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INTERNATIONAL MEDICAL INSURANCE AND HEALTH INSURANCE FOR OVERSEAS |
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INTERNATIONAL MEDICAL INSURANCE AND HEALTH INSURANCE FOR OVERSEAS |
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- add to favoritesGLOBAL COVERAGE, INTERNATIONAL HEALTH INSURANCE |
Although international medical insurance is important it is also important to be so prepared in order to avoid health problems overseas.
EXPATRIATE HEALTH
Diseases
| Malaria and Prevention | Tuberculosis | Sun Protection | |
| Leishmaniasis | Deep Vein Thrombosis | ||
| Hepatitis | Leptospirosis | Altitude Sickness | Diabetes |
| Influenza A & B | Lyme Disease | AIDS |
Malaria is still a great killer. Over 30,000 American and European travelers are infected each year. It has a 4 – 20% mortality rate. There are many areas with chloroquine resistance, covered later.
Three types:
Plasmodium Vivax, which is 50% of the world’s malaria It has some chloroquine resistance, especially in Indonesia
Plasmodium Falciparun is 40%, the most dangerous and often most resistant to chloroquine and has caused the most deaths. It is seen especially in Central Asia and the Middle East
Plasmodium ovale is the most mild. It rarely causes death.
Insect Bite Prevention – the best malaria offensive
Deet, the common insect repellent ingredient, varies from 17 - 35% Found in brands like Off, etc. Should be sprayed directly on the skin, never on clothes or gear Permethrin-impregnated mosquito netting, can often be obtained overseas. This liquid can also be used to cover the lower ends of the mosquito netting or window screens. Avoiding or reducing activity after dusk helps. If one lives in a malaria-free city and goes into the country during the day and returns to the city by day, very few cases of malaria have been contacted. Anti-malarials may not be indicated.
Mosquito coils are effective and ought to be considered.
Spraying the room an hour before bedtime when children are not in the bedrooms is worthwhile.
Long-sleeved shirts and pants, light in color are also somewhat protective. Contrary to many expatriates’ opinions, Avon “Skin-so-Soft” is not effective in preventing mosquito bites.
It should be kept in mind that IN VIRAL-BORNE DISEASES like dengue fever, Japanese encephalitis and yellow fever, prophylaxis and AVOIDANCE of mosquito bites is important.
Malaria Drug Prophylaxis (drugs taken for prevention)
Chloroquine, trade name Arlen, manufactured by Sandoz 300 mg. base tablet taken once weekly. Continue taking till 4 weeks after return from exposure.
Mefloquine, trade name Lariam by Roche 250 mg. weekly, most often prescribed by American doctors and CDC, some mild resistance. Should not be given in the first 12 weeks of pregnancy Some psychotic and mood changes, panic insomnia, depression, 1 in 500 users Contraindicated in people who need to rely on spatial judgment (airline pilots, etc.)
Doxycycline, trade name Vibramycin by Pfizer, 100 mg. daily Used common by U.S. military Start when leaving for exposure zone, MUST have 100 mg. daily Less likely to upset stomach if taken with food; Milk inhibits absorption. Contraindicated in pregnancy and in children under 8 years of age. Least expensive Probably worth taking when one goes to highly infested areaContinue dosage until 4 weeks after exposure period Malaria parasite resides in the red cells of the blood, having a 14-21 day cycle. Hence, the 4-week advice covers the time when the parasite opens into red cells. WHO and CDC tend not to recommend because of LACK OF COMPLIANCE for 4 weeks after exposure period Military has sergeant ORDERING troops to take their pill for the prescribed time. Women on oral contraceptives should be on at least a 35-microgram monophasic pill. In lower dose pills the doxycycline may cause the liver to metabolize the pill. Pregnancies have occurred in these cases. Malarone Available in Europe, Canada, Mexico- Combination pill of atovaquone and progouanil 250 mg. per week with two weeks prior to exposure & one week post exposure. Expense greater than $5, Canadian per pill
Fansidar, Used for self treatment when symptoms of headache, fever, malaise occur. 3 tablets for presumptive malarial symptoms. Contraindicated in pregnancy or with sulfa allergic patients. Azithromycin (Zithromax) has been used as prophylaxis and side treatment. Not recommended by any agencies
Malaria vaccine is not yet available but is being worked on.
Cholera
Cholera vaccine is generally not recommended by the World Health Organization (WHO) except in certain epidemic areas. You must have the immunization at least 3 weeks before visiting those areas. You must have a need, and usually a local epidemic triggers the local health authorities to recommend vaccine. Cholera changes rapidly, so a vaccine generally does not work except for a specific area. Therefore, previous cholera vaccinations will not be applicable to any given situation. Repeated vaccination is recommended within 6 months if a person remains in a high epidemic area.
Hepatitis
Hepatitis A
This organization requires vaccinations for both hepatitis A & B, both being preventable.
Hepatitis A is common throughout the world, including the U.S. and has caused some deaths. Transferred primarily through water and food, easily contacted. It is endemic in the developing world. Vaccination is 2-doses, four weeks apart. New vaccine, Twinrix, combines Hepatitis A & B, though a third vaccination for B is required 6 months out from the first.
Hepatitis B
This organization requires vaccination for several reasons. Even if you are not a health care worker (OSHA requires that in the U.S. for health care workers at any level), there are still reasons for getting the vaccination. All newborns in the U.S. have been required to be vaccinated in the past ten years. You may get health care in a place where needles have been re-autoclaved and have had prior exposure to someone else’s blood or fluids. IV solution bottles are also reused, and of course blood products are possibly contaminated with hepatitis in places where they do not have capability for testing for that. Hepatitis B is considered a sexually transmitted disease. The most frequent source besides in the medical community in the developing world is illicit sexual behavior. The three doses virtually make it almost impossible to obtain the disease. There is some cross-reactivity to lessening the effect for Hepatitis C and perhaps E, if A & B have been obtained. Hepatitis G is most often seen in pregnant women. C, E, and G do not have vaccines.
Influenza A & B
People with respiratory changes and those who are over 60 should obtain the vaccine.
Hemorrhagic Fevers
Those such as Lassa Fever or Hanta virus are caused by viruses and present with abnormal bleeding or small polka-dot hemorrhages under the skin. Anti-viral drug therapy is the only thing which prevents that. Avoidance of contact with rodents lessens those diseases. Virtually every area has its own viral equivalent, whether tropical or colder Northern climates.
Leishmaniasis
This is a parasitic disease spread by sand flies. Cutaneous leishmaniasis is characterized by skin sores and has been seen in a recent epidemic in Afghanistan among workers and military people. There is no vaccination. Preventive measures include lessening contact with flies and bites. Sand flies are primarily nighttime biters. They can occur in daytime when sand flies are disturbed. Insect repellent with Deet is the primary method of avoidance.
Leptospirosis
This is a spiro bacteria spread via fresh water, damp soil, vegetation and mud especially after flooding. Penicillin, Amoxicillin, Doxycycline are used for treatment.
Lyme Disease
This is primarily a North American and European disease. A vaccine is available for those living in endemic areas.
Tuberculosis
Historically TB has been the largest killer worldwide. Both AIDS and malaria are challenging its dominance in recent years. Some countries have a prevalence rate of up to 80%. It is worse in communities that have crowded living conditions. It starts out as primarily a respiratory disease but can affect the brain, abdomen, genitalia, kidneys, skin, eyes, etc. Any fever lasting a week or more should be considered TB, malaria or typhoid in the developing world. There are effective antibiotic treatments through physicians. Some developing countries require all TB patients to be treated only by government clinics. The expatriate worker should test with a simple skin test called a PPD, at least every two years. Positive skin tests without any obvious lesions in the lung or elsewhere require simple antibiotic therapy for 6 months. Neglected TB can be fatal in both adults and children, and chronic coughs should never be ignored. A TB skin test is a must for everyone returning to the U.S. after spending time in an endemic area. It is a disease that should not be feared but respected and should be promptly treated.
Parasitic Disease
We have mentioned parasites throughout this discussion. Primarily many parasitic diseases are diagnosed by either serum antibody blood tests or stool cultures and examinations. It is recommended for everyone returning from overseas that stool cultures be obtained. Persistent diarrhea is a reason to initiate stool examinations. Some organizations make the requirement of yearly stool exams in asymptomatic patients. Stool exam for ova and parasites should be obtained, not just a culture. Tests are done for pinworms, especially in children. Sometimes intact worms are passed. If that occurs, they should be placed in 70% alcohol solution for laboratory exams.
Occasionally tests such as duodenal string tests (swallowing a pill with a string and biopsy of the GI canal for evaluation) are required.
Schistosomiasis- primarily contacted by bathing in fresh water; many lakes and rivers are contaminated by snails that carry and discharge the parasite into the water. The parasite is able to penetrate intact skin (without lacerations). The parasite can be killed by chlorine disinfectants.
Giardia – contact with infected water through ingestion or bathing
Worms – contacted through poorly cooked food
Man-animal contact (ascaris), ESPECIALLY in children
Scabies (due to a mite)
possible even with meticulous cleaning
Highly contagious – simple touching
Intensely itching red spots (can usually see little red or black lines between the spots) Frequently starts in the webbed spaces between fingers, around wrists or ankles, affecting scalp but not the face. 1% Lindane solution applied to the affected area, repeated 1 week later. Meticulous cleaning of bed linen, underclothes treatment of bedroom with bug bombs (aerosol insecticides). Should not occupy room for 8 hours after insecticide use. Dog-cat contact for children under 5 years is a source of parasitic infection, affecting the liver, gut, skin, etc.
Lice Affects all ages but especially children.
You will observe little moving hairy creatures on the hairy areas of the body such as the head and pubic areas. The hair has little white flecks, which are the eggs.Treatment is to shave affected areas, use Lindane 1%, as with scabies. Repeat Lindane 7 days later
In summary, when obtaining a consultation over the phone or via e-mail, an accurate and specific description of symptoms should be given, including fever, skin appearance, respiratory symptoms, pulse, locations of pain, etc. Often locals know what organisms are common, and that should be relayed on to the professional as well as your knowledge of geographic distribution. Knowing the vector (such as animal-borne or mosquito-borne) is important and is essential for avoidance of disease. Often drug therapy is available at the local level. But we are happy to be a sounding board for whether this is adequate control.
ALTITUDE SICKNESS
Often above 6,000 feet severe forms can cause need for medical treatment. Expatriates in some parts of North India and Pakistan can require medical treatment. However, the usual treatment is return to a lower altitude and resting until one equilibrates.
JETLAG
“East is the beast, and West is the best.” Traveling east seems to be more disruptive to most people than going west. Avoiding carbohydrates (sugars), caffeine and fat helps. Other helpful medications:
Melatonin 3 mg. taken 3-4 hours before one expects to sleep along with an over-the-counter sleeping pill
.g. Sominex, Benadryl, 100 mg. is appropriate to help you sleep on the eplane. Planning to have jetlag when one is flying toward the East and giving yourself a day to sleep is the best plan.
SUN PROTECTION
The best sun protection is clothing, and sunscreens are useful especially in lighter-skinned people. They will help prevent skin cancers.
DEEP VEIN THROMBOSIS – killer of frequent fliers
This is a blood clot in the deep veins of the legs and pelvis. It causes death by releasing the clot, which goes to the lung, causing a fatal reaction such as cardiac arrest and disseminated bleeding problems.
¼ to 1 adult aspirin should be taken 4 hours prior to flying,
Aspirin recommended for everyone over 40 to prevent heart attacks.
Weight reduction whenever possible before flying is recommended.
Support stockings are helpful but if the aircraft were to catch fire, nylon burns more rapidly.
DIABETES
Diabetics should be well controlled with at least a year of stable management prior to going to a foreign country to live, where stress will be a major factor, contributing to instability.
Medical kits for diabetics should be taken, for emergency treatment as well.
Problems of maintaining insulin and syringes in the host country should be checked out in the geographic area before going.
AIDS (Human Immune Deficiency Syndrome)
AIDS is becoming the developing world dilemma. There are parts of Africa where 55% of the population are HIV-positive. That means that they carry a positive antigen for active disease. They may not have the AIDS wasting syndrome and all of the associated symptoms that lead to death, but they will sometime in their lifetime--anywhere from a few months to a few decades--develop the fatal part of the disease. Since it is so much a part of the developing world, many of the expatriate workers ask whether they are at risk. It is to that end that I would like to answer some of these fears.
AIDS cannot be obtained by casual contact or even a dirty toilet seat. It is basically transmitted by body fluids—blood and seminal/vaginal fluids. In Zaire 50% of the midwives contacted AIDS from exposure to blood and amniotic fluids (pregnancy liquers). It is debatable whether saliva and urine transmit AIDS. But these fluids are certainly less infective. Anal intercourse is the main transmission for male-to-male transmission, so rectal fluids are infective both for AIDS and hepatitis. Mothers who are HIV-positive have a 30% risk of transmitting AIDS to their fetuses unless they are treated with anti-viral medication, which reduces it to about 2% of the infants infected.
The expatriate worker should not fear those afflicted with AIDS. Medical workers use latex gloves for their own protection when handling patients and fluids. Unfortunately, in the developing world, many needles which are meant for one-time use are re-used, and the attempt to rid them of AIDS and hepatitis is ineffective. Some agencies like Johns Hopkins University send most of their workers with their own supply of disposable needles along with IV tubing and solution when they go to high risk areas. This approach is not always possible, but being aware of the problem and insisting on the needles’ being brand new—seeing them come out of the unopened package—is somewhat of an assurance to you that you should be okay. These principles are also true for hepatitis viruses, A through G.
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