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IDL-5260.Pdf The International Development Research Centre is a public corpora­ tion created by the Parliament of Canada in 1970 to support research designed to adapt science and technology to the needs of developing countries. The Centre's activity is concentrated in five sectors: agriculture, food and nutrition sciences; health sciences; information sciences; publications; and social sciences. IDRC is financed solely by the Government of Canada; its policies, however, are set by an international Board of Governors. The Centre's headquarters are in Ottawa, Canada. Regional offices are located in Africa, Asia, Latin America, and the Middle East. ©1978 International Development Research Centre Postal Address: Box 8500, Ottawa, Canada KlG 3H9 Head Office: 60 Queen Street, Ottawa Dupuis, R. Keystone, J. Losos, J. Meltzer, A. IDRC-106e Travelers to the tropics - guidelines for physicians. Ottawa, Ont., IDRC, 1978. 36p. /IDRC publication/. Guidelines for physicians on the treatment of /tropical disease/s - discusses the importance of /immunization/s, /diagnosis/, treatment of patients with /parasitic disease/s; includes /bibliography/, /directory/ of tropical disease /information centre/s. UDC: 616.91 ISBN: 0-88936-166-5 Microfiche edition available IDRC-106e Travelers to the Tropics - Guidelines for Physicians R. Dupuis/ J. Keystone, 2 J. Losos, 3 and A. Meltzer4 1M.D., F.R.C.P.(C), Colonel and Chief of Medicine and Physician in Charge, Tropical Disease Clinic, National Defence Medical Centre, Ottawa, Canada. 2M.D., MSc. (CTM), F.R.C.P.(C), Director, Tropical Disease Unit, Toronto General Hospital, Toronto, Ontario. 3M.D., D.E.C.H., Associate Director, Health Sciences Division, International De­ velopment Research Centre, Ottawa, Canada. 4M.B.Ch.B., D. OBST., D.T.M.&H., Physician, Health Unit, Carleton University, Ottawa, Canada. Contents Introduction . 3 Preparing for a Visit to the Tropics . 4 Immunizations . 7 The Patient Returning from the Tropics . 11 The Patient with Malaria . 12 The Patient with a Fever . 18 The Patient with Diarrhea . 20 The Patient with Amoebiasis . .. 22 The Patient with a Worm Infection........................ 24 The Patient with an Eosinophilia . 27 The Patient with Other Tropical and Parasitic Infections . 28 Acknowledgments . 31 Appendix A. International Immunization Requirements (1978) . 32 Appendix B. Canadian Reference Centres for Tropical Diseases . 34 Appendix C. Recommended Reading . 35 Index . 36 2 Introduction Most physicians are now seeing patients who have traveled in many parts of the world, and there is a growing awareness that tropical and travel medicine have an important role to play as far as the health of the individual and the community is concerned. As in most branches of medicine, preventive aspects are of supreme importance: by taking adequate precautions most travelers will have few problems. The aim of these guidelines is to provide some basic information for physicians and health workers who are dealing with subjects who intend to visit the tropics or have returned from such areas. In general, only the more likely conditions that may be encountered are mentioned. In some instances patients may have to be referred to a tropical disease unit for appropriate investigation and therapy. However, in all instances it is essential that physicians should have a high index of suspicion for tropical and parasitic diseases and all subjects should be asked for details of their travels (e.g., Where have you been?). In many instances the history will yield a clue to possible parasitic infections (e.g., malaria). Many parasitic diseases continue to go undetected in patients, and it is hoped that these brief notes will assist physicians to be on the alert for such conditions. For further details the material mentioned in Appendix C, Recommended Reading, will be of use. It should be stressed that many parasitic infections may remain "asymptomatic" for a long time and that all travelers should have an appropriate checkup and investigation for parasitic diseases on their return from the tropics. This is particularly important if the subject has a history of unexplained fever, diarrhea, or weight loss. Also it must be remembered that the symptoms of such diseases as malaria may mimic other conditions (e.g., influenza) and are easily misdiagnosed. Again with many parasitic infections, symptoms may appear long after the traveler has been away from the tropics and physicians must keep this fact in mind. When possible, investigations are best carried out in a laboratory experienced in parasitic diseases. 3 Preparing for a Visit to the Tropics The tropics impose various physical and mental stresses on all travelers, and in particular, on individuals with diseases such as mental disorders (especially depression), alcoholism, renal calculi and chronic renal diseases, chronic liver diseases, bowel conditions such as ulcerative colitis, significant cardiovascular disease (particularly unstable hyperten­ sion), and immunosuppressive conditions. Unstable diseases such as diabetes are also subject to stress as a result of changes in diet, fatigue, and alterations in circadian rhythm due to "jet lag." Although none of the above conditions constitute absolute contra­ indications to life in the tropics, they should be evaluated and discussed with the patient. Individuals on medication should be advised to take an adequate supply with them (e.g., insulin, steroids), and a summary of the medical conditions should be given to the patient before his departure to take with him. Preparation for the tropics should include a dental and complete medical examination as these services may not be available in the countries that are to be visited. Patients should be advised to carry a medical kit with them. This is not meant to delay consultation with proper medical authorities, but may be useful while awaiting medical help. This should include an antimalarial, an antidiarrhea agent (Lomotil), a broad spectrum antibiotic, an antacid, an analgesic, an antihistamine, a topical antifungal, first aid material, insect repellent, and suntan lotion. The following points should be brought to the attention of the traveler: acclimatization; food; water and drink; swimming; barefoot walking; prevention of diarrhea; protection from insects; and antimalarials. Acclimatization On arriving in the tropics one should allow several days to adapt to the local conditions and recover from "jet lag." Exposure to the sun should initially be for short periods and then be increased gradually over the next few days. Light-coloured cotton clothing is preferable. Heat in the tropics can be intense enough to cause syncope in susceptible individuals. Heat exhaustion can occur from water depletion resulting from loss through sweating and other routes such as diarrhea. The patient is thirsty with scanty urine of high specific gravity. Treatment is by fluid replacement. Another form of heat exhaustion can occur from salt depletion, which is secondary to loss through sweating. The patient is not thirsty in the pure form of this syndrome and the sodium chloride content of urine 4 is low. Treatment consists of the replacement of salt in the body, either in drinks or intravenously (i.v.). Heatstroke occurs when temperature regulatory mechanisms do not function. Body temperature is high and successful treatment depends on lowering body temperature. Prickly heat (miliaria rubra) is associated with high humidity and appears as a rash on areas covered by clothing and subject to friction. This condition may be alleviated by moving to cooler surroundings, taking a cool shower, drying the skin, and applying calamine lotion. All of these conditions can be prevented by prudent activity in hot climates, the wearing of appropriate apparel, and sufficient salt and fluid intake. Food Milk (and dairy products) and salads are best avoided. Vegetable, meat, or fish dishes should be well cooked. The visitor should stick to fruit that can be peeled by himself. Extra salt should be added to food. Water and Drink In general, all water should be boiled before use. Bottled carbonated drinks are usually safe. Ice cubes should be made from purified water. If the local water is not safe for drinking, then it is not suitable for dental use. Halazone tablets may be used to purify drinking water, or a 2% tincture of iodine can be used (five drops added to 1 litre of "clear" water or 10 drops added to 1 litre of "cloudy" water). The water should be thoroughly mixed and allowed to stand for 30 minutes before being used. Swimming Visitors to the tropics should be advised against swimming in fresh untreated water in regions endemic for schistosomiasis. Barefoot Walking In most tropical areas barefoot walking is inadvisable because of the risk of acquiring hookworm infections. Shoes also lessen the chance of being bitten by certain insects or snakes. Prevention of Diarrhea The best preventive measure is to take care with food and drink. "Prophylactic" drugs are not generally recommended, and preparations containing iodochlorhydroxyquin should be avoided as they are relatively ineffective, may mask infections, and have serious potential adverse reactions (optic nerve lesions). Diphenoxylate-atropine (Lomotil) is useful in controlling diarrhea, but is contraindicated when diarrhea is accompanied by a high fever or blood in the stools, and should not be used in young children. All travelers should have appropriate stool tests carried out on their return, particularly those who were symptomatic while
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