Read below for travel health advice on Panama from the MDtravelhealth channel on Red Planet Travel.
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Summary of recommendations
Most travelers to Panama will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for malaria prophylaxis and travelers' diarrhea. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), doxycyline, or primaquine is recommended for provinces east of the Panama Canal toward the border with Colombia (provinces of Panamá east of the canal and Darién)
|Hepatitis A||Recommended for all travelers|
|Typhoid||Recommended for all travelers|
|Yellow fever||Recommended for mainland areas east of the Canal Zone, encompassing the entire comarcas (autonomous territories) of Emberá and Kuna Yala, the entire province of Darién, and designated areas of the provinces of Colón and Panamá that are east of the Canal Zone. Not recommended for areas west of the Canal Zone, the city of Panama, the Canal Zone itself, the San Blas Islands, and the Balboa Islands. Required for all travelers arriving from a country with risk of yellow fever transmission.|
|Hepatitis B||Recommended for all travelers|
|Rabies||For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats|
|Measles, mumps, rubella (MMR)||Two doses recommended for all travelers born after 1956, if not previously given|
|Tetanus-diphtheria||Revaccination recommended every 10 years|
Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal 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 associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.
Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.
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.
Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.
Malaria in Panama: prophylaxis is recommended for provinces east of the Panama Canal toward the border with Colombia (provinces of Panamá east of the canal and Darién). Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), doxycycline, or primaquine may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics. Primaquine may cause hemolytic anemia in those with G6PD deficiency, so a blood test documenting normal G6PD levels must be obtained before starting primaquine. In those with normal G6PD levels, the main side-effect of primaquine is gastrointestinal disturbance, which can be minimized by taking the medication with food. Insect protection measures are also advised.
There is also a small malaria risk in the provinces of C. Ngöbe-Buglé, Chiriqui, Coclé, Kuna Yala (San Blas), and Veraguas. For these areas, insect protection measures are advised, but malaria medications are not recommended.
There is no malaria risk in Panama City or in the former Canal Zone.
For further information about malaria in Panama, including maps showing the risk of malaria in different parts of the country, go to the World Health Organization and the Pan American Health Organization.
The following are the recommended vaccinations for Panama.
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. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.
Typhoid vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. 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 immunocompromised travelers.
Yellow fever vaccine is recommended for all travelers greater than nine months of age traveling to mainland areas east of the Canal Zone, encompassing the entire comarcas (autonomous territories) of Emberá and Kuna Yala, the entire province of Darién, and areas of the provinces of Colón and Panamá that are east of the Canal Zone (see map). The vaccine is not recommended for travelers whose itineraries are limited to areas west of the Canal Zone, the city of Panama, the Canal Zone itself, the San Blas Islands, and the Balboa Islands (see map). Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy. The vaccine should not in general be given to anyone who is younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.
Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Panama, rabies is transmitted mainly by vampire bats. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.
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.
Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
Cholera vaccine is not recommended. Cholera is not being reported from Panama at this time.
Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.
An outbreak of cutaneous leishmaniasis was reported in April 2012 from Campana community, Capira District, Western Panama, causing 150 cases. Leishmaniasis is a chronic parasitic infection transmitted by the bites of sandflies. The cutaneous form is manifested by chronic skin lesions which are typically painless, enlarge slowly, and develop central ulceration, often covered with eschar and surrounded by an erythematous, indurated border. The disease is found in rural and forested areas throughout Panama, especially the eastern and south-central regions. Cases have been reported in American military personnel and in an American traveler. Travelers to Panama should follow insect protection measures, as below.
An outbreak of Eastern equine encephalitis was reported from Panama in June 2010, causing 17 confirmed cases, onse of them fatal. Most of the cases were reported from the provinces of Darien and Panama East (see Pro-MED mail, June 27, 2010). Eastern equine encephalitis, which is transmitted by mosquitoes, is reported from scattered foci in Panama. Insect protection measures, as below, are strongly advised.
An outbreak of Venezuelan equine encephalitis was reported from Darien in June 2010, causing 28 cases, one of them fatal. The infection, which is transmitted by mosquitoes, is reported from scattered foci in Panama, including the Fort Sherman area on the Caribbean side of the isthmus. Insect protection measures, as below, are strongly advised.
Cases of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, are reported annually from Panama. More than 1000 confirmed cases, including six deaths, were reported during the first nine months of 2011. The incidence is highest in San Miguelito and in the Panama City metropolitan area. Dengue fever is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are advised, as outlined below.
An outbreak of hantavirus pulmonary syndrome, a severe viral infection typically leading to respiratory failure and frequently resulting in death, was reported from the province of Los Santos in late 1999 and early 2000, resulting in 11 cases, three of them fatal. Cases were also reported from the provinces of Cocle and Veraguas. A single case was reported from Los Santos province in July 2008, followed by two fatal cases from Los Santos in May 2009. An isolated case was reported from Cocle province in October 2008. Ten cases were reported in the first three months of 2010: seven from Herrera Province, two from Los Santos and one from Cocle. One case was reported from Los Santos in October 2010. A fatal case was reported from Santiago, Veraguas province, in April 2011. Two cases were reported from the Azuero region of Los Santos in April 2011.
Hantavirus infections are acquired through close contact with rodents or their excreta. Most tourists are at extremely low risk. Those visiting rural areas should avoid entry into homes and other buildings unless known to be free of rodents and cleansed of rodent excreta. See Emerging Infectious Diseases, MMWR, and Pro-MED mail for further information.
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.
Other infections include
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, including ceviche. 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, and sea bass.
All travelers should bring along an antibiotic and an antidiarrheal 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.
Insect and Tick Protection
Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.
To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.
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.
Make sure your health insurance covers you for medical expenses abroad. If not, supplemental 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. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. 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.
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. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.
Ambulance and Emergency Services
For an ambulance in Panama, call one of the following:
There is no ambulance service outside urban centers.
Good medical care is widely available in Panama City, but is extremely limited elsewhere. Many travelers go to one of the following hospitals or clinics:
For a guide to other hospitals and clinics in Panama, go to the U.S. Embassy website at http://panama.usembassy.gov/panama/medical_info.html. In Panama, most hospitals accept credit cards for hospital charges, but not for doctors' fees. Life-threatening medical problems will require air evacuation to a country with state-of-the-art medical facilities.
Quality control of pharmaceuticals is not adequate. In October 2006, an expectorant syrup that was accidentally contaminated with diethylene glycol, better known as antifreeze, poisoned 82 people and caused 34 deaths (see Pro-MED mail, Oct. 28, 2006).
The pharmacy at the Hospital Nacional (Ave. Cuba - Calle 38 and Calle 39, Panama City, tel. 507-207-8130) is well-supplied and open 24 hours a day. The Clinica Hospital San Fernando operates two pharmacies: San Fernando Pharmacy (located on the grounds of the Policlinica Sur, open 6 AM to 11 PM, tel. 507-261-6945) and the Javillo Pharmacy (on the grounds of the Centro Especializado San Fernando, open daily from 7 AM to 9 PM and on Saturdays from 8 AM to 4:15 PM,tel. 507-229-6745/46/47).
Traveling with children
Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).
All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).
The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.
When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.
Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.
Travel and pregnancy
International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.
As a rule, pregnant women should avoid visiting areas where malaria occurs. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.
Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.
Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.
(reproduced from the U.S. State Dept. Consular Information Sheet)
Americans living or traveling in Panama are encouraged to register with the Consular Section of the U.S. Embassy in Panama City through the State Department's travel registration website, https://travelregistration.state.gov, and to obtain updated information on travel and security within Panama. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy to contact them in case of emergency.
The Consular Section of the U.S. Embassy is located in The Clayton Building (formerly Fort Clayton Building 520) in the Clayton section of Panama City.
The international mailing address is: Apartado 6959, Panama 5, Republic of Panama.
The U.S. mailing address is U.S. Embassy Panama, Department of State, Washington, D.C. 20521-9100.
The telephone numbers for the Embassy are 011-507-207-7000, after hour emergencies, 011-507-207-7200; Consular Section 011-507-207-7030 and fax 011-507-207-7278.
The Embassy web site is http://panama.usembassy.gov.
E-mail inquiries may be addressed to Panama-ACS@state.gov.
For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.
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