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Puerto Rico

Health & safety

Before you go

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.

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Insurance

If your health insurance does not cover you for medical expenses abroad, consider supplemental insurance. US travelers can find a list of medical evacuation and travel insurance companies on the US State Department website (www.travel.state.gov). Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures.

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Recommended vaccinations

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.

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Internet resources

There is a wealth of travel health advice on the internet:

MD Travel Health (www.mdtravelhealth.com) A website of general interest which provides complete travel health recommendations for every country, updated daily, at no cost.

World Health Organization (www.who.int/ith) Available online at no cost as well as in book form – International Travel and Health – which is revised annually.

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

United States www.cdc.gov/travel

Canada www.hc-sc.gc.ca

United Kingdom www.dh.gov.uk

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Further reading

If you’re traveling with children, you might want to read Lonely Planet’s Travel with Children before you leave. The ABC of Healthy Travel, by E Walker et al, is another valuable resource.

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Medical checklist

Antibiotics

Antidiarrheal drugs (eg loperamide)

Acetaminophen (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 (for poison ivy and other allergic rashes)

Bandages, gauze, gauze rolls

Adhesive or paper tape

Scissors, safety pins, tweezers

Thermometer

Pocket knife

Insect repellent for the skin

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

Sun block

Oral rehydration salts

odine tablets (for water purification)

Syringes and sterile needles

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In transit

Deep vein thrombosis

Blood clots may form in the legs (deep vein thrombosis; DVT) 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 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 make breathing difficult. Travelers with any of these symptoms should seek immediate 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.

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Jet lag & motion sickness

Jet lag is common when crossing more than five time zones, and can result 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. An herbal alternative is ginger, which works like a charm for some people.

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While you're there

From a medical standpoint, Puerto Rico is generally safe and its close relationship with the US means standards are generally higher than elsewhere in the Caribbean. The most common travel-related diseases, such as dysentery and hepatitis, are acquired by consumption of contaminated food and water. Mosquito-borne illnesses are not a significant concern in most of the islands, except during outbreaks of dengue fever.

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Availability & cost of health care

For emergencies in Puerto Rico, call 911. Excellent medical facilities are available in Puerto Rico. A number of hospitals have emergency rooms, including:

Ashford Presbyterian Memorial Community Hospital (787-721-2160; 1451 Av Ashford, Condado, San Juan)

General Hospital Dr Ramón Emeterio Betances (787-735-8001; Rte 2 Km 157, Mayagüez)

Hospital Manuel Comunitario Dr Pila (787-848-5600; Av Las Américas east of Av Hostos, Ponce)

Hospital Damas (787-840-8686; 2213 Ponce By Pass, Ponce)

Hospital Dr Dominguez (787-852-0505; 300 Font Martello, Humacao)

University of Puerto Rico School of Medicine (787-758-7910; UPR School of Medicine, A-878 Main Building, Medical Sciences Campus, San Juan) For more complicated medical problems, make an appointment here. The Faculty Practice Plan at the university offers a broad array of specialists and sophisticated diagnostic facilities.

Many 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. This could cost tens of thousands of dollars, so be sure you have insurance to cover this before you depart.

Pharmacies (farmacias) in Puerto Rico are generally well-stocked with medications up to North American standards. All pharmacists are fully trained and professionally licensed.

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Dengue fever

Dengue fever is a viral infection found throughout the Caribbean. In Puerto Rico, the incidence usually peaks between September and November. Major outbreaks occurred in 1994 and 1998. Dengue is transmitted by Aedes mosquitoes, which tend to bite 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 flulike 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. Severe cases usually occur in children under age 15 who are experiencing their second dengue infection.

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 insect protection measures.

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Hepatitis A

Hepatitis A is the second most common travel-related infection (after travelers’ ­diarrhea). It occurs throughout the Caribbean, particularly in the northern islands. Hepatitis A is a viral infection of the liver that is usually acquired by ingestion, though it may also be acquired by direct contact with infected persons. It 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 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. It’s a good idea to get it before you go to Puerto Rico or any other developing area. 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 gammaglobulin injection.

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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 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.

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Malaria

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

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Rabies

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. Rabies occurs in several of the Caribbean islands, including Puerto Rico.

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

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

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Other infections

An outbreak of viral meningitis caused by echovirus 30 occurred between June and September 2004, resulting in more than 400 cases, chiefly in children. The outbreak began in the southern coastal town of Arroyo, then spread to the eastern coastal town of Cieba and the mountain town of Aibonito. Echoviruses are spread by direct contact with the respiratory secretions or feces of an infected person. To protect yourself from viral meningitis, you should pay careful attention at all times to hand-washing and personal hygiene, especially after using the toilet, before eating, and after changing diapers (nappies). The chief symptoms of meningitis are fever, severe headache, stiff neck, sensitivity to bright light, drowsiness or confusion, and nausea and vomiting. Anyone who develops these symptoms should immediately seek medical attention. Viral meningitis, unlike bacterial meningitis, does not in general lead to serious complications.

An outbreak of acute hemorrhagic conjunctivitis (pink-eye), a viral infection characterized by the sudden onset of painful, swollen, red eyes with bleeding and tearing, occurred between August and October 2003. Almost half a million people were involved, chiefly school-aged children and those living in crowded urban areas. A previous outbreak was reported in 1997. In most cases, the illness resolves uneventfully, but may cause significant discomfort and temporary incapacity. You can protect yourself from acute hemorrhagic conjunctivitis by frequent hand-washing and by not sharing towels or bedding.

Schistosomiasis is a parasitic infection acquired by swimming, wading, bathing or washing in fresh water that contains infected snails. Early symptoms may include fever, loss of appetite, weight loss, abdominal pain, weakness, headaches, joint and muscle pains, diarrhea, nausea and cough, but most infections are asymptomatic at first. Long-term complications may include kidney failure, malabsorption, enlargement of the liver and spleen, engorgement of the esophageal blood vessels, and accumulation of fluid in the ­abdominal cavity.

To protect yourself from schistosomiasis, you should avoid swimming, wading or rafting in bodies of fresh water, such as lakes, ponds, streams or rivers. Unless known to be safe, water for bathing or showering should be heated to 150° F for at least five minutes or held in a storage tank for at least three days. Toweling yourself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Swimming in the ocean or a chlorinated swimming pool carries no risk of schistosomiasis.

Typhoid fever is caused by ingestion of food or water contaminated by a species of Salmonella known as Salmonella typhi. It’s reported in most of the Caribbean islands, but is uncommon. Typhoid vaccine is recommended only for those planning an extended stay in rural areas or expecting to consume potentially contaminated food. The vaccine is usually given by mouth, but is also available as an injection. Neither vaccine is approved for use in children under age 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 travelers’ diarrhea.

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

HIV/AIDS has been reported from all Caribbean countries. Be sure to use condoms for all sexual encounters.

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Travelers’ diarrhea

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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Water

The tap water in Puerto Rico is generally safe to drink. If you have a sensitive stomach or prefer filtered water, most shops stock bottled varieties.

If you’re camping or out in the ‘wilds, ’ another option is to disinfect water with iodine pills. Instructions are usually enclosed and should be carefully followed. Alternatively, you can add 2% tincture of iodine to 1L of water (5 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.

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.

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. Manufacturers’ instructions must be carefully followed.

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Sun

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.

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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 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 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. 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.

Snakes are a hazard in some of the Caribbean islands. In the event of a venomous snake bite, place the victim at rest, keep the bitten area immobilized, and move the victim immediately to the nearest medical facility. Avoid tourniquets, which are no longer recommended. Spiny sea urchins and coelenterates (coral and jellyfish) are a hazard in some areas.

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Mosquito bites

Mosquito-borne illnesses are usually not a concern in Puerto Rico. However, outbreaks of dengue fever 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, hats and shoes rather than sandals) and apply a good insect repellent to exposed skin and clothing. A bug spray containing DEET does the best job of warding off insects, but try to use it sparingly as it also is known to kill some of the natural organisms that live in the island’s bays and inlets. 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 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 age two.

Insect repellents containing certain botanic­al products, including eucalyptus oil and soybean oil, are effective but last only 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.

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Children & pregnant women

In general, it’s safe for children and pregnant women to go to Puerto Rico. However, because some of the vaccines recommended are not approved for use in children or ­during pregnancy, these travelers should be particularly careful not to drink tap water or consume any questionable food or beverages. 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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