Guidance for Americans Living in Areas Affected by Earthquakes and Tsunami

Americans living in areas affected by the earthquake that struck on December 26, 2004 and subsequent tsunami should be aware that in addition to the thousands of lives that were lost and the widespread structural damage that occurred, thousands of people still remain unaccounted for and survivors now face possible shortages of food, housing and medical care; risk of disease outbreaks and injuries; and coping with the emotional impact of the disaster. This notice contains information about present health and security risks in affected areas and provides guidance about measures that can be taken to minimize those risks.

Areas affected by the disasters include:

Sri Lanka – coastal areas of south, north and east
Indonesia – Sumatra (province Aceh)
India – coastal areas of south and east, Andaman and Nicobar Islands
Thailand – Phang-Nga province, Phuket, Phi Phi Island and Krabi
Malaysia – northwestern states
Maldives – entire islands
Myanmar – southern coastline
Somalia,Tanzania, and Kenya – eastern coastlines

Immunizations

Because the possibility of infections and disease outbreaks is increased following disasters, the following vaccines are also recommended if you have not previously been immunized and if it is possible to locate a health-care provider who can administer them:

• Tetanus/diphtheria (Td) vaccine or booster, if vaccine or booster was 5 years ago or more.
• Hepatitis A
• Hepatitis B
• Influenza, if vaccine is available in your area or if you are in a priority group for vaccination (see www.cdc.gov/flu/),
• Typhoid (oral or injectable)
• Polio, if you have not had a booster since childhood.
• Measles , if you are not immune. Immunity can be assumed if you have documentation of measles diagnosed by a physician, laboratory evidence of measles immunity, proof of receipt of two doses of live measles vaccine on or after your first birthday, or you were born before 1957.
• Rabies, is endemic in these areas. Pre-exposure vaccination is recommended for persons living in these areas. Rabies pre-exposure series (days 0, 7 and 21 or 28) requires at least 3 weeks to complete. If exposed to a rabid animal, 2 additional doses of rabies vaccine are required. If you are unimmunized or are unable to be fully vaccinated, in the event of an exposure, you should receive full post exposure prophylaxis (i.e., rabies immune globulin (RIG) + 5 doses of vaccine). If either rabies immune globulin or rabies vaccine is not available in your location, in the event of an animal bite, you should either return home or travel to the closest major city where these biologics are available and initiate rabies post exposure prophylaxis as soon as possible.
• Japanese encephalitis (JE), is endemic in SE Asia, but not Africa. Vaccination is routinely recommended for those living or working in rural areas of endemic countries. Full vaccination requires 2-4 weeks to complete (days 0, 7, 14 or 30). If you have not previously been vaccinated or vaccine is not available, you should take measures to prevent mosquito bites, such as the use of insect repellent and sleeping under insecticide-treated bed nets (www.cdc.gov/travel/bugs.htm). An abbreviated schedule of 2 doses (days 0, 7) has been shown to provide seroconversion in 80% of vaccinees and possibly higher in some populations. Because serious adverse reactions to the vaccine (generalized itching, respiratory distress, angioedema, anaphylaxis) can occur in some individuals up to 1 week after vaccination, travelers should be aware of the possibility of delayed reactions, see www.cdc.gov/travel/diseases/jenceph.htm.
• Cholera vaccine, if outbreaks of cholera are being reported (since this immunization is not available in the U.S., it would have to be obtained at an intermediate destination and would require some time for antibody protection to develop). Drinking of potable water and precautions against food-borne illnesses are important defenses against cholera.
• Yellow fever vaccine is recommended only if you are residing in the affected areas in East Africa. There is no yellow fever risk in Asia. However, some countries may require documentation of yellow fever vaccination for people traveling from yellow fever endemic areas.

Malaria Prophylaxis

Because conditions for malaria transmission  may be present (flooding, potential migration of malaria-infected persons into affected areas, a breakdown in mosquito control) even in areas where antimalarial drugs had not previously been recommended, as a precaution, antimalarial drugs should be taken residents and travelers to all affected areas except the Maldives.

There is no immunization against malaria and although no antimalarial drug is 100% protective, taking antimalarial drugs correctly and consistently is the most important factor in preventing this debilitating and potentially fatal condition. Malaria symptoms can include fever and flu-like illness, including chills, headache, muscle aches, and fatigue. Malaria may also cause low blood cell counts (anemia) and yellowing of the skin and whites of the eye (jaundice). If not promptly treated, infection with Plasmodium falciparum, the most harmful malaria parasite, may cause coma, kidney failure, and death. Travelers who become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after returning home (for up to 1 year) should seek immediate medical attention and should tell the physician their travel history.

The following is a list of recommended antimalarial drugs* by country: The appropriate antimalarial drug for you will be determined by you and your health-care provider.

Doxycycline should be considered as the antimalarial drug of choice because it has the added benefit of protecting against other infections, such as leptospirosis, scrub typhus and other rickettsial infections and some bacterial infections that are endemic in these areas. See this website for a full description of the drugs and their side effects: www.cdc.gov/travel/malariadrugs.htm. Use of sunscreen is important when using doxycycline as it may make skin more sensitive to sun with resultant sunburn.

Sri Lanka – A/P, Dox, Mef
Indonesia – A/P, Dox, Mef
India – A/P, Dox, Mef
Thailand – A/P, Dox, Mef  (Phang-Nga province, Phuket, Phi Phi Island and Krabi) and Dox or A/P for areas bordering Burma/Cambodia
Malaysia – A/P, Dox, Mef
Burma ( Myanmar ) – A/P, Dox, Mef  and Dox or A/P in the eastern part of country.
Somalia , Tanzania and Kenya – A/P, Dox, Mef

*(Atovaquone/proguanil or A/P (brand name Malarone™) , Doxycycline or Dox (many brand names and generics are available), Mefloquine or Mef (brand name: Lariam™ and generic).

Risks from Injury

The risk for injury during and after a natural disaster is high. Persons who anticipate the need to travel in tsunami-affected areas should wear sturdy footwear to protect their feet from widespread debris present in these areas. Tetanus www.cdc.gov/travel/diseases/dtp.htm is a potential health threat for persons who sustain wound injuries. Any wound or rash has the potential for becoming infected and should be assessed by a health-care provider as soon as possible. Any wounds, cuts, or animal bites should be immediately cleansed with soap and clean water. You should also be familiar with basic first aid to self-treat any injury until you can get medical attention.

Motor vehicle crashes are a leading cause of serious injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

Preventing Electrocutions

During power outages, many people use portable electrical generators (emergency.cdc.gov/poweroutage/workersafety.asp). If the portable generator is improperly sized, installed, or operated, it can send power back to the electrical lines. This problem is called backfeed or feedback in the electrical energy in power lines. Backfeed can seriously injure or kill repair workers or people in neighboring buildings. Stay away from downed power lines. If you leave your home during a power outage, electrical power and natural gas or propane tanks should be shut off to avoid fire, electrocution, or explosions. Try to return to your home during the daytime so that you do not have to use any lights. Use battery-powered flashlights and lanterns, rather than candles, gas lanterns, or torches.

Risks from Food and Water

Natural disasters contribute to the spread of many serious food and water-borne diseases, especially since water supplies and sewage systems have been disrupted. Diarrheal diseases, typhoid, hepatitis A and E can possibly occur. Measures to ensure food and water are safe is of great importance in preventing the spread of such diseases. Food should be thoroughly cooked and salads and ice cubes should be avoided. If a trusted source of bottled water is not available, water should be boiled or disinfected with chlorine, iodine, or obtained by distillation or reverse osmosis. For more details, see www.cdc.gov/travel/foodwater.htm.

If travelers diarrhea (TD) develops, loperamide (Imodium) can be taken as directed and if carrying an antibiotic for self-treatment of acute diarrhea, such as a fluoroquinolone (e.g. ciprofloxacin), begin treatment. As an alternative, azithromycin can also be used. This medication can be taken until symptoms subside which typically takes anywhere from one to three days, although in the current circumstances, may take longer. If diarrhea is accompanied by high fever or blood, the individual should seek medical care. Hydration is key to the effective management of any diarrheal disease. Though oral rehydration solutions are ideal for treatment of severe diarrhea, replacement of lost fluids by drinking potable water is the most important means of maintaining wellness.

As with other infectious illnesses, one of the most important preventive practices is careful and frequent hand washing. Cleaning your hands often using either soap and water or waterless, alcohol-based hand wash removes potentially infectious materials from your skin and helps prevent disease transmission.

Risks from Insect Bites

Because of standing water in these areas, mosquito breeding can become a problem and outbreaks of malaria, Japanese encephalitis and dengue are possibilities. In addition to malaria prophylaxis and Japanese Encephalitis vaccine, other measures should be used for protection from mosquito and other insect bites. Use insect repellent containing DEET (www.cdc.gov/ncidod/dvbid/westnile/mosquitorepellent.htm), wear long sleeved shirts and long pants when outdoors, and sleep under an insecticide-treated bed-net, preferably treated with permethrin (www.cdc.gov/malaria/control_prevention/vector_control.htm#itn).

Risks from Snake Bites

Displaced reptiles, such as snakes, are likely to be found following flooding and other natural disasters. Attempts to kill snakes are dangerous. The venom of a small or immature snake can be even more concentrated than that of larger ones; therefore, all snakes should be left alone. Fewer than half of all snakebite wounds actually contain venom, but travelers should be advised to seek medical attention any time a bite wound breaks the skin.

If medical care is rapidly available then initial treatment should include immobilization of the affected limb and minimizing physical activity as much as possible (ideally of the entire patient) while transport to a medical facility occurs. If care is delayed, then a loose fitting pressure bandage that does not restrict arterial and venous flow (but does limit lymphatic flow) are recommended first-aid measures while the victim is moved as quickly as possible to a medical facility. Tourniquets that impair blood flow to the affected limb are generally contraindicated.

Specific therapy for snakebites is controversial, and should be left to the judgment of local emergency medical personnel. Snakes tend to be active at night and in warm weather. As a precaution, boots and long pants should be worn when walking outdoors at night in areas possibly inhabited by venomous snakes. Proper protection such as the aforementioned clothing, careful attention to one’s surroundings and overall avoidance of contact are the best measures that can be taken to avoid injury.

Other Risks

Leptospirosis may occur in those who wade, swim, or bathe in waters contaminated by animal urine. Plague infection is usually caused through the bite of rodent fleas, but also may be acquired by direct contact with infectious materials or inhalation of infectious droplets. In addition, exposure to animal bites, most notably dogs in resource-poor countries, poses a risk for rabies and other infections.

Potential hazards exist from displaced land mines in areas of prior conflict. Stay on highways and asphalt roads to minimize chances of contact with landmines . Aftershocks may continue to occur so for safety, avoid coastal areas affected by tsunami, including avoidance of travel by boat and swimming in bodies of water in those regions. Arrange to sleep in the highest location possible.

Psychological/emotional

Because of the tremendous loss of life, serious injuries, missing and separated families, and destruction of whole areas, it is important to recognize the situation you encounter may be extremely stressful. Keeping an item such as a family photo or religious material nearby can often offer comfort in such situations. Checking in with family members and close friends from time-to-time can also be a source of support. For additional mental health resources, see emergency.cdc.gov/mentalhealth/.

If illness occurs

If you develop fever, cough, unusual rash, difficulty breathing, or become extremely anxious or depressed, you should get medical attention as soon as you possibly can.

Realize that most functioning hospitals and clinics may be busy receiving hundreds of people who have been injured. Ask Embassy personnel to help you identify a health-care provider if you do not already have one. If you become seriously ill, you may require evacuation to other parts of a country or out of the country to receive adequate medical care. Consider purchasing a supplemental health insurance policy that includes evacuation insurance (see the U.S. Department of State website for additional information, http://travel.state.gov). The U.S. Embassy can also assist family members in making arrangements with local authorities to prepare and transport the remains of a relative who has died.

Security

The U.S. Department of State urges all American citizens living or traveling in any part of the countries affected by the tsunamis, even if they were not directly affected by the disaster, to call or e-mail family members to let them know about their safety. The U.S. Embassy in these areas is working to locate American citizens and assist those in need. Additionally, all U.S. citizens in Indonesia, Thailand, Sri Lanka, and the Maldives are encouraged to register with the U.S. Embassy in those countries. If you have called to inform the Department of State about an unaccounted for American citizen and have since determined that the individual is safe, please call 1-888-407-4747 to relay that information. For details about how to contact U.S. embassies, to register, and obtain up-to-date information on security conditions, you can call 1-888-407-4747 toll-free in the United States and Canada (317-472-2328 from overseas) and visit the U.S. State Department website, http://travel.state.gov/.

Some of the affected countries are also restricting access to certain areas because of health or security concerns. Follow any local laws pertaining to restricted travel, curfews, etc.

Always carry your passport and travel documents (in a water-tight packet) and make sure a family member/friend has copies of the passport and other travel documents, as well as details of your travel plans and how to contact you. Also, make arrangements to check in with family/friends from time to time.

After returning home

On return from one of the affected areas, if you become ill for any reason, you should be evaluated by a doctor. This should include psychological support and counseling as necessary. If you become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and tell the doctor your travel history.