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Acute Mountain Sickness (AMS) & Periodic Breathing (PB) AMS, commonly referred to as high altitude sickness, is a concern for travelers to mountainous regions. It is likely to occur in "flatlanders" who fly into airports located at high elevation, such as La Paz, Bolivia which has the highest paved airport in the world, at 13,313 ft. (4063 m). Even experienced climbers making rapid ascents in climbing expeditions may be troubled by AMS. Susceptible persons may experience AMS when driving from their low altitude residence to moderately high elevations for vacation. The symptoms of AMS are mild to severe headache, lethargy, nausea and vomiting, and restlessness at night with difficulty sleeping. About 20% to 40% of high altitude travelers experience AMS to some degree. Travelers flying into any high altitude location like La Paz, Bolivia and Cuzco, Peru are at a disadvantage because they do not have time to acclimate like slow moving climbing expeditions. Administering oxygen or descending 1000 feet can bring significant and rapid improvement in symptoms. Consequently, some hotels in the Andes or other high altitude tourist locations may have oxygen bottles for patrons to use. Ravenhill first described AMS in 1913 in Chile, calling it "puna."
The locals in the Andes call AMS "soroche" and recommend a tea made from the leaves of the coca plant. Coca leaves have a rich history in the Andes and the tea is offered at all hotels. Also, it is prized by the locals for aiding digestion, used as part of religious ceremonies and appears to have a mild stimulant effect. Soroche pills (also known as Sorojchi High Altitude pills) are sold in drugstores possibly more for commercial reasons than medical effect. The Sorojchi brand medication has a highly visible advertisement campaign, with posters in the front of pharmacies, showing 4 trekkers smiling and the 5th vomiting, presumably because he didn't take Sorojchi pills. Mountain climbers may experience AMS in spite of resting at camps for acclimatization. Climbers on Mount Kilimanjaro 19,330 ft, (5892 m) have a high rate of AMS because it does not require a high degree of technical skill to climb, thus, the summit may be reached without long rest periods for acclimatization. For this reason, some experts recommend that all climbers on Mount Kilimanjaro use acetazolamide (Diamox®) to prevent AMS. In three different studies, children were noted to experience AMS at the same rate as adults.
Acetazolamide (Diamox®) has a long history of use in the treatment of the common eye disease, glaucoma. It has also been shown to be very effective in preventing or lessening symptoms of AMS. The newer dosing recommendation is 3-5 mg/kg/day in two divided doses, about 125 mg twice a day for adults. Start the night before reaching altitude. This small dose is usually effective and results in minimal side effects. The most commonly reported side effects are the sensation of mild tingling of the finger tips and the causing of carbonated beverages to taste strangely flat. This dosage may be less than enough for larger patients, thus a third dose may be taken mid day or during the night if headache or other symptoms appear. Most people acclimate within three to four days, though AMS may reappear on later trips to that altitude. Treatment of AMS after the unset of symptoms may require acetazolamide 250 mg twice a day. Higher dosages can cause lightheadedness and an uncomfortable pins and needle tingling around the mouth, fingers tips and toes. Analgesics, such as acetaminophen, ibuprofen, or aspirin are helpful for headache. Keeping properly hydrated is important. Acetazolamide appears to be safe in children of all ages at 3 mg/kg/day in two divided doses. Acetazolamide is a very mild diuretic and increases urine output. If you are on a diuretic, such as furosemide (Lasix®) or HCTZ (hydrochlorothiazide) do not decrease or stop them, as the diuretic effect of acetazolamide is small. Traditionally, the use of acetazolamide has been discouraged in people with known allergy to sulfa antibiotics. Recent literature indicates that there may be no increased allergic risk with non-antibiotic sulfa drugs, such as acetazolamide. ("Absence of Cross-reactivity Between Sulfonamide Antibiotics and Sulfonamide Nonantibiotics." NEJM 2003; 349(17):1628-1635.) It is a category C drug and not recommended in pregnancy or breast feeding due to lack of safety studies. It is not recommended in those with kidney failure. Local guides and pharmacies generally encourage only coca leaves and soroche pills (Sorojchi pills). You may have difficulty finding acetazolamide in Cuzco or other cities of the Andes. Dexamethasone (Decadron®) is a potent steroid that can be used for AMS. The dose is 4 mg every six hours. It is usually used to treat AMS symptoms or the more serious conditions of high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). It can be used to prevent AMS symptoms when acetazolamide (Diamox®) is not tolerated. Short term use is considered safe, but this medicine can cause significant blood sugar elevation in diabetics. Ondansetron (Zofran®) though not a new drug, has recently been promoted in the field of AMS. It does not prevent AMS like acetazolamide, but is particularly useful for treating the nausea and vomiting that may accompany AMS. This drug is well tolerated and avoids the drowsiness and extra-pyramidal (neurologic) side effects that may occur with other anti-emetics (anti-nausea drugs). Climbing expeditions higher than routine tourist destinations should carry dexamethasone (Decadron®) to treat severe AMS, high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). AMS is not the same as high altitude pulmonary edema (HAPE) or high altitude cerebral edema (HACE). These are two serious and life threatening conditions that require urgent medical attention.
Questionable treatments for AMS:
Research studies showing effectiveness of the above mentioned herbs and medications is lacking at this time. Summary tips for moderate high altitude trips, such as, Cuzco:
Bedbugs Bedbugs are usually not found on their victims except when feeding at night. They hide in crevices of bedding, mattresses, beds, flooring and furniture or behind peeling paint and wall paper. Some experts believe that Chagas disease and hepatitis B may be transmitted by bedbugs.
These wingless creatures are 5-7 mm (1/4 inch) long, reddish brown, blood sucking, true bugs that pierce the skin of sleeping victims to feed. They may resemble an unfed tick or a small cockroach to the untrained eye. Bedbug infestation can be determined by looking for specks of brown or black fecal smears under mattress covers and along seams, along the bed frame and along box springs seams. Sometime after feeding on their victims, small raised inflamed bite sites appear that itch intensely. These are usually treated with topical steroid creams and antihistamines. If no victims are available, they may live for up to one year without feeding.
Bedbugs may be imported home with you in luggage, clothes or any purchased
items. Once established, bedbugs may be difficult to eradicate. On returning home, launder all clothes or dry clean.
Check luggage or other items for these creatures hiding in
crevices. Vacuum out and lightly fog the inside of luggage with an
appropriate aerosol
insecticide. For a good review of the subject with photos see:
Dengue Fever (DF) These mosquitoes are found along the southern USA, down through Mexico, Central America, South America, the Caribbean and Pacific, Asia, India, Torres Strait of Australia and parts of Africa. DF is only occasionally reported in the USA in Texas, and last reported in Maui, Hawaii in 2002. The Aedes aegpyti mosquito is a day time bitter and highly domesticated. It prefers residential areas. Breeding occurs around homes where it lays eggs in any standing water, such as, in flower pots on outside porches, water buckets, discarded tin cans and tires, and roof gutters. Biting may occur in any residential, rural or urban area. In the tropics, cases of DF have been rising steadily for years. Epidemics of thousands can occur in certain areas, depending on rainfall and other factors. DF is usually an adult disease whereas, Dengue Hemorrhagic Fever (DHF) is more common in children and can be fatal. In many areas of the tropics, the risk of contracting DF is much higher than malaria. Dengue fever maps. DF has the common name of "break-bone fever" causing severe headache, pain behind the eyes, muscle and joint pain and fever. A faint rash is often present in DF. Symptoms last 7 to 10 days. For mild cases, treatment is symptomatic with Tylenol or other pain relieving agents, fluids and rest. Avoid aspirin or aspirin like products such as ibuprofen (Advil) and naproxen (Aleve). Symptoms can easily be confused with malaria. Protect yourself with DEET or picaridin mosquito repellants. There is no licensed vaccine.
Hepatitis A & B
Hepatitis A Older children, adolescence and adults have a significant and prolonged illness of 3-4 weeks with fever, jaundice (yellow skin and eyes), right upper abdominal pain, nausea and vomiting, fatigue, and dark or tea colored urine. Symptoms do not appear until 4-6 weeks after exposure. A person becomes infectious to others several weeks before symptoms appear. Complete recovery may take one month or more. Full recovery is usually the case. There is a fatality rate of 1 to 2 percent in persons over the age of 60 years, in those immunocompromised by other illnesses or in those with chronic liver disease. Hepatitis A is usually contracted by ingestion of contaminated food and water in restaurants. However, it can be acquired by close contact with infected persons in day care centers, schools, and homes. Large outbreaks occasionally occur in the US from contaminated produce, as in March 1997, when a total of 153 cases of hepatitis A were reported in Calhoun County, Michigan. Travelers may contract hepatitis A when infected food handlers contaminate food, water and ice through poor hand washing and hygiene. Infections may occur during standard vacation itineraries, and at "five star hotels" in developing countries. Hepatitis A is virtually 100% preventable by vaccination or by an immunoglobulin (IG) injection prior to travel. On October 19, 2007 the CDC updated the ACIP recommendations regarding the use of hepatitis A vaccine and IG for prevention of hepatitis A, after exposure to hepatitis A virus and in international travelers.
On February 25, 2009, the Advisory Committee on Immunizations Practice
(ACIP) recommended routine hepatitis A vaccination for all household members
and other close personal contacts (e.g., regular baby-sitters) of adopted
children newly arriving from countries with high or intermediate hepatitis A
infection rates. This is based on numerous episodes of hepatitis A
infections occurring in family members and close contacts of adopted
children brought to the US.
Hepatitis A Vaccine In 2006, the minimum recommended age for vaccination was lowered from age 2 years to age 1 year old. Adult doses are given from age 19 years on. A booster is given for both pediatric and adult patients after 6 to 12 months. The frequency of or need for further boosters has not been determined. Experts believe there is life time protection after a single booster. In regard to immunocompromised persons from cancer, immune disorders, or immunosuppressive therapy no special precautions are needed. However, the response to vaccination may be less than desired, in which case, immune globulin (IG) may be considered. The safety of hepatitis A vaccine during pregnancy has not been determined. Because hepatitis A vaccine is produced from inactivated hepatitis A virus, the theoretical risk to the developing fetus is expected to be low. As an alternative, immune globulin (IG) is a safe and effective means of preventing hepatitis A. Travel & Routine Immunizations 2009-2010, 18th ed, pg 68, Shoreland, Inc. Hepatitis A vaccine may be given to anyone wanting travel protection in any country. The following countries are very low risk and vaccination is not generally recommended:
A combination vaccine containing both hepatitis A and B vaccines is very effective and convenient when both hepatitis A and B vaccination is desirable. See Twinrix® below.
Hepatitis B Hepatitis B virus is not transmitted casually and cannot be spread through sneezing, coughing, hugging or by food or water. It is 50-100 times more infectious than the AIDS virus. Symptoms of infection are the same as with hepatitis A but often less dramatic. Infection may not become apparent until two months after exposure due a prolonged incubation time. Unlike hepatitis A, hepatitis B can result in a chronic carrier state in which one remains infectious for life. Also, unlike hepatitis A, 10% of hepatitis B chronic carriers will develop cirrhosis of the liver and 10% of those will develop cancer of the liver. Hepatitis B infection is vaccine preventable. Any person who performs tasks involving contact with blood, blood-contaminated body fluids, needles or other sharps should be vaccinated against hepatitis B. All health care workers are routinely immunized in the US and other developed countries. Travelers should be vaccination if they frequently travel to, or spend more than one month in, countries that have intermediate to high rates of hepatitis B infections. These areas include Asia, India, Africa, the Middle East, Eastern Europe, the Pacific, South America and Alaska. When possible, adopting parents should learn the hepatitis B status of the child and vaccinate household contacts, as needed, prior to adoption. International travelers to areas of intermediate or high rates of hepatitis B or engaging in any of the below activities should be vaccinated for hepatitis B:
Vaccination should be considered for all young people regardless of travel plans, as a matter of good health maintenance. In adults this vaccine is usually given as three doses over six months, but an hyper-accelerated schedule over 21 days with a final booster after 12 months can be used. Twinrix® is a well accepted combination vaccine for the prevention of hepatitis A and hepatitis B. It is normally given on the same schedule as hepatitis B. In May of 2007, the US approved the use of Twinrix® in an accelerated dosing schedule of days 0, 7, and 21 with a final booster in one year. This schedule is very useful for travelers leaving in less than a month because they complete the series in 21 days instead of six months. To ensure lifelong protection a booster at 1 year is recommended.
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