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Middle East

Health & safety

Before you go

Further reading

Recommended references include Traveller's Health by Dr Richard Dawood (Oxford University Press), International Travel Health Guide by Stuart R Rose, MD (Travel Medicine Inc), and The Travellers' Good Health Guide by Ted Lankester (Sheldon Press), an especially useful health guide for volunteers and long-term expatriates working in the Middle East.

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Insurance

Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures (in many Middle Eastern countries doctors expect payment in cash). It's also worth ensuring that your travel insurance will cover repatriation home or to better medical facilities elsewhere. Your insurance company may be able to locate the nearest source of medical help, or you can ask at your hotel. In an emergency, contact your embassy or consulate. Your travel insurance will not usually cover you for anything other than emergency dental treatment. Not all insurance covers emergency aeromedical evacuation home or to a hospital in a major city, which may be the only way to get medical attention for a serious emergency.

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Internet resources

There is a wealth of travel health advice on the Internet. The WHO (www.who.int/ith/) publishes a superb book, International Travel and Health, which is revised annually and is available online at no cost. Another website of general interest is MD Travel Health (www.mdtravelhealth.com), which provides complete travel health recommendations for every country, updated daily, also at no cost. The website of the Centers for Disease Control & Prevention (www.cdc.gov) is a very useful source of traveller health information.

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Medical checklist

Following is a list of other items you should consider packing in your medical kit:

antibiotics (if travelling off the beaten track)

antidiarrhoeal drugs (eg loperamide)

acetaminophen/paracetamol (eg Tylenol) or aspirin

anti-inflammatory drugs (eg ibuprofen)

antihistamines (for hay fever and allergic reactions)

antibacterial ointment (eg Bactroban) for cuts and abrasions

steroid cream or cortisone (allergic rashes)

bandages, gauze, gauze rolls

adhesive or paper tape

scissors, safety pins, tweezers

thermometer

pocket knife

DEET-containing insect repellent for the skin

permethrin-containing insect spray for clothing, tents and bed nets

sun block

oral-rehydration salts

iodine tablets (for water purification)

syringes and sterile needles (if travelling to remote areas)

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A little planning before departure, particularly for pre-existing illnesses, will save you a lot of trouble later. See your dentist before a long trip; carry a spare pair of contact lenses and glasses (and take your optical prescription); and carry a first-aid kit with you.

It's tempting to leave it all to the last minute - don't! Many vaccines don't ensure immunity for two weeks, so visit a doctor 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, but it's a good idea to carry it wherever you travel.

Travellers can register with the International Association for Medical Advice to Travellers (IMAT; www.iamat.org). Its website can help travellers to find a doctor with recognised training. Those heading off to very remote areas may like to do a first-aid course, (Red Cross and St John Ambulance can help) or attend a remote medicine first-aid course, such as those offered by the Royal Geographical Society (www.rgs.org).

Bring medications in their original, clearly labelled 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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Recommended vaccinations

The World Health Organization (WHO) recommends that all travellers, regardless of the region they are travelling in, should be covered for diphtheria, tetanus, measles, mumps, rubella and polio, as well as hepatitis B. While making preparations to travel, take the opportunity to ensure that all of your routine vaccination cover is complete. The consequences of these diseases can be severe and outbreaks do occur in the Middle East.

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Dangers & annoyances

Don't believe everything you read about the Middle East. Yes, there are regions where travellers would be ill-advised to visit. But alongside the sometimes disturbing hard facts is a vast corpus of exaggeration, stereotyping and downright misrepresentation.

The Middle East's reputation for danger is built on news of political turmoil, the Arab-Israeli conflict and the emergence of Islamic fundamentalism in many countries. Don't let this deter you. The trouble spots are usually well defined, and as long as you keep track of political developments, you're unlikely to come to any harm.

In general, theft is not really a problem in the Middle East and robbery (mugging) even less of one, but don't let the relative safety lull you. Take the standard precautions. Always keep valuables with you or locked in a safe - never leave them in your room or in a car or bus. Use a money belt, a pouch under your clothes, a leather wallet attached to your belt, or internal pockets in your clothing. Keep a record of your passport, credit card and travellers cheque numbers separately; it won't cure problems, but it will make them easier to bear.

However, beware of your fellow travellers; there are more than a few backpackers who make their money go further by helping themselves to other people's.

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In transit

Deep Vein Thrombosis (DVT)

Deep vein thrombosis occurs when blood clots form in the legs during plane flights, chiefly due to prolonged immobility. The longer the flight, the greater the risk. Most blood clots are reabsorbed uneventfully, but some may break off and travel through the blood vessels to the lungs, where they may cause life-threatening complications.

The chief symptom of DVT is swelling or pain of 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. Travellers with any of these symptoms 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 contract 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, and results in insomnia, fatigue, malaise or nausea. To avoid jet lag try drinking plenty of fluids (nonalcoholic) and eating light meals. Upon arrival, seek 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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While you're there

Heat illness

Heat exhaustion occurs after heavy sweating and excessive fluid loss with inadequate replacement of fluids and salt. It is particularly common in hot climates when taking unaccustomed exercise before full acclimatisation. Symptoms include headache, dizziness and tiredness. Dehydration is already happening by the time you feel thirsty - aim to drink sufficient water so that you produce pale, diluted urine. The treatment of heat exhaustion consists of fluid replacement with water or fruit juice or both, and cooling by cold water and fans. The treatment of the salt-loss component consists of salty fluids as in soup or broth, and adding a little more table salt to foods than usual.

Heat stroke is much more serious. This occurs when the heat-regulating mechanism in the body breaks down. An excessive rise in body temperature leads to sweating ceasing, irrational and hyperactive behaviour, and eventually loss of consciousness and death. Rapid cooling by spraying the body with water and fanning is an ideal treatment. Emergency fluid and electrolyte replacement by intravenous drip is usually also required.

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Insect bites & stings

Mosquitoes may not carry malaria but can cause irritation and infected bites. Using DEET-based insect repellents will prevent bites. Mosquitoes also spread dengue fever.

Bees and wasps only cause real problems to those with a severe allergy (anaphylaxis). If you have a severe allergy to bee or wasp stings you should carry an adrenaline injection or similar.

Sand flies are located around the Mediterranean beaches. They usually only cause a nasty itchy bite but can carry a rare skin disorder called cutaneous leishmaniasis. Bites may be prevented by using DEET-based repellents.

Scorpions are frequently found in arid or dry climates. They can cause a painful bite, which is rarely life threatening.

Bed bugs are often found in hostels and cheap hotels. They lead to very itchy lumpy bites. Spraying the mattress with an appropriate insect killer will do a good job of getting rid of them.

Scabies are also frequently found in cheap accommodation. These tiny mites live in the skin, particularly between the fingers. They cause an intensely itchy rash. Scabies is easily treated with lotion available from pharmacies; people who you come into contact with also need treating to avoid spreading scabies between asymptomatic carriers.

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Snake bites

Do not walk barefoot or stick your hand into holes or cracks. Half of those bitten by venomous snakes are not actually injected with poison (envenomed). If bitten by a snake, do not panic. Immobilise the bitten limb with a splint (eg a stick) and apply a bandage over the site, firm pressure, similar to a bandage over a sprain. Do not apply a tourniquet, or cut or suck the bite. Get the victim to medical help as soon as possible so that antivenin can be given if necessary.

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Water

Tap water is not safe to drink in the Middle East. Stick to bottled water, boil water for 10 minutes, or use water-purification tablets or a filter. Do not drink water from rivers or lakes; this may contain bacteria or viruses that can cause diarrhoea or vomiting.

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Diphtheria

Diphtheria is spread through close respiratory contact. It causes a high temperature and severe sore throat. Sometimes a membrane forms across the throat requiring a tracheostomy to prevent suffocation. Vaccination is recommended for those likely to be in close contact with the local population in infected areas. The vaccine is given as an injection alone, or with tetanus, and lasts 10 years.

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Hepatitis A

Hepatitis A is spread through contaminated food (particularly shellfish) and water. It causes jaundice, and although it is rarely fatal, can cause prolonged lethargy and delayed recovery. Symptoms include dark urine, a yellow colour to the whites of the eyes, fever and abdominal pain. Hepatitis A vaccine (Avaxim, VAQTA, Havrix) is given as an injection: a single dose will give protection for up to a year, while a booster 12 months later will provide a subsequent 10 years of protection. Hepatitis A and typhoid vaccines can also be given as a single dose vaccine (hepatyrix or viatim).

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Hepatitis B

Infected blood, contaminated needles and sexual intercourse can all transmit hepatitis B. It can cause jaundice, and affects the liver, occasionally causing liver failure. All travellers should make this a routine vaccination. (Many countries now give hepatitis B vaccination as part of routine childhood vaccination.) The vaccine is given singly, or at the same time as the hepatitis A vaccine (hepatyrix). A course will give protection for at least five years, and can be given over four weeks or six months.

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HIV

Countries in the Middle East that require a negative HIV test as a visa requirement for some categories of visas include Egypt, Iran, Iraq, Jordan, Lebanon and Libya.

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Leishmaniasis

Spread through the bite of an infected sand fly, leishmaniasis can cause a slowly growing skin lump or ulcer. It may develop into a serious life-threatening fever usually accompanied by anaemia and weight loss. Infected dogs are also carriers of the infection. Sand fly bites should be avoided whenever possible. Leishmaniasis is present in Iran, Iraq, Israel and the Palestinian Territories, Jordan, Lebanon, Syria and Turkey.

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Leptospirosis

Leptospirosis is spread through the excreta of infected rodents, especially rats. It can cause hepatitis and renal failure that may be fatal. It is unusual for travellers to be affected unless living in poor sanitary conditions; the greatest risk is in Turkey. It causes a fever and jaundice.

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Malaria

The prevalence of malaria varies throughout the Middle East. Many areas are considered to be malaria free, while others have seasonal risks. The risk of malaria is minimal in most cities; however, check with your doctor if you are considering travelling to any rural areas. It is important to take antimalarial tablets if the risk is significant. For up-to-date information about the risk of contracting malaria in a specific country, contact your local travel health clinic.

Anyone who has travelled in a country where malaria is present should be aware of the symptoms of malaria. It is possible to contract malaria from a single bite from an infected mosquito. Malaria almost always starts with marked shivering, fever and sweating. Muscle pains, headache and vomiting are common. Symptoms may occur anywhere from a few days to three weeks after the infected mosquito bite. The illness can start while you are taking preventative tablets if they are not fully effective, and may also occur after you have finished taking your tablets.

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Poliomyelitis

Generally spread through contaminated food and water, polio is present, though rare, throughout the Middle East. It is one of the vaccines given in childhood and should be boosted every 10 years, either orally (a drop on the tongue), or as an injection. Polio may be carried asymptomatically, although it can cause a transient fever and, in rare cases, potentially permanent muscle weakness or paralysis.

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Rabies

Spread through bites or licks on broken skin from an infected animal, rabies (present in all countries of the Middle East) is fatal. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours. Three injections are needed over a month. If you have not been vaccinated you will need a course of five injections starting within 24 hours or as soon as possible after the injury. Vaccination does not provide you with immunity, it merely buys you more time to seek appropriate medical help.

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Rift valley fever

This haemorrhagic fever, which is found in Egypt, is spread through blood or blood products, including those from infected animals. It causes a 'flu-like' illness with fever, joint pains and occasionally more serious complications. Complete recovery is possible.

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Schistosomiasis

Otherwise known as bilharzia, this is spread through the freshwater snail. It causes infection of the bowel and bladder, often with bleeding. It is caused by a fluke and is contracted through the skin from water contaminated with human urine or faeces. Paddling or swimming in suspect freshwater lakes or slow running rivers should be avoided. There may be no symptoms. Possible symptoms include a transient fever and rash, and advanced cases of bilharzia may cause blood in the stool or in the urine. A blood test can detect antibodies if you have been exposed and treatment is then possible in specialist travel or infectious disease clinics. Be especially careful in Egypt, Iraq and Syria.

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Tuberculosis (TB)

Tuberculosis is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccine is recommended for those likely to be mixing closely with the local population. It is more important for those visiting family or planning on a long stay, and those employed as teachers and health-care workers. TB can be asymptomatic, although symptoms can include coughing, weight loss or fever months or even years after exposure. An X-ray is the best way to confirm if you have TB. BCG gives a moderate degree of protection against TB. It causes a small permanent scar at the site of injection, and is usually only given in specialised chest clinics. As it's a live vaccine it should not be given to pregnant women or immunocompromised individuals. The BCG vaccine is not available in all countries.

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Typhoid

Typhoid is spread through food or water that has been contaminated by infected human faeces. The first symptom is usually fever or a pink rash on the abdomen. Septicaemia (blood poisoning) may also occur. Typhoid vaccine (typhim Vi, typherix) will give protection for three years. In some countries, the oral vaccine Vivotif is also available.

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Yellow fever

Yellow fever vaccination is not required for any areas of the Middle East. However, the mosquito that spreads yellow fever has been known to be present in some parts of the Middle East. It is important to consult your local travel health clinic as part of your predeparture plans for the latest details. For this reason, any travellers from a yellow fever endemic area will need to show proof of vaccination against yellow fever before entry. This normally means if arriving directly from an infected country or if the traveller has been in an infected country during the last 10 days. We would recommend, however, that travellers carry a certificate if they have been in an infected country during the previous month to avoid any possible difficulties with immigration. There is always the possibility that a traveller without an up-to-date certificate will be vaccinated and detained in isolation at the port of arrival for up to 10 days, or even repatriated. The yellow fever vaccination must be given at a designated clinic, and is valid for 10 years. It is a live vaccine and must not be given to immunocompromised or pregnant travellers.

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Travelling with children

All travellers with children should know how to treat minor ailments and when to seek medical treatment. Make sure the children are up to date with routine vaccinations, and discuss possible travel vaccines well before departure as some vaccines are not suitable for children aged under one year.

In hot, moist climates any wound or break in the skin may lead to infection. The area should be cleaned and then kept dry and clean. Remember to avoid contaminated food and water. If your child is vomiting or experiencing diarrhoea, lost fluid and salts must be replaced. It may be helpful to take rehydration powders for reconstituting with boiled water. Ask your doctor about this.

Children should be encouraged to avoid dogs or other mammals because of the risk of rabies and other diseases. Any bite, scratch or lick from a warm blooded, furry animal should immediately be thoroughly cleaned. If there is any possibility that the animal is infected with rabies, immediate medical assistance should be sought.

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Availability & cost of health care

The health care systems in the Middle East are varied. Medical care can be excellent in Israel, with well-trained doctors and nurses, but can be patchier elsewhere. Reciprocal arrangements with countries rarely exist and you should be prepared to pay for all medical and dental treatment.

Medical care is not always readily available outside major cities. Medicine, and even sterile dressings or intravenous fluids, may need to be bought from a local pharmacy. Nursing care may be limited or rudimentary as this is something families and friends are expected to provide. The travel assistance provided by your insurance may be able to locate the nearest source of medical help, otherwise ask at your hotel. In an emergency, contact your embassy or consulate.

Standards of dental care are variable and there is an increased risk of hepatitis B and HIV transmission via poorly sterilised equipment. And keep in mind that your travel insurance will not usually cover you for anything other than emergency dental treatment.

For minor illnesses such as diarrhoea, pharmacists can often provide valuable advice and sell over-the-counter medication. They can also advise when more specialised help is needed.

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Traveller's diarrhoea

To prevent diarrhoea, avoid tap water unless it has been boiled, filtered or chemically disinfected (with iodine tablets). Eat only fresh fruits or vegetables if cooked or if you have peeled them yourself and avoid dairy products that may contain unpasteurised milk. Buffet meals are risky, as food should be piping hot; meals freshly cooked in front of you in a busy restaurant are more likely to be safe.

If you develop diarrhoea, be sure to drink plenty of fluids, preferably an oral rehydration solution containing 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 antidiarrhoeal agent (such as loperamide). If diarrhoea is bloody, persists for more than 72 hours, is accompanied by fever, shaking chills or severe abdominal pain you should seek medical attention.

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Women's health

Emotional stress, exhaustion and travelling through different time zones can all contribute to an upset in the menstrual pattern. If using oral contraceptives, remember some antibiotics, diarrhoea and vomiting can stop the pill from working and lead to the risk of pregnancy - remember to take condoms with you just in case. Condoms should be kept in a cool, dry place or they may crack and perish.

Emergency contraception is most effective if taken within 24 hours after unprotected sex. The International Planned Parent Federation (www.ippf.org) can advise about the availability of contraception in different countries. Tampons and sanitary towels are not always available outside of major cities in the Middle East.

Travelling during pregnancy is usually possible but there are important things to consider. Have a medical check-up before embarking on your trip. The most risky times for travel are during the first 12 weeks of pregnancy, when miscarriage is most likely, and after 30 weeks, when complications such as high blood pressure and premature delivery can occur. Most airlines will not accept a traveller after 28 to 32 weeks of pregnancy, and long-haul flights in the later stages can be very uncomfortable. Antenatal facilities vary greatly between countries in the Middle East and you should think carefully before travelling to a country with poor medical facilities or where there are major cultural and language differences from home. Taking written records of the pregnancy, including details of your blood group, are likely to be helpful if you need medical attention while away. Ensure your insurance policy covers pregnancy, delivery and postnatal care, but remember insurance policies are only as good as the facilities available.

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