Health & safety
For further information, see Healthy Travel Central & South America, also from Lonely Planet. If you’re traveling with children, Lonely Planet’s Travel with Children may be useful. The ABC of Healthy Travel, by E Walker et al, is another valuable resource.
There is a wealth of travel-health advice on the internet. A superb book called International Travel and Health, revised annually and available online at no cost, is published by the World Health Organization (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, updated daily, also at no cost.
It’s usually a good idea to consult your government’s travel-health website before departure, if one is available:
United Kingdom (www.doh.gov.uk/traveladvice/index.htm)
United States (www.cdc.gov/travel/)
Acetaminophen (Tylenol) or aspirin
Adhesive or paper tape
Antibacterial ointment (eg Bactroban) for cuts and abrasions
Antidiarrheal drugs (eg loperamide)
Antihistamines (for hay fever and allergic reactions)
Anti-inflammatory drugs (eg ibuprofen)
Bandages, gauze, gauze rolls
DEET-containing insect repellent for the skin
Iodine tablets (for water purification)
Malaria pills – recommended if going to the Darién
Oral rehydration salts
Permethrin-containing insect spray for clothing, tents and bed nets
Scissors, safety pins, tweezers
Steroid cream or cortisone (for poison ivy and other allergic rashes)
Syringes and sterile needles
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, but it’s a good idea to carry it wherever you travel.
Bring medications in their original containers, clearly labeled. A signed, dated letter from your physician describing all 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.
Most doctors and hospitals expect payment in cash, regardless of whether you have travel health insurance. 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 the insurance to cover this before you depart. You can find a list of medical-evacuation and travel-insurance companies on the US State Department website (www.travel.state.gov/travel/abroad_health.html). If your health insurance does not cover you for medical expenses abroad, consider supplemental insurance. Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures.
Crime is a problem in certain parts of Panama City. The city’s better districts, however, are safer than in many other capitals: witness the all-night restaurants and activity on the streets at night. On the other hand, it is not safe to walk around at night on the outskirts of Casco Viejo – be careful in the side streets of this district even in the daytime. In general, stay where it’s well lit and there are plenty of people around.
Colón has some upscale residential areas, but most of the city is a sad slum widely known for street crime. If you walk around, even in the middle of the day, well-meaning residents will inform you that you are in danger.
Parts of the Darién Province, which borders Colombia, are extremely dangerous. Not only is it easy to get hopelessly lost, but parts of the province are used by guerillas from Colombia, the paramilitary chasing the guerillas, and narcotraffickers. Particularly treacherous is the area between Boca de Cupe and Colombia, which is the traditional path through the Darién Gap.
Plying the waters of the Archipiélago de San Blás are numerous Colombian boats that run back and forth between the Zona Libre in Colón and Cartagena, Colombia. It has been well documented that some of these boats carry cocaine on their northbound voyages. If you decide to ride on one of these slow cargo boats, be forewarned that your crew may be trafficking drugs.
Deep vein thrombosis (DVT)
Blood clots (deep vein thrombosis) may form in the legs during long-haul 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 deep vein thrombosis 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. Travelers with any of these symptoms should immediately seek medical attention.
To prevent the development of deep vein thrombosis 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.
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 drinking plenty of fluids (nonalcoholic) and eating 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 can work like a charm for some people.
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 animal 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 the application of an antiseptic such as iodine or alcohol. The local health authorities should be contacted immediately for possible post-exposure rabies treatment, whether or not you’ve been immunized against rabies. 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.
To prevent mosquito bites, wear long sleeves, long pants, hats and shoes (rather than sandals). Bring along a good insect repellent, preferably one containing DEET, which should be applied to exposed skin and clothing, but not 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 years of age should use preparations containing 25% to 35% DEET, which usually last 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 oil of eucalyptus and soybean oil, are effective but last only 1½ to two hours. DEET-containing repellents are preferable for areas where there is a high risk of malaria or yellow fever. 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.
Don’t sleep with the window open unless there is a screen. If sleeping outdoors or in accommodations that allow entry of mosquitoes, use a bed net, preferably treated with permethrin, with edges tucked in under the mattress. The mesh size should be less than 1.5mm. If the sleeping area is not otherwise protected, use a mosquito coil, which will fill the room with insecticide through the night. Repellent-impregnated wristbands are not effective.
Panama is home to several venomous snakes and any foray into forested areas will put you at (a very slight) risk of snake bite. The best prevention is to wear closed, heavy shoes or boots and to keep a watchful eye on the trail. Snakes like to come out to cleared paths for a nap, so watch where you step.
In the event of a venomous snake bite, place the victim in an restful position, keep the bitten area immobilized and move the victim immediately to the nearest medical facility. Avoid using tourniquets, which are no longer recommended.
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.
Tap water in Panama City is safe to drink, as is the water in most other parts of the country. However, you’re better off buying bottled water or purifying your own water in the provinces of Bocas del Toro and Kuna Yala.
If you have the means, vigorous boiling for one minute is the most effective way of water purification. Another option is to disinfect water with iodine pills; add 2% tincture of iodine to one quart or liter of water (five drops to clear water, 10 drops to cloudy water) and let stand for 30 minutes. If the water is cold, longer times may be required.
Chagas’ disease is a parasitic infection that is transmitted by triatomine insects (reduviid bugs), which inhabit crevices in the walls and roofs of substandard housing in South and Central America. In Panama, Chagas’ disease occurs in rural areas. The triatomine insect lays its feces on human skin as it bites, usually at night. A person becomes infected when he or she unknowingly rubs the feces into the bite wound or any other open sore. Chagas’ disease is extremely rare in travelers. However, if you sleep in a poorly constructed house, especially one made of mud, adobe or thatch, you should be sure to protect yourself with a bed net and a good insecticide.
Cholera has not been reported in Panama in recent years. Cholera vaccine is not recommended.
Dengue fever (breakbone fever)
Dengue fever is a viral infection found throughout Central America. In Panama, most cases occur in San Miguelito and in the Panama City metropolitan area. Dengue is transmitted by aedes mosquitoes, which bite preferentially during the daytime and are usually found close to human habitations, often indoors. They breed primarily in artificial water containers, such as jars, barrels, cans, cisterns, metal drums, plastic containers and discarded tires. As a result, dengue is especially common in densely populated, urban environments.
Dengue usually causes flu-like symptoms, including fever, muscle aches, joint pains, headaches, nausea and vomiting, often followed by a rash. The body aches may be quite uncomfortable, but most cases resolve uneventfully in a few days. There is no treatment for dengue fever except to take analgesics such as acetaminophen/paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is to avoid being bitten.
Hantavirus pulmonary syndrome
This is a rapidly progressive viral infection that typically leads to respiratory failure and is frequently fatal. The disease is acquired by exposure to the excretions of wild rodents. Most cases occur in those who live in rodent-infested dwellings in rural areas. An outbreak of hantavirus pulmonary syndrome was recently reported from Los Santos Province.
Hepatitis A is the second most common travel-related infection (after traveler’s diarrhea). It’s 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 twelve months later, it lasts for at least 10 years. You really should get it before you go to Panama or any other developing nation. Because the safety of hepatitis A vaccine has not been established for pregnant women or children under age two, they should instead be given a gammaglobulin injection.
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 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.
Hepatitis B vaccine is safe and highly effective. However, a total of three injections is necessary to establish full immunity. Several countries added hepatitis B vaccine to the list of routine childhood immunizations in the 1980s, so many young adults are already protected.
This has been reported from all Central American countries. Be sure to use condoms for all sexual encounters. Reliable, American-made brands are available at most pharmacies.
Leishmaniasis occurs in rural and forested areas throughout Panama, especially the eastern and south-central regions. The disease is generally limited to the skin, causing slow-growing ulcers over exposed parts of the body, but the infection may become generalized, especially in those with HIV. Leishmaniasis is transmitted by sandflies, which are about one-third the size of mosquitoes. There is no vaccine. To protect yourself from sandflies, follow the same precautions as for mosquitoes, except that netting must be finer-size mesh (at least 18 holes to the linear inch).
Leptospirosis is acquired by exposure to water contaminated by the urine of infected animals. In Panama, leptospirosis is reported throughout the country. The greatest risk occurs at times of flooding, when sewage overflow may contaminate water sources. Outbreaks have been reported among military personnel performing jungle training exercises. 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 engaging in high-risk activities in an area where an outbreak is in progress, 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.
Malaria is transmitted by mosquito bites, usually between dusk and dawn. The main symptom is high-spiking fevers, which may be accompanied by chills, sweats, headache, body aches, weakness, vomiting, or diarrhea. Severe cases may involve the central nervous system and lead to seizures, confusion, coma and death.
In Panama, malaria pills are recommended for rural areas in the provinces of Bocas del Toro, Darién and Kuna Yala. For Bocas del Toro, the first-choice malaria pill is chloroquine, taken once weekly in a dosage of 500mg, starting one to two weeks before arrival and continuing through the trip, and for four weeks after departure. Chloroquine is safe, inexpensive and highly effective. Side effects are typically mild and may include nausea, abdominal discomfort, headache, dizziness, blurred vision or itching. Severe reactions are uncommon.
Protecting yourself against mosquito bites is just as important as taking malaria pills, since no pills are 100% effective.
If you may not have access to medical care while traveling, you should bring along additional pills for emergency self-treatment, which you should take if you can’t reach a doctor and you develop symptoms that suggest malaria, such as high-spiking fevers. One option is to take four tablets of Malarone once daily for three days. If you start self-medication, you should try to see a doctor at the earliest possible opportunity.
In areas east of the Canal Zone, including the Darién and Kuna Yala, there are chloroquine-resistant mosquitoes. Your options there are mefloquine (which has severe side effects for some travelers), doxycycline (which is milder on the system, but makes you more susceptible to sunburn) or Malarone.
If you develop a fever after returning home, see a physician, as malaria symptoms may not occur for months.
Rabies is a viral infection of the brain and spinal cord that is almost always fatal. The rabies virus is carried in the saliva of infected animals and is typically transmitted through an animal bite, though contamination of any break in the skin with infected saliva may result in rabies.
In Panama, rabies is transmitted mainly by vampire bats. All animal bites and scratches must be promptly and thoroughly cleansed with large amounts of soap and water, and local health authorities contacted to determine whether or not further treatment is necessary.
Tick-borne relapsing fever
This fever, which may be transmitted by either ticks or lice, is caused by bacteria that are closely related to those which cause Lyme disease and syphilis. The illness is characterized by periods of fever, chills, headaches, body aches, muscle aches and cough, alternating with periods when the fever subsides and the person feels relatively well. To minimize the risk of relapsing fever, follow tick precautions and practice good personal hygiene at all times.
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.
Unless you expect to take all your meals in major hotels and restaurants, typhoid vaccine is a good idea. It’s usually given orally, but is also available as an injection. Neither vaccine is approved for use in children under the age of two.
The drug of choice for typhoid fever is usually a quinolone antibiotic such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), which many travelers carry for treatment of traveler’s diarrhea. However, if you self-treat for typhoid fever, you may also need to self-treat for malaria, since the symptoms of the two diseases may be indistinguishable.
Yellow fever is a life-threatening viral infection transmitted by mosquitoes in forested areas. The illness begins with flu-like symptoms, which may include fever, chills, headache, muscle aches, backache, loss of appetite, nausea and vomiting. These symptoms usually subside in a few days, but one person in six enters a second, toxic phase characterized by recurrent fever, vomiting, listlessness, jaundice, kidney failure and hemorrhage, leading to death in up to half of the cases. There is no treatment.
Yellow-fever vaccine is not required for travel to Panama, but is strongly recommended for all travelers greater than nine months of age, especially those visiting Chepo, Darién and Kuna Yala.
The vaccine is given only in approved yellow-fever vaccination centers, which provide validated International Certificates of Vaccination (yellow booklets). The vaccine should be given at least 10 days before any potential exposure to yellow fever and remains effective for approximately 10 years. Reactions to the vaccine are generally mild and may include headaches, muscle aches, low-grade fevers or discomfort at the injection site. Severe, life-threatening reactions have been described but are extremely rare. In general, the risk of becoming ill from the vaccine is far less than the risk of becoming ill from yellow fever and you’re strongly encouraged to get the vaccine.
Taking measures to protect yourself from mosquito bites is an essential part of preventing yellow fever.
Traveling with children
In general, pregnant women and children less than nine months of age should avoid going to Panama, since yellow-fever vaccine, which is strongly recommended for all parts of the country, may not be safe during pregnancy or the first few months of life.
Older children may be brought to Panama. However, you should be particularly careful not to let them 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.
Availability of health care
Good medical care is widely available in Panama City. The following hospitals and clinics are generally reliable:
Centro Medico Paitilla (265 8800; cnr Av Balboa & Calle 53, Paitilla)
Clinica Hospital San Fernando (278 6300, emergency 278 6305; www.hospitalsanfernando.com; Vía España, Las Sabanas Apartado 363)
Clinica Hospital San Fernando Hospital Pediatrico (229 2299/229 2477; www.hospitalsanfernando.com; Vía España, Las Sabanas 363)
Hospital Nacional (switchboard207 8100, emergency room 207 8110; Av Cuba btwn Calle 38 & 39)
Medical facilities outside Panama City are limited. David has the best hospitals outside the capital:
Hospital Centro Medico Mae Lewis (775 4616; Vía Panamericana, Apartado 333)
To prevent diarrhea, avoid tap water unless it has been boiled, filtered or chemically disinfected (iodine tablets); only eat fresh fruits or vegetables if cooked or peeled; be wary of dairy products that might 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 or 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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