Health, Prevention, and Vaccination

Before you go

Travelers to Central America need to be vigilant about food-borne as well as mosquito-borne infections. Most of these illnesses are not life-threatening, but they can certainly ruin your trip. Besides getting the proper vaccination, it's important that you bring along a good insect repellent and exercise great care what you eat and drink.

Since most vaccines don't produce immunity until a t least two weeks after they're given, visit a physician four or 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 medication in their original containers, clearly labelled. 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.

Insurance

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. As this may cost tens of thousands of dollars, be sure you have insurance to cover this before you depart.

If your health insurance does not cover you for medical expenses abroad, consider supplemental insurance. Find out directly if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures.

Deep Vein Thrombosis (DVT)

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

The chief symptom of DVT is swelling or pain in the foot, ankle or calf, usually but now always on just one side. When a blood clot travels through 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 fluid, and avoid alcohol and tobacco.

Jet Lag and 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 (non-alcoholic) 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 medizine (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.

Chagas' Desease

Chagas' desease 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 Costa Rica most cases occur in Alajuela, Liberia and Puntarenas. The triatomine insect lays its faeces on human skin as it bites, usually at night. A person becomes infected when he or she unknowingly rubs the faces into the bite wound or any other open sore. Chagas' disease is extremely rare in travellers. However if you sleep in a poorly constructed house, especially one made out of mud, adobe or thatch, you should be sure to protect yourself with a bed net and a good insecticide.

Dengue Fever (Breakbone Fever)

Dengue fever is a viral infection found throughout Central America. In Costa Rica outbreaks involving thousands of people occur every year. Dengue is transmitted by Aedes mosquitoes, which bite preferentially during 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 causesflu-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. 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 hospitalisation for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is insect protection measures.

Hepatitis A

Hepatitis A is the second most common travel-related infection (after traveller's diarrhoea). It's 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 ifected 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 6 or 12 month later, it lasts for at least 10 years. You really should get it before you go to Costa Rica or any other developing nation. Because the safety for a hepatitis A vaccine has not been established for pregnant women or children under age 2, they should instead be given a gammaglobulin injection.

Hepatitis B

Like hepatitis A, hepatitis B is a liver infection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is recommended only for long-term travellers (on the road more than six month) 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 are 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.

Sexually Transmitted Diseases

Prostitution is legal in Costa Rica, and female prostitutes are required to be registered and receive regular medical checkups. Nevertheless, incidence of sexually transmitted diseases, including HIV/Aids, is increasing among Costa Rican prostitutes. In addition, male prostitutes, including transvestites, are unlikely to receive the required medical checkups. Travellers are strongly advised against sex with prostitutes. Having sex with a person other than a prostitute may be somewhat safer, but it's still far from risk-free. The use of condoms minimizes, but does not eliminate, the chances of contracting a sexually transmitted disease. Condoms (preservativos), including some imported brands, are available in Costa Rican pharmacies.

Diseases such as syphilis and gonorrhoea are marked by rashes or sores in the genital area and burning pain during urination. Women's symptoms may be less obvious than men's. These diseases can be cured relatively easily by antibiotics. If untreated, they can become dormant, only to emerge in much more difficult-to-treat forms a few month or years later. Costa Rica doctors know about to treat most sexually transmitted diseases - if you have a rash, discharge, or pain, see a doctor. Herpes and AIDS are incurable as of this writing. Herpes is not fatal.

HIV / AIDS

The human immunodeficiency virus (HIV) may develop into AIDS, acquired immune deficiency syndrome (SIDA in Spanish). HIV is a significant problem all Latin American countries, particularly among prostitutes of both sexes. Any exposure to infected blood, blood products, or bodily fluids may put the individual at risk. Transmission in Costa Rica is predominantly through homosexual male sexual activity, with about 70% of cases reported in men who have sex with men. However, many of these men also have sex with women, and the disease is spreading among heterosexual women too.

The virus HIV / AIDS can also be spread through infected blood transfusions; if you need a transfusion, go to the best clinic available and make sure they screen blood used for transfusion. It can also be spread by dirty needles - vaccinations, acupuncture, tattooing, and body piercing can be as dangerous as intravenous drug use if the equipment is not clean. If you do need an injection, ask to see the syringe unwrapped in front of you, or buy a needle and syringe pack from a pharmacy if you have any doubt about the sterility of the needle.

Apart from abstinence, the most effective way to prevent sexual transmission of HIV is to always practice safe sex using latex barriers such as condoms, gloves, and dams. Condoms are available in Costa Rican pharmacies. It is impossible to detect the HIV status of a healthy-looking person without a blood test. Figures from 1999 give estimates that 05% of Costa Rican adults are HIV+. This figure rises to over 1% of sex workers and 3% to 6% of gay males.

Unfortunately, many of them don't know they are infected and continue to be sexually active, so the virus is spreading. Information about safe sex and condoms - indeed, any kind of sex education - lags in Costa Rica because sex education is opposed by the powerful Roman Catholic church. Other problems are cultural and have to do with machismo - a 'real' man doesn't need to use a condom. Also, it is widely thought that HIV+ people look sick, when the reality is that HIV+ people are likely to look and act completely healthy for several years after infection, all the time carrying and perhaps spreading the disease.

Fear of HIV infection should never preclude treatment for serious medical conditions. Although there may be a risk of infection, it is very small indeed.

Leishmaniasis

Leishmaniasis occurs in the mountains and jungles of all Central American countries. The infection is transmitted by sand flies, which are about one-third the size of a mosquito. Most cases occur in newly cleared forest or areas of secondary growth . the highest incidence is in Talamanca. In Costa Rica the disease is generally limited to the skin, causing slowly-growing ulcers over exposed parts of the body, but more severe infections may occur in those with HIV. There is no vaccine for Leishmaniasis. To protect yourself form sandflies, follow the same precautions as for mosquitoes, except that netting must be of finer mesh (at least 18 holes to the linear inch).

Leptospirosis

Leptospirosis is acquired by exposure to water contaminated by the urine of infected animals. Whitewater rafters are at particularly high risk. In Costa Rica most cases occur in Limón, Turrialba San Carlos and Golfito. Cases have been reported among residents of Puerto Limón who have bathed in local streams. Outbreaks may occur at times of flooding, when sewage overflow may contaminate water sources.

The initial symptoms, which resemble a mild flu, usually subside uneventfully in a few days, with or without treatment, but a minority of are complicated by jaundice or meningitis. There is no vaccine. You can minimize your risk by staying our of bodies of fresh water that may be contaminated by animal urine. If you're engaging in high-risk activities, such as river running, 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

Malaria occurs in every country in Central America. It's 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 diarrhoea. Sever cases may involve the central nervous system and lead to seizures, confusion, com and death.

Taking malaria pills is recommended for the provinces of Alajuela, Limón (except for Limón City), Guanacaste and Heredia. The risk is greatest in the cantons of Los Chiles (Alajuela Province) and Matina and Talamanca (Limón Province).

For Costa Rica the first-choice malaria pill is chloroquine, taken once weekly in a dosage if 500mg, starting one or 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. Sever reactions are uncommon.

Protecting yourself against mosquito-bites is just as important as taking pills, since no pills are 100% effective.

If you are not having access to medical care while travelling, you should bring along additional pills for emergency self-treatment, which you should take if you cannot reach a doctor and you develop symptoms that suggest malaria, such as high spiking fevers. One option is to take four tablets of Malaria once daily for three days. If you start self-medication, you should try to see a doctor at the earliest possible opportunity.

If you develop a fever after returning home, see a physician as malaria symptoms may not occur for months.

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 all Central American countries. However in Costa Rica only two cases have been reported over the last 30 years. Rabies vaccine is therefore recommended only for those at particularly high risk, such as spelunkers (cave explorers) and animal handlers.

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.

Typhoid

Typhoid fever is caused by ingestion of food or water contaminated by a species of Salmonella known as Salmonella typhi. Fever occurs in virtually all cases. Other symptoms may include headache, malaise, muscle aches, dizziness, loss of appetite, nausea and abdominal pain. Either diarrhoea 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 travellers carry for treatment of traveller's diarrhoea. 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.

Traveller's Diarrhoea

To prevent diarrhoea, 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 diarrhoea, 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 antidiarrhea agent (such as loperamide). If diarrhoea 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.

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 cleaned with large amounts of soap and water, following by application of an antiseptic such as iodine or alcohol. The local health authorities should be contacted to immediately for possible post-exposure rabies treatment, whether or not you've been immunized against rabies. It may also be advisable to start a antibiotic, since wounds caused by animal bites and scratches frequently become infected. One of the newer quinolones, such as levofloxacin (Levaquin), which many travellers carry in case of diarrhoea, would be an appropriate choice.

Insect Bites

No matter how much you safeguard, getting bitten by mosquitos is part of every traveller's experience in the country. While there are occasional outbreaks of dengue in Costa Arica, for the most part the greatest worry you will have with bites is the general discomfort that comes with them, namely itching.

The best prevention is to stay covered up - wearing long pants, long sleeves, and a hat, and shoes rather than sandals. Unfortunately, Costa Rica's sweltering temperatures might make this a bit difficult. Therefore the best measure you can take is to invest in a good insect repellent, preferably one containing DEET. (These repellents can also be found in Costa Rica). This should be applied to exposed skin and clothing (but not to eyes, mouth, cuts, wounds, or irritated skin).

In general, adults and children over 12 can use preparations containing 25% to 35% DEET, which usually lasts about six hours. Children between 2 and 12 years of age should use preparations containing no more tha 10% DEET, applied sparingly, which will usually last about three hours. Neurologic toxidity 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 oil of eucalyptus and soybean oil are effective but last only for 1 ½ to two hours.

A particularly good item for every traveller to take is a bug net to hang over the beds (along with a few thumbnails or nails with which to hang it). Many hotels in Costa Rica don't have windows (or screens) and a cheap little net will save you plenty of night-time aggravation. The mesh size should be less than 1.5 mm.

Dusk is the worst time for mosquitoes, so take extra precautions once the sun starts to set.

Snake Bites

Costa Rica is home of all manner of venomous snalkes and any foray into forested areas will put you at (a very sight) risk for snake bite.

The best prevention is to wear closed , heavy shoes of 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. The most poisonous snakes are the coral snake and the most dangerous ones the bushmaster and Costa Rica's fer-de-lance (terciopelo).

In the event of a snake bite from a venomous snake, 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.

Heat and Sun

The heat and humidity of the coastal tropics make you sweat profusely and can also make you feel apathetic. It is important to maintain a high fluid intake and ensure that you food is well slated. If fluids lost through perspiration are not replaced, heat exhaustion and cramps may result. The feeling of apathy that some people experience usually fades after a week or two.

If you're arriving in the tropics with a great desire to improve you tan, you've certainly come to the right place. The tropical sun will not only improve your tan but also burn you to a crisp. Travellers may enjoy the sun for an afternoon and then spend the next couple of days with a severe sunburn. The power of the tropical sun cannot be overemphasizeed.

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. Travellers should also drink plenty of fluids and avoid strenuous exercise when the temperature is high.

Water

Tap water in Costa Rica is claimed to be safe to drink. My personal opinion and that of Lonely Planet is that is NOT safe to drink. Buying botteled water is your best bet. If you have the means, boiling water for one minute is the most effective means of water purification. At altitudes greater than 2000 m (6500 feet), boil for three minutes. Another option is to disinfect water with iodine pills: add 2% tincture of iodine to one quart or liter of water (5 drops to clear water, 10 drops to cloudy water) and let it stand for 30 minutes. If the water is clod, longer times may be required.

Pictures by Angela and Jörn Malek. The team of 1-CostaRicaLink wishes you the best of times in our little paradise called Costa Rica.

Text partly by Lonely Planet. To buy the complete book click here.