10 years, after which time a booster is required to maintain immunity. Infants younger than 9 months and pregnant women should not be routinely immunized, unless they are at high risk for contracting the disease. It is also contraindicated in persons with immunosuppression (e.g., HIV infection) or an allergy to eggs. Yellow fever vaccinations must be given at an officially designated Yellow Fever Vaccination Center, and the certificate must be validated at the same center. The vaccine is not required for travel from the U.S. into Canada, Mexico, Europe, or Caribbean countries. As mentioned above, cholera and yellow fever vaccines should be administered at the same time or at least three weeks apart for maximum effectiveness.

MENINGOCOCCUS

Meningococcus is a bacterium (Neisseria meningitidis) that can cause meningitis, particularly in children and young adults. Because of frequent cases reported in Nepal, it is a wise idea for travelers, particularly hikers and backpackers, to be immunized. The vaccine is given in one injection, with protection for three years achieved one to two weeks after administration.

HEPATITIS

A recombinant DNA vaccine (Recombivax, not derived from human plasma) for immunization against viral hepatitis type B is recommended for travel in underdeveloped countries. A series of three injections requires six months to complete. Another recombinant vaccine is Engerix B, which can be given on an accelerated schedule over two months.

Hepatitis A virus is spread through contamination of water and food, and is often encountered in developing nations and areas of poor hygiene. A new inactivated hepatitis A vaccine (Vaqta) is available. It is administered intramuscularly to persons ages 2 years or older at least two weeks prior to exposure to hepatitis A virus. The dose is 0.5 ml (25 units) up to the age of 17 years, and 1.0 ml (50 units) in persons older than 17 years. It is given in a series of two injections. Alternatively pooled immune serum globulin (ISG, or “gamma globulin”) is administered to prevent or diminish the effects of viral hepatitis type A. The administration of ISG interferes with the antibody response stimulated by other live virus vaccines, so it should be administered two to four weeks after the other vaccines. Because the effects of ISG disappear after six months, it should be administered just prior to the trip, and at appropriate booster intervals during prolonged travel in endemic areas.

BUBONIC PLAGUE

A pre-exposure vaccine is available for immunization against bubonic plague caused by Yersinia pestis. This is administered only to persons whose travels or occupations place them at high risk. In most countries where plague is reported, the risk is greatest in rural mountain or upland regions. Vaccination is generally considered for those who will reside in regions where plague is endemic, and where avoidance of rodents and fleas is impossible. The vaccine is injected in two doses one month apart, followed by a booster dose after six months.

TYPHOID FEVER

A vaccine is available for immunization against typhoid fever caused by Salmonella typhi. Immunization is recommended only for travelers who visit tropical regions known to harbor the disease. A two-injection series given four or more weeks apart is required, followed by booster injections at one- to three-year intervals, depending on the local disease risk. An oral vaccine is given as one capsule every other day for four doses in persons age 6 years or older. A booster series is necessary every five years. Side effects, which include fever, headache, and flu-like symptoms, are commonly associated with the injections.

TYPHUS FEVER

Typhus vaccine is no longer available in the United States and is not recommended for the foreign traveler.

INFLUENZA

Influenza vaccine is administered in one or two injections to children (particularly those receiving long-term aspirin therapy) and adults in October and November prior to the flu season (December through March), with a maximum duration of effectiveness of six months. Vaccination of high-risk persons (older than 65 years or with chronic illness) prior to flu season is essential. Each year, the vaccine contains the influenza virus strains that are felt to be most prevalent in the United States. Inactivated (killed virus) influenza vaccine should not be given to persons who are sensitive to egg products. Amantadine hydrochloride (Symmetrel) is a prescription oral drug that is moderately effective in preventing influenza A. However, because it confers no protection against influenza B, it is not considered a substitute for appropriate immunization. “Whole” vaccines should not be given to children under the age of 13 years. Children should be given “split” vaccines, which have been chemically treated to reduce adverse reactions.

PNEUMOCOCCAL PNEUMONIA

A polyvalent pneumococcal polysaccharide vaccine is available against pneumonia caused by Streptococcus pneumoniae (pneumococcus). In general, this vaccine is recommended for elderly (over 65 years) or infirm (those with cancer or chronic heart, kidney, liver, or lung disease; persons without a spleen; alcoholics; diabetics; persons with sickle cell anemia) travelers who would be debilitated by a bout of pneumonia. The vaccine is not routinely recommended for children.

JAPANESE B ENCEPHALITIS

Japanese B encephalitis is a viral disease transmitted by Culex mosquitoes in Asia and Southeast Asia. The victim first suffers a mild nonspecific viral illness with fever and headache. Most infections are mild. However, in an extremely small number of cases, the victim goes on to develop severe headache, weakness and fatigue, fever, confusion, seizures, and altered mental status (“encephalitis”). There is no specific therapy beyond supportive care. Travelers for more than one month to tropical Asia, particularly into rural rice-growing settings, are candidates for Japanese B encephalitis vaccine, which is given in a series of three injections over two weeks to one month. A booster dose may be given after two to three years. The vaccine is obtained from the Vector-Borne Viral Disease Branch of the Centers for Disease Control in Atlanta.

PROBLEMS RELATED TO AIR TRAVEL

Many travelers suffer from jet lag, which is most likely due to disruption of circadian rhythms due to time-zone changes and sleep-rest disturbance. There have been many proposed remedies, but none appears more effective than adequate hydration (drink lots of water), avoidance of alcohol and excessive caffeine, and judicious (for a few days only) use of short-acting sleeping pills. Melatonin and L-tryptophan have not been proven to be effective.

If you fly with an upper respiratory infection (“cold”), you will be exposed to pressure changes that can cause an ear squeeze similar to that incurred with descent underwater, when the eustachian tube collapses and the ears cannot be “cleared” by equalizing the pressure within the middle ear and across the eardrum. If this occurs, the traveler may end up with fluid in the middle ear, which makes it more difficult to descend underwater. Be certain to use proper decongestants if necessary prior to air travel.

Traveling abroad and observing different cultures is part of the appeal of diving. However, the wise diver takes care to prepare properly, which greatly increases the chance for a medically uneventful expedition.

The Traveling Diver’s First Aid Kit

At a minimum, the diver’s first aid kit should include:

• General supplies: waterproof dry bag or hard case (e.g., Pelican) to carry first aid supplies, medical guidebook, needle-nose pliers with wire cutter, disposable scalpel, paramedic or EMT shears (scissors), splinter forceps (tweezers), standard oral thermometer, wooden tongue depressors (“tongue blades”), rolled duct tape (388 x 1 yard), CPR mouth barrier or pocket mask, sterile surgical gloves, oral rehydration salts.

• Wound care (preparation and dressings): elastic bandages (Band-Aid or Coverlet) in assorted sizes (strip, knuckle, and broad), cloth with adhesive, preferably adhesive strips for wound closure (Steri-Strip or Cover-Strip II) in assorted sizes, 388x 388or 488 x 488 sterile gauze pads in packets of two to five (e.g., Nu-Gauze highly absorbent), 588 x 988 or 888 x 1088 sterile gauze (“trauma”) pads in packets of two to five, nonstick sterile bandages (Telfa or Metalline), assorted sizes 188, 288, 388, and 488 rolled conforming gauze (C-wrap or Elastomull), 188 x 10 yards rolled waterproof adhesive tape, liquid soap, sterile disposable surgical scrub brush, cotton-tipped swabs or sterile applicators, two-per-package safety razors, syringe (10-ml or 12-ml) and 18-gauge intravenous catheter (plastic portion) for wound irrigation, tincture of benzoin bottle or swabsticks, povidone-iodine 10% solution (Betadine) 1-ounce bottle or swabsticks.

• Splinting and sling material: 388 elastic wrap (Ace) 4 1/488 x 36,88 SAM splint.

• Eye medications and dressings: prepackaged individual sterile oval eye pads, prepackaged eye bandages (Coverlet Eye Occlusor), metal or plastic eye shield, sterile eyewash, 1 ounce sodium sulamyd or gentamicin eye drops.

• Topical skin preparations: hydrocortisone cream, ointment, or lotion 0.5 to 1%; mupirocin ointment miconazole nitrate 2%; antifungal cream; insect repellent; sunscreen lotion or cream; lip balm/sunscreen; hemorrhoidal ointment with pramoxine 1%.

• Nonprescription medications: motion sickness medicine, acetic acid (vinegar) 5%, isopropyl alcohol 40%, hydrogen peroxide, buffered aspirin 325 mg tablets, ibuprofen 200 mg tablets, acetaminophen 325 mg tablets, antacid, decongestant tablets (e.g., pseudoephedrine), decongestant (e.g., oxymetazoline) nasal spray, loperamide (Imodium AD) 2 mg caplets, stool softener (docusate calcium 240 mg gelcaps).

• Prescription medications: codeine 30 mg tablets (with or without acetaminophen), prednisone 10 mg tablets, amoxicillin-clavulanate 500 mg tablets, erythromycin 250 mg tablets, cephalexin 250 mg tablets, ciprofloxacin 500 mg tablets, promethazine (Phenergan) suppositories 25 mg, Vosol otic solution.

• Allergy kit: allergy kit with injectable epinephrine (EpiPen or EpiEZPen [0.3 mg] and EpiPen Jr. or EpiEZPen Jr. [0.15 mg]), diphenhydramine 25 mg capsules.

 

by Paul S. Auerbach, M.D.