Health & safety
Contents
Before you go
Prevention is the key to staying healthy while abroad. A little planning before departure, particularly for pre-existing illnesses, will save trouble later. See your dentist before a long trip, carry a spare pair of contact lenses and glasses, and take your optical prescription with you. 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.
Insurance
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. (In many countries doctors expect payment in cash.)
For Americans, be sure to check whether your health plan covers expenses in American Samoa. Serious illness or injury may require an evacuation, eg to Apia or Pago Pago, or even to a major regional centre such as Los Angeles or Auckland; make sure that health insurance has provision for evacuation. Under these circumstances hospitals will accept direct payment from major international insurers but for all other health costs cash up front is the usual requirement.
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Recommended vaccinations
The World Health Organization (WHO) recommends that all travellers be covered for diphtheria, tetanus, measles, mumps, rubella and polio, regardless of their destination. Since most vaccines don't produce immunity until at least two weeks after they're given, you will need to visit a physician approximately six weeks before departure. A recent influenza vaccination is always a good idea when travelling. If you have not had chicken pox (varicella), consider being vaccinated.
Medical checklist
It is a very good idea to carry a medical and first-aid kit with you, to help yourself in the case of minor illness or injury. Following is a list of items you should consider packing.
acetaminophen (paracetamol) or aspirin
adhesive or paper tape
antibacterial ointment, eg Bactroban for cuts and abrasions (prescription only)
antibiotics (by prescription only), eg ciprofloxacin (Ciproxin) or norfloxacin (Utinor; Noroxin)
antibiotic as well as steroid eardrops (by prescription only), eg Sofradex, Kenacort Otic
antidiarrhoeal drugs, eg loperamide
anti-inflammatory drugs, eg ibuprofen
antihistamines (for hay fever and allergic reactions)
antigiardia tablets, eg tinidazole (by prescription only)
bandages, gauze, gauze rolls, waterproof dressings
DEET-containing insect repellent for the skin
iodine tablets (for water purification)
oral rehydration salts, eg Gastrolyte, Diarolyte, Replyte
Permethrin-containing insect spray for clothing, tents, and bed nets
pocket knife
scissors, safety pins, tweezers
steroid cream or hydrocortisone cream (for allergic rashes)
sun block (30+)
syringes and sterile needles, and intravenous fluids if travelling in very remote areas
thermometer (digital)
Note that aspirin should not be used for fever - it can cause bleeding in dengue fever. Remember, don't take your scissors, tweezers or pocket knife in your carry-on luggage.
Internet resources
There is a wealth of travel health advice on the Internet. The WHO produces a superb text entitled International Travel and Health, which is revised annually. It is no longer published in book form but is available online at no cost at www.who.int/ith/. Other websites of general interest are MD Travel Health at www.mdtravelhealth.com, which provides complete travel health recommendations for every country, updated daily and also at no cost; the Centers for Disease Control and Prevention at www.cdc.gov; Fit for Travel at www.fitfortravel.scot.nhs.uk, which has up-to-date information about outbreaks and is very user-friendly; and www.traveldoctor.com.au, a similar Australasian site.
It's also a good idea to consult your government's travel health website before departure:
Australia (www.dfat.gov.au/travel/)
Canada (www.hc-sc.gc.ca/hl-vs/travel-voyage/index_e.html)
New Zealand (www.mfat.govt.nz/travel)
UK (www.dh.gov.uk/PolicyAndGuidance/HealthAdviceForTravellers/fs/en)
USA (www.cdc.gov/travel/)
Further reading
Good options for further reading include Travel with Children by Cathy Lanigan; Healthy Travel Australia, New Zealand and the Pacific by Dr Isabelle Young; and, Your Child's Health Abroad: A Manual for Travelling Parents by Dr Jane Wilson-Howarth and Matthew Ellis.
In transit
Deep vein thrombosis (dvt)
Blood clots may form in the legs during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. 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 breathing difficulties. 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, contract the leg muscles while sitting, drink plenty of fluids and avoid alcohol and tobacco.
Jet lag & motion sickness
To avoid jet lag (common when crossing more than five time zones) try drinking plenty of nonalcoholic fluids and eating light meals. Upon arrival, get exposure to natural sunlight and readjust your schedule (for meals, sleep and so on) as soon as possible.
Antihistamines such as dimenhydrinate (Dramamine) and meclizine (Antivert, Bonine) are usually the first choice for treating motion sickness. A herbal alternative is ginger.
While you're there
Availability & cost of health care
American Samoa has readily available doctors in private practice, and standard hospital and laboratory facilities with consultants in the major specialties - internal medicine, obstetrics/gynaecology, orthopaedics, ophthalmology, paediatrics, pathology, psychiatry and general surgery. Private dentists, opticians and pharmacies are also available.
In Samoa and Tonga, specialised services may be limited or available periodically, but private general practitioners, dentists and pharmacies are present.
Not surprisingly, the further you get from main centres, the more basic are the services.
Private consultation and private hospital fees are approximately equivalent to Australian costs, and particularly less expensive in Tonga. Government-provided service fees vary from modest to negligible but waiting times can be very long. Direct payment is required everywhere except where a specific arrangement is made, eg in the case of evacuation or where prolonged hospital stay is necessary; your insurer will need to be contacted by you. Although large hospitals are coming into line in accepting credit cards, there will be difficulty with the more remote, small hospitals and most private practitioners are reluctant to accept this form of payment except for the larger private doctor groups in American Samoa. Even they still prefer cash and not all credit cards are acceptable - check with the relevant company beforehand. If a credit card is not accepted you should be able to arrange cash on credit through the local banking system.
Most commonly used medications are available in countries with good or reasonable health care. Where only basic care is available, even aspirin and antiseptics may be hard to come by. Private pharmacies are not allowed by law to dispense listed drugs without prescription from a locally registered practitioner, but many will do so for travellers if shown the container. While the container should preferably specify the generic name of the drug, this has become much less of a problem with the use of Internet search engines. Asthma inhalers and most anti-inflammatories are over-the-counter preparations in the Samoan islands. It is best to have a sufficient supply of a regularly taken drug as a particular brand may not be available and sometimes quantities can be limited. This applies particularly to psychotropic drugs like antidepressants, antipsychotics, anti-epileptics or mood elevators. Insulin is available even in smaller centres, but you cannot guarantee getting a particular brand, combination or preferred administration method. If you have been prescribed 'the very latest' oral antidiabetic or antihypertensive, make sure you have enough for the duration of your travel.
Except in the remote, poorly staffed clinics, the standard of medical and dental care is generally quite good even if facilities are not sophisticated. The overall risk of illness for a normally healthy person is low, the most common problems being diarrhoeal upsets, viral sore throats, and ear and skin infections, all of which can mostly be treated with self-medication. For serious symptoms, eg sustained fever, or chest or abdominal pains, it is best to go to the nearest clinic or private practitioner in the first instance.
Tampons and pads are readily available in main centres. Dengue fever, especially in the first three months of pregnancy, poses a hazard because of fever but otherwise there is no reason why a normal pregnancy should prevent travel to the region. However, on general principles immunisation in the first three months of pregnancy is not recommended and yellow fever vaccines should not be given.
For young children, it is again dengue fever that could be a problem. The disease tends to come in epidemics mainly in the hotter, wetter months so it should be possible to plan holidays accordingly.
Infectious diseases
Despite the long list, the realistic risks to visitors to the region from infectious diseases are very low with the exception of dengue fever.
Dengue
Risk All countries
Dengue fever is a virus disease spread by the bite of a day-biting mosquito. It causes a feverish illness with headache and severe muscle pains similar to those experienced with a bad, prolonged attack of influenza. Another name is 'break bone fever' and that's what it feels like. Danger signs include prolonged vomiting, blood in the vomit and a blotchy rash. There is no preventive vaccine and mosquito bites should be avoided whenever possible. Self-treatment involves paracetamol, fluids and rest. Do not use aspirin, as this can cause bleeding. Haemorrhagic dengue has been reported only occasionally, manifested by signs of bleeding and shock and requires medical care.
Eosinophilic meningitis
Risk Tonga
This is a strange illness manifested by scattered abnormal skin sensations, fever and sometimes by the meningitis (headache, vomiting, confusion, neck and spine stiffness), which gives it its name. Eosinophilic meningitis is caused by a microscopic-size parasite - the rat lungworm - which contaminates raw food. There is no proven specific treatment, but symptoms may require hospitalisation. For prevention pay strict attention to advice on food and drink.
Filiriasis
Risks All countries
Also known as elephantiasis, this disease is spread by mosquitoes. It can cause a fever with lymph gland enlargement and later chronic leg swelling. It is now rare and requires prolonged exposure. Antimosquito precautions are essential. Specific treatment is available.
Hepatitis a
Risk All countries
Hepatitis A is a virus disease causing liver inflammation and is spread by contaminated food or water. Fever, nausea, debility and jaundice (yellow colouration of the skin, eyes and urine) occur and recovery is slow. Most people recover completely but it can be dangerous to people with other forms of liver disease, the elderly and sometimes to pregnant women towards the end of pregnancy. Food is easily contaminated by food preparers, handlers or servers, and by flies. There is no specific treatment. The vaccine is close to 100% protective.
Hepatitis b
Risk All countries
This virus disease causes liver inflammation but the problem is much more serious than hepatitis A and frequently goes on to cause chronic liver disease and even cancer. It is spread, like HIV, by mixing body fluids, ie sexual intercourse, contaminated needles and accidental blood contamination. Treatment is complex and specialised but vaccination is highly effective.
Hepatitis c
Risk Incidence is uncertain within the region but must be assumed to be present
This virus disease is similar to hepatitis B, causing liver inflammation which can go on to chronic liver disease or result in a symptomless carrier state. It's spread almost entirely by blood contamination from shared needles or contaminated needles used for tattooing or body piercing. Treatment is complex and specialised. There is no vaccine available.
Hiv/aids
Risk All countries
The incidence of HIV infection is on the rise in the whole region. Safe sex practices are essential at all times. If an injection is needed in a smaller clinic it is best to provide your own needles. Blood transfusion laboratories do tests for HIV.
Japanese b encephalitis
Reported outbreaks No outbreaks in region, but potential exists for this to happen
This is a serious, but quite rare, virus disease spread by mosquitoes. It can cause brain fever (encephalitis) with an approximate death rate of 30%. There is no specific treatment. An effective vaccine is available but is expensive and involves a course of three injections over a month. Allergic reactions to the vaccine, though rare, can occur. Vaccination is only recommended for anyone staying more than a month and going to work in village situations, and certainly if there has been a reported recent outbreak.
Leptospirosis
RiskAmerican Samoa
Also known as Weil's disease, leptospirosis produces fever, headache, jaundice and, later, kidney failure. It is caused by a spirochaete organism found in water contaminated by rat urine. The organism penetrates skin, so swimming in flooded areas is a risk practice. If diagnosed early it is cured with penicillin.
Typhoid fever
Risk All countries
This is a bacterial infection acquired from contaminated food or water. The germ can be transmitted by food handlers or flies, and can be present in inadequately cooked shellfish. It causes fever, debility and late onset diarrhoea. Untreated it can produce delirium and is occasionally fatal, but the infection is curable with antibiotics. Vaccination is moderately effective, but care with eating and drinking is equally important.
Traveller's diarrhoea
Diarrhoea is caused by viruses, bacteria or parasites present in contaminated food or water. In temperate climates the cause is usually viral, but in the tropics bacteria or parasites are more usual. If you develop diarrhoea, be sure to drink plenty of fluids, preferably an oral rehydration solution (eg Diarolyte, Gastrolyte, Replyte). 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 or is accompanied by fever, shaking, chills or severe abdominal pain you should seek medical attention. Giardiasis is a particular form of persistent, although not 'explosive', diarrhoea caused by a parasite present in contaminated water. One dose (four tablets) of tinidazole usually cures the infection.
Environmental hazards
Threats to health from animals and insects (including wasps) are rare indeed but you need to be aware of them.
Jellyfish
The notorious box jellyfish (seawasp) has not been recorded in these waters, but the blue-coloured Indo-Pacific 'Man o' War' is found in all waters. If you see these floating in the water or stranded on the beach it is wiser not to go in. The sting is very painful. Treatment involves ice packs and vinegar; do not use alcohol. Smaller cubo-medusae are abundant and are found particularly on still, overcast days. They usually produce only uncomfortably irritating stings but can cause generalised symptoms (although this is rare), especially in someone with poorly controlled heart disease.
Poisonous cone shells
Poisonous cone shells abound along shallow coral reefs. Stings mainly cause local reactions but nausea, faintness, palpitations or difficulty in breathing are signs flagging the need for medical attention.
Sea snakes
As in all tropical waters, sea snakes may be seen around coral reefs. Unprovoked, sea snakes are extremely unlikely to attack and their fangs will not penetrate a wet suit. First-aid treatment consists of compression bandaging and splinting of the affected limb. Antivenin is effective, but may have to be flown in. Only about 10% of sea snake bites cause serious poisoning.
Coral cuts
Cuts and abrasions from dead coral cause no more trouble than similar injuries from any other sort of rock, but live coral can cause prolonged infection. If you injure yourself on live coral don't wait until later to treat it. Get out of the water as soon as possible, cleanse the wound thoroughly (getting out all the little bits of coral), apply an antiseptic and cover with a waterproof dressing. Then get back in the water if you want to.
Coral ear
This is a commonly used name for inflammation of the ear canal. It has nothing to do with coral but is caused by water entering the canal, activating fungal spores resulting in secondary bacterial infection and inflammation. It usually starts after swimming, but can be reactivated by water dripping into the ear canal after a shower, especially if long, wet hair lies over the ear opening. Apparently trivial, it can be very, very painful and can spoil a holiday. Apart from diarrhoea it is the most common reason for tourists to consult a doctor. Self-treatment using an antibiotic-plus-steroid eardrop preparation (eg Sofradex, Kenacort Otic) is very effective. Stay out of the water until the pain and itch have gone.
Diving hazards
Because the region has wonderful opportunities for scuba diving, it is easy to get overexcited and neglect strict depth and time precautions. Diving on old shipwrecks is fascinating and some of these dives can be up to or beyond 30m. Coral-viewing dives are not so deep but the temptation to spend longer than safe times at relatively shallow depths is great and is probably the main cause of decompression illness (the 'bends') in the region. Early pains may not be severe and attributed to other causes but any muscle or joint pain after scuba diving must be suspect. There are no compression chambers in the Samoan islands or Tonga. Even experienced divers should check with organisations like DAN (Divers' Alert Network) about the current site and status of compression chambers in the region, and insurance to cover costs both for local treatment and evacuation. Novice divers must be especially careful. If you have not taken out insurance before leaving home you may be able to do so online with DAN.
Food & water
The municipal water supply in Apia, Pago Pago and Nuku'alofa can be trusted, but elsewhere avoid untreated tap water. In some areas the only fresh water available may be rain water collected in tanks, and this should be boiled. Steer clear of ice. Only eat fresh fruits or vegetables if cooked or peeled; be wary of dairy products that might contain unpasteurised milk. Eat food which is hot right through and avoid buffet-style meals. Food in restaurants frequented by locals is not necessarily safe, but most resort hotels have good standards of hygiene, although individual food-handlers can carry infection. Food which comes to you piping hot is likely to be safe. Be wary of salads. If you are preparing your own salads from market produce, make sure that each piece and leaf is thoroughly washed with water that is safe. Be adventurous by all means but expect to suffer the consequences if you succumb to adventurous temptation by trying raw fish or crustaceans as eaten by some locals.
Fish poisoning
Ciguatera is a form of poisoning that affects otherwise safe and edible fish unpredictably. Poisoning is characterised by stomach upsets, itching, faintness, slow pulse and bizarre inverted sensations, eg cold feeling hot and vice versa. Ciguatera has been reported in many carnivorous reef fish, especially barracuda but also red snapper, Spanish mackerel and moray eels. There is no safe test to determine whether a fish is poisonous or not. Although local knowledge is not entirely reliable, it is reasonable to eat what the locals are eating. However, fish caught after times of reef destruction, eg after a major hurricane, are more likely to be poisonous. Treatment consists of rehydration and if the pulse is very slow, medication may be needed. Healthy adults will make a complete recovery, although disturbed sensation may persist for some weeks.
Heat exhaustion
The region lies within the tropics so it is hot and frequently humid. Heat exhaustion is actually a state of dehydration associated to a greater or lesser extent with salt loss. Natural heat loss is through sweating, making it easy to become dehydrated without realising it. Thirst is a late sign. Small children and old people are especially vulnerable. For adults, heat exhaustion is prevented by drinking at least 3L of water per day and more if actively exercising. Children need about 1½L to 2½L per day. Salt replacement solutions are useful since muscle weakness and cramps are due to salt as well as water loss and can be made worse by drinking water alone. The powders used for treating dehydration due to diarrhoea are just as effective when it is due to heat exhaustion. Apart from commercial solutions, a reasonable drink consists of a good pinch of salt to a pint (½L) of water. Salt tablets can result in too much salt being taken in, causing headaches and confusion.
Heatstroke
When the cooling effect of sweating fails, heat stroke ensues. This is a dangerous and emergency condition characterised not only by muscle weakness and exhaustion, but by mental confusion. Skin will be hot and dry. If this occurs 'put the fire out' by cooling the body with water on the outside and if possible with cold drinks for the inside. Seek medical help as a follow-up anyway, but urgently if the person can't drink.
Sunburn
It should go without saying that exposure to the ultraviolet (UV) rays of the sun causes burning of the skin with accompanying pain, dehydration and misery (together with the long-term danger of skin cancer) but experience shows that reminders are necessary. The time of highest risk is between 11am and 3pm and remember that cloud cover does not block out UV rays. The Australian Slip, slop, slap slogan is a useful 'mantra' - slip on a T-shirt or blouse, slop on a sunscreen lotion of at least 15+ rating, and slap on a hat. Treat sunburn like any other burn - cool, wet dressings are best. Severe swelling may respond to a cortisone cream.
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