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countries, particularly in areas with poor sanitation. Larvae of the parasite live in the soil, and your risk of infestation increases if your skin comes in contact with infested soil or if you eat or drink contaminated food or water. The hookworms enter the bloodstream and travel to the lungs. From the lungs they travel to the trachea, are swallowed, and end up in the small intestine. The worms then “hook” themselves to the lining of the intestine, where they feed on blood, causing blood loss. Severe infestations can result in anemia (see page 610).

While you are traveling in a developing country, the following precautions can help you stay healthy during your trip:

• Wash your hands before handling or eating food.

• Drink only bottled water or milk, or boil water to make it safe to drink. Alternatively, use both a water filter and iodine tablets to purify water and other liquids by the glassful. Avoid ice cubes. Carbonated beverages such as colas in sealed cans and bottles are usually safe.

• Do not use tap water for brushing your teeth.

• Avoid salads and reheated foods. Do not eat peeled fruit; always peel it yourself.

• If you plan to visit rural or remote areas, make sure that your clothing protects you adequately from insect bites, especially if you plan to sleep outside or travel at night (when insects can be most active). Wear long-sleeved shirts, long pants, and socks when traveling.

• Use an insect repellent containing DEET or permethrin (in a 35 percent solution for adults and a 6 to 10 percent solution for children).

• Stay in air-conditioned or well-screened areas.

• Don’t use scented products such as lotions or perfumes, which can attract some insects.

Cholera

Cholera is a disease caused by bacteria that damage the intestinal lining. The bacteria are transmitted through polluted water, shellfish, or raw fruits and vegetables in places where sanitation is poor. Cholera seldom occurs in developed nations. When it does, it usually can be traced to visits to (or residence in) developing countries. However, every year the US Public Health Service reports a few cases of illness caused by contamination of American shellfish with bacteria related to the cholera bacillus.

Symptoms

The symptoms of cholera are abdominal pain and severe diarrhea. Cholera can cause such severe diarrhea that up to 4 gallons of fluid are lost in a day. A person who has cholera may have bowel movements resembling murky water that may be passed almost continuously. He or she may have muscle cramps, extreme thirst, and sudden vomiting, sometimes without the usual initial feeling of nausea. If dehydration is not treated immediately, cholera can be fatal quickly. If you are abroad or have just returned home and have extremely watery, continuous diarrhea that does not improve within a couple of hours, get medical help immediately.

Diagnosis and Treatment

If you have symptoms of cholera, see your doctor immediately. He or she will ask for stool samples to look for the bacteria in the stool. He or she may also order a blood test to look for antibodies (infection-fighting proteins) produced by the immune system to fight the cholera-causing bacteria.

The main treatment for cholera is to prevent or treat dehydration by replacing fluids. If the diarrhea is severe, you may need to be hospitalized. You will be given a rehydration fluid either orally or intravenously (through a vein) until your body chemistry is restored to normal. Your doctor also may prescribe an antibiotic.

Malaria

Malaria is a disease caused by any of four species of parasites called plasmodia that are transmitted from one person to another through the bite of an Anopheles mosquito (the only carrier). Plasmodia enter the bloodstream only if the Anopheles mosquito that bites you has previously bitten a person who has malaria.

Mosquito (magnified)

Once in the bloodstream, the plasmodia travel to the liver, where they multiply rapidly. After 9 to 16 days, thousands of plasmodia flow back into the bloodstream, where they