Health   Dr David Goldberg

CONTENTS

   Before You Go
   Insurance
   Medical Checklist
   Internet Resources
   Further Reading
   In Transit
   Deep Vein Thrombosis (DVT)
   Jet Lag & Motion Sickness
   In Cuba
   Availability & Cost of Health Care
   Infectious Diseases
   Traveler’s Diarrhea
   Environmental Hazards
   Traveling with Children
   Women’s Health
   Traditional Medicine


From a medical point of view, the Caribbean islands are generally safe as long as you’re reasonably careful about what you eat and drink. The most common travel-related diseases, such as dysentery and hepatitis, are acquired by the consumption of contaminated food and water. Mosquito-borne illnesses are not a significant concern on most of the islands within the Cuban archipelago.

Prevention is the key to staying healthy while traveling around Cuba. Travelers who receive the recommended vaccines and follow commonsense precautions usually come away with nothing more than a little diarrhea.

BEFORE YOU GO

Since most vaccines don’t produce immunity until at least two weeks after they’re given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the ‘yellow booklet’), which will list all the vaccinations you’ve received. This is mandatory for countries that require proof of yellow-fever vaccination upon entry. Cuba doesn’t require yellow-fever vaccination, but it’s a good idea to carry your yellow booklet wherever you travel.

Bring medications in their original, clearly labeled containers. A signed and dated letter from your physician describing your medical conditions and medications, including generic names, is also a good idea. If carrying syringes or needles, be sure to have a physician’s letter documenting their medical necessity.

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INSURANCE

If your usual health insurance doesn’t cover you for medical expenses abroad, consider getting extra insurance; Click here and check out the Travel Services/Insurance section at lonelyplanet.com for more information. Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. (In many countries, doctors expect payment in cash.)

Should you get into trouble health-wise and end up in hospital, call Asistur ( 7-866-8527; www.asistur.cu) for help with insurance and medical assistance. The company has regional offices in Havana, Varadero, Cienfuegos, Cayo Coco, Camagüey, Guardalavaca and Santiago de Cuba.

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MEDICAL CHECKLIST

GOVERNMENT TRAVEL HEALTH ADVICE

It’s usually a good idea to consult your government’s travel health website before departure, if one is available:

RECOMMENDED VACCINATIONS

No vaccines are required for Cuba, but a number are recommended:

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INTERNET RESOURCES

There is a wealth of travel health advice on the internet. For further information, lonelyplanet.com is a good place to start. The World Health Organization publishes a superb book called International Travel and Health, which is revised annually and is available online at no cost (www.who.int/ith). Another website of general interest is MD Travel Health (www.mdtravelhealth.com), which provides complete travel health recommendations for every country and is updated daily.

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FURTHER READING

If you’re traveling with children, Lonely Planet’s Travel with Children may be useful. The ABC of Healthy Travel, by Eric Walker et al, is another valuable resource.

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IN TRANSIT

DEEP VEIN THROMBOSIS (DVT)

Blood clots may form in the legs (deep vein thrombosis) during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. Though most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they could cause life-threatening complications.

The chief symptom of DVT is swelling or pain in the foot, ankle or calf, usually – but not always – on just one side. When a blood clot travels to the lungs, it may cause chest pain and difficulty breathing. Travelers with any of the symptoms noted above should immediately seek medical attention.

To prevent the development of DVT on long flights, you should walk about the cabin, perform isometric compressions of the leg muscles (ie flex the leg muscles while sitting), drink plenty of fluids and avoid alcohol and tobacco.

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JET LAG & MOTION SICKNESS

Jet lag is common when crossing more than five time zones, resulting in insomnia, fatigue, malaise or nausea. To avoid jet lag, try to drink plenty of (nonalcoholic) fluids and eat light meals. Upon arrival, get exposure to natural sunlight and readjust your schedule (for meals, sleep etc) as soon as possible.

Antihistamines such as dimenhydrinate (Dramamine) and meclizine (Antivert, Bonine) are usually the first choice for treating motion sickness. Their main side effect is drowsiness. A herbal alternative is ginger, which works like a charm for some people.

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IN CUBA

AVAILABILITY & COST OF HEALTH CARE

The Cuban government has established a for-profit health system for foreigners called Servimed ( 7-24-01-41), which is entirely separate from the free, not-for-profit system that takes care of Cuban citizens. There are more than 40 Servimed health centers across the island, offering primary care as well as a variety of specialty and high-tech services. If you’re staying in a hotel, the usual way to access the system is to ask the manager for a physician referral. Servimed centers accept walk-ins. While Cuban hospitals provide some free emergency treatment for foreigners, this should only be used when there is no other option. Remember that in Cuba medical resources are scarce and the local populace should be given priority in free healthcare facilities.

Almost all doctors and hospitals expect payment in cash, regardless of whether you have travel health insurance or not. If you develop a life-threatening medical problem, you’ll probably want to be evacuated to a country with state-of-the-art medical care. Since this may cost tens of thousands of dollars, be sure you have insurance to cover this before you depart. Click here for details.

There are special pharmacies for foreigners also run by the Servimed system, but all Cuban pharmacies are notoriously short on supplies, including pharmaceuticals. Be sure to bring along adequate quantities of all medications you might need, both prescription and over-the-counter. Also, be sure to bring along a fully stocked medical kit.

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INFECTIOUS DISEASES

Dengue (Break-bone) Fever

Dengue fever is a viral and mosquito-borne infection found throughout the Caribbean. A major outbreak of dengue fever, centering on Havana and resulting in more than 3000 cases, was reported from November 2001 through to March 2002. Since then, an aggressive government program has all but eradicated dengue from the island. See also Click here for information on avoiding mosquito bites.

Hepatitis A

Hepatitis A is the second most common travel-related infection (after traveler’s diarrhea). It occurs throughout the Caribbean, particularly on the northern islands. Hepatitis A is a viral infection of the liver that is usually acquired by ingestion of contaminated water, food or ice, though it may also be acquired by direct contact with infected persons. The illness occurs throughout the world, but the incidence is higher in developing nations. Symptoms may include fever, malaise, jaundice, nausea, vomiting and abdominal pain. Most cases resolve without complications, though hepatitis A occasionally causes severe liver damage. There is no treatment.

The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months after the first vaccine, it lasts for at least 10 years. You really should get this vaccine before you go to Cuba or any other developing nation. Because the safety of the hepatitis A vaccine has not been established for pregnant women or children under the age of two, they should instead be given a gamma globulin injection.

Hepatitis B

Like hepatitis A, hepatitis B is a liver infection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is recommended only for long-term travelers (on the road for more than six months) who expect to live in rural areas or have close physical contact with the local population. Additionally, the vaccine is recommended for anyone who anticipates sexual contact with the local inhabitants or a possible need for medical, dental or other treatments while abroad, especially if a need for transfusions or injections is expected.

The hepatitis B vaccine is safe and highly effective. However, a total of three injections are necessary to establish full immunity. Several countries added the hepatitis B vaccine to the list of routine childhood immunizations in the 1980s, so many young adults are already protected.

Malaria

In the Caribbean, malaria occurs only in Haiti and certain parts of the Dominican Republic. Malaria pills aren’t necessary for Cuba.

Rabies

Rabies is a viral infection of the brain and spinal cord that is almost always fatal. The virus is carried in the saliva of infected animals and is usually transmitted through an animal bite, though contamination of any break in the skin with infected saliva may result in rabies. Rabies occurs in several Caribbean islands, including Cuba. Most cases in Cuba are related to bites from dogs, bats and wild animals, especially the small Indian mongoose.

The rabies vaccine is safe, but a full series requires three injections and is quite expensive. Those at high risk of rabies, such as animal handlers and spelunkers (cave explorers), should certainly get the vaccine. Those at lower risk of animal bites should consider asking for the vaccine if they are traveling to remote areas and might not have access to appropriate medical care if needed. The treatment for a possibly rabid bite consists of rabies vaccine with rabies immune globulin. It’s effective but must be given promptly. Most travelers don’t need the rabies vaccine.

All animal bites and scratches must be promptly and thoroughly cleansed with large amounts of soap and water, and local health authorities must be contacted to determine whether or not further treatment is necessary (Click here).

Typhoid

Typhoid fever is caused by ingestion of food or water contaminated by a species of salmonella known as Salmonella typhi. Fever occurs in virtually all cases. Other symptoms may include headache, malaise, muscle aches, dizziness, loss of appetite, nausea and abdominal pain. Either diarrhea or constipation may occur. Possible complications include intestinal perforation, intestinal bleeding, confusion, delirium or (rarely) coma.

The typhoid vaccine is usually given orally, but is also available as an injection. Neither vaccine is approved for use in children under two. If you get typhoid fever, the drug of choice is usually a quinolone antibiotic such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), which many travelers carry for treatment of diarrhea.

Other Infections

BRUCELLOSIS

Brucellosis is an infection of domestic and wild animals that may be transmitted to humans through direct animal contact or by consumption of unpasteurized dairy products from infected animals. In Cuba, most human cases are related to infected pigs. Symptoms may include fever, malaise, depression, loss of appetite, headache, muscle aches and back pain. Complications may include arthritis, hepatitis, meningitis and endocarditis (heart valve infection).

FASCIOLIASIS

This is a parasitic infection that is typically acquired by eating contaminated watercress grown in sheep-raising areas. Early symptoms may include fever, nausea, vomiting and painful enlargement of the liver.

HIV/AIDS

HIV/AIDS has been reported in all Caribbean countries. Be sure to use condoms for the purposes of safe sex.

LEPTOSPIROSIS

Acquired by exposure to water contaminated by the urine of infected animals. Outbreaks often occur at times of flooding, when sewage overflow may contaminate water sources. The initial symptoms, which resemble a mild flu, usually subside uneventfully in a few days, with or without treatment, but a minority of cases are complicated by jaundice or meningitis. There is no vaccine. You can minimize your risk by staying out of bodies of fresh water that may be contaminated by animal urine. If you’re visiting an area where an outbreak is in progress, as occurred in Cuba in 1994, you can take 200mg of doxycycline once weekly as a preventative measure. If you actually develop leptospirosis, the treatment is 100mg of doxycycline twice daily.

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TRAVELER’S DIARRHEA

To prevent diarrhea, avoid tap water unless it has been boiled, filtered or chemically disinfected (with iodine tablets); only eat fresh fruits or vegetables if cooked or peeled; be wary of dairy products that may contain unpasteurized milk; and be highly selective when eating food from street vendors.

If you develop diarrhea, be sure to drink plenty of fluids, preferably an oral rehydration solution containing lots of salt and sugar. A few loose stools don’t require treatment, but if you start having more than four or five stools a day, you should start taking an antibiotic (usually a quinolone drug) and an antidiarrheal agent (such as loperamide). If diarrhea is bloody, persists for more than 72 hours or is accompanied by fever, shaking chills or severe abdominal pain, you should seek medical attention.

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ENVIRONMENTAL HAZARDS

Animal Bites

Do not attempt to pet, handle or feed any animal, with the exception of domestic animals known to be free of any infectious disease. Most injuries are directly related to a person’s attempt to touch or feed the animal.

Any bite or scratch by a mammal, including bats, should be promptly and thoroughly cleansed with large amounts of soap and water, followed by application of an antiseptic such as iodine or alcohol. The local health authorities should be contacted immediately for possible postexposure rabies treatment, whether or not you’ve been immunized against rabies (Click here). It may also be advisable to start an antibiotic, since wounds caused by animal bites and scratches frequently become infected. One of the newer quinolones, such as levofloxacin (Levaquin), which many travelers carry in case of diarrhea, would be an appropriate choice.

Spiny sea urchins and coelenterates (coral and jellyfish) are a hazard in some areas. Some stings (eg from a Portuguese man-of-war) can produce a bad reaction, and if you start to feel nauseous or faint you should seek medical treatment.

Heatstroke

To protect yourself from excessive sun exposure, you should stay out of the midday sun, wear sunglasses and a wide-brimmed sun hat, and apply sunscreen with SPF 15 or higher, with both UVA and UVB protection. Sunscreen should be generously applied to all exposed parts of the body approximately 30 minutes before sun exposure and should be reapplied after swimming or vigorous activity. Travelers should also drink plenty of fluids and avoid strenuous exercise when the temperature is high.

Insect Bites & Stings

Because of an aggressive program of mosquito control, mosquito-borne illnesses are usually not a concern in Cuba. However, outbreaks of dengue fever (Click here) have occurred in the recent past, so you should be aware of the means of preventing mosquito bites, if necessary. If dengue or other mosquito-borne illnesses are being reported, you should keep yourself covered (wear long sleeves, long pants, a hat, and shoes rather than sandals) and apply a good insect repellent, preferably one containing DEET, to exposed skin and clothing. Do not apply DEET to eyes, mouth, cuts, wounds or irritated skin. Products containing lower concentrations of DEET are as effective, but for shorter periods of time. In general, adults and children over 12 should use preparations containing 25% to 35% DEET, which usually lasts for about six hours. Children between two and 12 years of age should use preparations containing no more than 10% DEET, applied sparingly, which will usually last about three hours. Neurologic toxicity has been reported from DEET, especially in children, but appears to be extremely uncommon and generally related to overuse. DEET-containing compounds should not be used on children under the age of two.

Insect repellents containing certain botanical products, including eucalyptus and soybean oil, are effective but last only for 1½ to two hours. Products based on citronella are not effective.

For additional protection, you can apply permethrin to clothing, shoes, tents and bed nets. Permethrin treatments are safe and remain effective for at least two weeks, even when items are laundered. Permethrin should not be applied directly to skin.

Water

Tap water in Cuba is not reliably safe to drink. Vigorous boiling for one minute is the most effective means of water purification.

You may also disinfect water with iodine pills. Instructions are included and should be carefully followed. Or you can add 2% tincture of iodine to 1L of water (five drops to clear water, 10 drops to cloudy water) and let it stand for 30 minutes. If the water is cold, longer times may be required. The taste of iodinated water may be improved by adding vitamin C (ascorbic acid). Iodinated water should not be consumed for more than a few weeks. Pregnant women, those with a history of thyroid disease, and those allergic to iodine should not drink iodinated water. Click here for more treatment options.

A number of water filters are on the market. Those with smaller pores (reverse osmosis filters) provide the broadest protection, but they are relatively large and are readily plugged by debris. Those with somewhat larger pores (microstrainer filters) are ineffective against viruses, although they remove other organisms. Follow the manufacturers’ instructions carefully.

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TRAVELING WITH CHILDREN

In general, it’s safe for children to go to Cuba. However, because some of the vaccines listed previously are not approved for use on children (or during pregnancy), travelers with children should be particularly careful not to drink tap water or consume any questionable food or beverage. Also, when traveling with children, make sure they’re up to date on all routine immunizations. It’s sometimes appropriate to give children some of their vaccines a little early before visiting a developing nation. You should discuss this with your pediatrician.

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WOMEN’S HEALTH

You can get sanitary items in Cuba, but they are usually more expensive than in Europe, North America or Australia and they are not always readily available (eg easy to find in Varadero, but not quite so easy in Bayamo). Advice: bring a good supply of your own. If pregnant while traveling, see left.

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TRADITIONAL MEDICINE

The following table lists some traditional remedies for common travel-related issues:


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