INTRODUCTION
GENERAL MEDICAL ADVICES BEFORE TRAVELING TO CHINA

Medical Consultation before traveling
Medical Kit

TRAVEL AND HEALTH RECOMMENDATION

Prevention and Vaccination
Other Recommendation

OUTBREAKS 2006

ENVIRONMENTAL RISKS

Food and Water
Altitude and Mountain sickness

BLOOD TRANSFUSION

GENERAL INFORMATION

To be considered before departure
General Recommendation

CHINA
The third largest country in the world, next to Canada and Russia, with 9,6 millions square kilometers.

China is bordered by Korea in the northeast; Russia and Mongolia in the north; Afghanistan, Pakistan, Nepal,
Sikkim, Bhutan and India in the southwest; and Burma, Laos and Vietnam in the south. Across the seas to the east and
southeast it faces Japan, the Philippines, Malaysia, Brunei and Indonesia.

The largest population in the world with 1,3 billions citizens (40,53% urban and 59,47% rural).

Medical facilities in China offer a very limited number of International standard hospitals and clinics, mainly located in Beijing, Shanghai and Guangzhou. In other cities, medical facilities are with local standard where you may face some difficulties and disappointment especially concerning medical care and communication matter.






MEDICAL CONSULTATION BEFORE TRAVELING

It is highly recommended to visit your general practitioner before departure.

Get your latest check up of your medical condition. Be sure that you are fit to travel to China.
Visiting China is an exciting experience but extremely tiring trip if you are traveling with a group. Minor injury and or a common illness can happen if you don’t have enough energy.

Renew your medical prescription and bring your daily medication
Ask your general practitioner to prepare the list of your usual daily medication and our recommendation is to bring more than just your need in case you may have to stay longer. It may be difficult to find the same drug that you usually take. In some places especially remote areas, it may be impossible to find it.

Check your vaccination book
There is no specific vaccination needed to travel in China except if you travel in remote areas and or for more than one month. However be sure that the usual vaccinations are done. (See chapter related to vaccination).

Get medical advice.
Ask your general practitioner some specific recommendation related to your medical condition. For instance if you are traveling to high altitude like in Tibet, ask your doctor some drug in order to prevent Altitude Mountain Sickness (See chapter Environmental risks)

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity. Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Pack a personal medical kit, customized for your trip (see description below). Take appropriate measures to prevent motion sickness and jet lag. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

MEDICAL KIT

The contents of the kit will vary depending upon the destination, the duration of the trip, the range of potential exposures, the age and health of the travelers, and the availability of medical care. Most travelers should pack a personal medical kit when traveling in China especially in remote areas.

The following should be considered for inclusion in the kit:

PREVENTION – VACCINATION

A. COMMON RECOMMENDED VACCINATIONS.

All travelers should visit either their general physician 4-8 weeks before departure in case any booster has to be done.

1.Hepatitis A
Vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Travelers who are less than one year of age, are pregnant, or have less than two weeks before departure should receive a single intramuscular dose of gamma-globulin instead of vaccine.

2.Typhoid
Vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major International standard restaurants and hotels, such as business travelers and cruise passengers. It is generally given in an oral form or injectable. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immuno-compromised travelers.
See your general practitioner

3.Hepatitis B
Vaccine is recommended for travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. A full series consists of three intramuscular doses
See you general practitioner.

4.Measles, mumps, rubella (MMR)
Vaccine is recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immuno-compromised individuals.

5.Tetanus-diphtheria
Vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.

6.Varicella (chickenpox)
Vaccine is recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immuno-compromised individuals.)

7.Polio Vaccine
The Vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. In October 2000, the World Health Organization certified that polio had been eradicated from the Western Pacific region, including China.

8. Tuberculosis.
Most travelers are at low risk for Tuberculosis.
The risk for long-term travelers (> 3 months) becomes comparable to the risk for local residents. Living conditions, as well as duration of travel, are important in determinating the risk of infection: hight-risk settings include health facilities, prisons and shelters for the homeless. BCG should be considered for infants traveling from an area of low incidence to one of high incidence.
For further information, contact your general practitioner.

1. Yellow fever
A yellow fever vaccination certificate is required from travelers coming from infected areas.

2. Malaria
Malaria risk—including P. falciparum malaria—occurs in Hainan and Yunnan. Chloroquine and sulfadoxine-pyrimethamine resistant P. falciparum reported. Limited risk of P. vivax malaria exists in southern and some central provinces, including Anhui, Henan, Hubei, and Jiangsu. The risk may be higher in areas of focal outbreaks. There is no malaria risk in urban areas nor in the densely populated plain areas nor at altitudes above 1500 m.
Recommended prevention in risk areas: in Hainan and Yunnan

3. Japanese encephalitis
Vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. At the present time, it should also be considered for any travelers to Henan, Shaanxi, and Shanxi provinces, including Yunching City.
The vaccine (JE-VAX; Aventis Pasteur Inc.) is given as a series of three injections on days 0, 7 and 30. If time is short, the third dose may be given on day 14. Mild side effects including fever, headache, muscle aches, malaise and soreness at the injection site occur in about 20% of those vaccinated. Serious allergic reactions including urticaria, angioedema, respiratory distress and anaphylaxis occur in approximately 0.6% of vaccinees and may occur as long as one week after vaccination. Any person who receives the vaccine should be observed in the doctor's office for at least 30 minutes following the injection and should complete the full series at least 10 days before departure. There are no data concerning the safety of Japanese encephalitis vaccine during pregnancy.

4. Rabies
Vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. In China, most cases are related to dog bites; a majority are reported from five southern provinces: Guangxi, Hunan, Jiangxi, Guangdong, and Jiangsu. A complete pre exposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

OTHER RECOMMENDATIONS
Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed.

Use condoms for all sexual encounters.






MAJOR OUTBREAKS

A malaria outbreak was reported from Anhui province in September 2006, resulting in almost 18,000 cases as of September 25. To lower the risk of malaria, a weekly dose of chloroquine is recommended for all travelers to Anhui province during the warm weather months. Insect protections measures, as below, are also advised.

An outbreak of dengue fever was reported in September 2006 from Guangdong Province, in the southern part of the country.. Dengue fever is a flu-like illness, sometimes complicated by hemorrhage or shock, transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. Outbreaks are periodically reported from China, chiefly the provinces of Guangdong, Guangxi, Hainan and Yunnan in the southern part of the country. No vaccine is available at this time.
For further information on dengue, ask your general practitioner

Total of 21 human cases of H5N1 avian influenza ("bird flu") have been reported from China since November 2005 (four from Anhui Province, three each from Hunan and Sichuan Provinces, two from Fujian and Guangdong Provinces, one each from Shanghai and Beijing, and one each from Guangxi, Jiangxi, Hubie, Liaoning, and Xinjiang Uygur Provinces). Fourteen of the cases were fatal. Since January 2004, outbreaks of avian influenza have been reported from poultry farms in many parts of the country, including the provinces of Guangxi, Hunan, Hubei, Gansu, Shaanxi, Anhui, Shanghai, Guangdong, Zhejiang, Yunnan, Henan, Jiangxi, and Xinjiang Uygar Autonomous Region.

The most recent poultry outbreaks were reported from the Changsha region of Hunan in August 2006 and from the Ningxia Hui region and neighbouring Inner Mongolia in October 2006. The live poultry markets in Beijing have been permanently closed.Most travelers are at extremely low risk for avian influenza, since almost all human cases have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The World Health Organization and the Centers for Disease Control do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked.

The currently available influenza vaccines do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to China should seek immediate medical attention, which may include testing for avian influenza. For further information, contact your general practitioner.

An increased number of cases of rabies is being reported from China, especially the southern province of Guangdong. As of September 2006, a total of 2254 confirmed cases had been reported for the year, almost 30% more than during the same period in 2005. The rise appears to be related to the increased popularity of keeping dogs as pets, as well as a failure to seek treatment after a dog bite.

Outbreaks of Japanese encephalitis were reported in August 2006 from the provinces of Henan, Shaanxi, and Shanxi (including Yuncheng City), which share borders in the central part of China. Japanese encephalitis is a life-threatening viral infection which is transmitted by Culex mosquitoes, usually in rural areas.

Tuberculosis. With about 4.5 million sufferers, China is one of the world‘s 22 high-tuberculosis countries. The World Health Organization (WHO) estimated that each year China has 1.45 million new tuberculosis cases, 650,000 of which are highly infectious

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions

FOOD AND WATER PRECAUTIONS
Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.

All travelers should bring along an antibiotic and an anti diarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

ALTITUDE AND MOUNTAIN SICKNESS
Most roads and towns in Tibet, Qinghai, parts of Xinjiang, and western Sichuan are situated at altitudes over 10,000 feet. Travelers in these areas should seek medical advice in advance of travel, allow time for acclimatization to the high altitude, and remain alert to signs of altitude sickness.

With poor medical facilities in Lhasa and all other cities within Tibet as well as some provinces where altitude is greater than 3,000m, we recommend extreme precaution before considering traveling to this part of China and to consult their general practitioner for recommendation.

Acute Mountain Sickness (AMS) is a constellation of symptoms that represents your body not being acclimatized to its current altitude.

As you ascend, your body acclimatizes to the decreasing oxygen (hypoxia). At any moment, there is an "ideal" altitude where your body is in balance; most likely this is the last elevation at which you slept. Extending above this is an indefinite gray zone where your body can tolerate the lower oxygen levels, but to which you are not quite acclimatized. If you get above the upper limit of this zone, there is not enough oxygen for your body to function properly, and symptoms of hypoxic distress occur - this is AMS. Go too high above what you are prepared for, and you get sick.

Anyone who goes to altitude can get AMS. It is primarily related to individual physiology (genetics) and the rate of ascent; there is no significant effect of age, gender, physical fitness, or previous altitude experience. Some people acclimatize quickly, and can ascend rapidly; others acclimatize slowly and have trouble staying well even on a slow ascent.
Travel to high altitudes is not generally recommended for those with a history of heart disease, lung disease, or sickle cell disease.

More serious are High Altitude Cerebral Edema and High Altitude Pulmonary Edema

High Altitude Cerebral Edema

AMS is a spectrum of illness, from mild to life-threatening. At the "severely ill" end of this spectrum is High Altitude Cerebral Edema; this is when the brain swells and ceases to function properly. HACE can progress rapidly, and can be fatal in a matter of a few hours to one or two days. Persons with this illness are often confused, and may not recognize that they are ill.

The hallmark of High Altitude Cerebral Edema is a change in mentation, or the ability to think. There may be confusion, changes in behavior, or lethargy. There is also a characteristic loss of coordination that is called ataxia. This is a staggering walk that is similar to the way a person walks when very intoxicated on alcohol. Any delay for receiving good care could be fatal. Immediate descent to sea level is the best treatment.

High Altitude Pulmonary Edema

Another form of severe altitude illness is High Altitude Pulmonary Edema, or fluid in the lungs. Though it often occurs with AMS, it is not felt to be related and the classic signs of AMS may be absent. Signs and symptoms of High Altitude Pulmonary Edema include any of the following:

In some persons, the hypoxia of high altitude causes constriction of some of the blood vessels in the lungs, shunting all of the blood through a limited number of vessels that are not constricted. This dramatically elevates the blood pressure in these vessels and results in a high-pressure leak of fluid from the blood vessels into the lungs. Exertion and cold exposure can also raise the pulmonary blood pressure and may contribute to either the onset or worsening of HAPE.

Immediate descent to sea level is the treatment of choice for high altitude Pulmonary Edema; unless oxygen is available delay may be fatal.

It is common for persons with severe High Altitude Pulmonary Edema to also develop High Altitude Brain Edema, presumably due to the extremely low levels of oxygen in their blood (equivalent to a continued rapid ascent). It can resolve rapidly with descent, and one or two days of rest at a lower elevation may be adequate for complete recovery. Once the symptoms have fully resolved, cautious re-ascent is acceptable.

PREVENTION

Acetazolamide ( Diamox®) is the drug of choice to prevent altitude sickness.

Acetazolamide (Diamox®) is a medication that forces the kidneys to excrete bicarbonate, the base form of carbon dioxide; this re-acidifies the blood, balancing the effects of the hyperventilation that occurs at altitude in an attempt to get oxygen. This re-acidification acts as a respiratory stimulant, particularly at night, reducing or eliminating the periodic breathing pattern common at altitude. Its net effect is to accelerate acclimatization. It makes a process that might normally take about 24-48 hours speed up to about 12-24 hours.

Acetazolamide is a sulfonamide medication, and persons allergic to sulfa medicines should not take it. Common side effects include numbness, tingling, or vibrating sensations in hands, feet, and lips. Also, taste alterations, and ringing in the ears. These go away when the medicine is stopped. Since acetazolamide works by forcing a bicarbonate diuresis, you will urinate more on this medication. Uncommon side effects include nausea and headache. A few trekkers have had extreme visual blurring after taking only one or two doses of acetazolamide; fortunately they recovered their normal vision in several days once the medicine was discontinued.

The usual dosage is 250 mg two or three times daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence.

Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude; since there is a risk that altitude sickness will occur as the dosage is reduced.

Consult your general practitioner for further information about above drugs.




Because of inherent risks, blood transfusion to traveler should be prescribed in a medical emergency situation involving sudden massive blood loss such as:

Safety of blood and blood products depends on careful selection of donors, testing all donations for transfusion-transmissible infectious agents and rigorous control of all procedures involved in donation, testing and transfusion.

As some of above mentioned procedures cannot be confirmed as safe in health care facilities in China, it is difficult to recommend having blood transfusion in China. In many cases, it would be more recommended to avoid transfusion of blood by replacing the blood volume with plasma substitutes and to move the patient to a medical center of excellence such as Hong Kong.






TO BE CONSIDERED BEFORE DEPARTURE

VISA

Our recommendation is to apply for an individual visa instead of Group visa. If you carry a group visa, In case of any medical emergency, you may have to be separated from the group. An individual visa becomes necessary. To apply for, it can take 24h to 48h depending of your location in China and can postpone any further emergency decision such as a medical transfer.

TRAVEL INSURANCE
Make sure your health insurance covers you for medical expenses abroad. If not, supplemental travel insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars.

Do not forget to bring copy of your travel insurance with you in order to contact your insurance for any emergency matter. When arriving in China, keep this document with you and don’t put it in the safety box inside your hotel room.
You may need it at any time .Your insurance can assist you 24h/24h and everywhere within China.

MOBILE PHONE

If you own a mobile phone, check with your provider if you can receive and send call in China. For long stay in China our recommendation is to buy a SIM card in China where you can make local call or call to overseas as well as to receive call. This option is cheaper. China Telecom and China Unicom are the best providers. It is also a plus for you to be connected immediately with your insurance if urgent assistance is needed

GENERAL RECOMMENDATION

VIOLENCE

It is a significant risk in China especially in remote areas. Criminals often target tourist and business travelers. To reduce the risk, some precautions are recommended as follows:

- Behave yourself in order to avoid any further dangerous action from your aggressor.
- Don’t carry expensive jewels and large sums of cash money
- Use taxi from authorized rank only and be sure that the meter is ON.
- Do not travel alone in remote areas. Employ the services of local guide/interpreter or local driver traveling to remote areas
- Avoid being involved or to participate in any demonstration that occurred during your trip
- Avoid walking in the streets at night especially in remote areas.

MEDICAL FACILITIES

Medical facilities have improved in China for the last ten years; Western medicine has replaced traditional Chinese medicine in many locations within China. However, there are still some hospitals specialized in traditional Chinese Medicine.

There is a distinction between rural and urban medical facilities. Both may have full range of medical equipment for performing usual investigation and treatment (medical or surgical) but it is still difficult to recommend being admitted in health medical facilities in remote areas where you may face different issues:

- Communication as doctors and staff may not speak other languages than Mandarin or their own dialect.
- Cleanliness and poorness of the facilities
- Knowledge in western medicine and procedures

Many other hospitals in major Chinese cities have so-called VIP department. These feature reasonably up-to-date medical technology and physicians who are both knowledgeable and skilled. Most VIP departments also provide medical services to foreigners and have English, French or Japanese-speaking doctors as they probably performed some training abroad especially in Europe (France, Germany, Italy), USA or Japan.
We usually recommend such medical facilities.

To see a doctor, you have to go to the hospital; either to the ER department or to a dedicated department for foreigners and usually no appointment can be scheduled in advance.

In major cities like Shanghai, Beijing, Guangzhou, there are some international clinics and hospitals that are under a private investor and where you can request for appointment and see a foreign doctor.
In remote areas, cost for a consultation including investigation such as X-ray, blood or urine test and pharmacy should be less than US$ 30.00 while in local hospitals in major cities average of cost should be between US$ 40.00 to US$ 60.00.

A consultation including investigation as mentioned above and treatment in an International clinic/hospital should cost between US$ 150 to 300.00

For further information: contact our medical team medical-desk@assistance-online.com.cn