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EXHIBIT 4A
Health Care Tips for International Travelers |
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- 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.
- 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.
- 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:
- Fruit juice (canned or boiled) or bottled sugar-soft
drinks alternating with
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- *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.
- *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.
- *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.
- *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).
- *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.
- 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.
- Plague
- Rabies
- Meningococcus
- Influenza
- Pneumococcus
- Mumps
- Rubella
- Hepatitis B
- Japanese B encephalitis
- Hemophilus
- 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.
- 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.
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