Blood Clots

Economy Class Syndrome
(Venous Thromboembolic Disease)
(Blood Clots)

Economy class syndrome is the name given to the medical condition called Deep Venous Thrombosis ( DVT ) or a blood clot in your leg or legs that can occur during air travel.  However blood clots can develop while traveling  in first or business class and even by automobile.

Air travel increases the risk of developing blood clots in the legs for the following reasons: 

  • Immobility: as little as 4 hours of continuous flight, but usually greater than 8 hours of continuous flight.
  • Dehydration: decreases the viscosity of blood.
  • Decreased Oxygen Concentration:  can  stimulate clotting of blood

The incidence of travel associated blood clots in the legs range from 5% - 10%

The greatest risk of these blood clots is that they can dislodge from the legs and travel to your lungs (pulmonary embolism) potentially resulting in death in severe cases.

What are the signs and symptoms of blood clots in the leg?

The signs and symptoms include swelling, pain and sometimes redness and warmth of the leg. Some have fevers and chills associated with this. The pain may be aggravated by walking.

What are the signs and symptoms of blood clots in the lung?

Symptoms can include any or all of the following; shortness of breath, chest pain, dry cough, fast heartbeat and sometimes fever. In severe cases one can cough up blood or pass out.

Are there any risk factors for getting blood clots?

The majority of individuals who develop blood clots have some underlying risk factors like:

  • Previous episode of blood clot in the leg.
  • Chronic swelling of legs and feet.
  • Varicose veins.
  • Obesity.
  • Cancer.
  • Recent trauma, hospitalization or surgery.
  • Pregnancy.
  • Hormone replacement treatment.
  • Genetic clotting disorders.
  • Congestive heart failure.

Can someone with none of the above risk factors develop blood clots?

Yes, individuals with no obvious risk factors can develop blood clots in their legs and suffer its complications for reasons of immobility and dehydration.

What can be done to prevent formation of blood clots while traveling?

  • Wear loose fitting clothing
  • Walk around the airplane at regular intervals if possible
  • Exercise your legs by bending and straightening your feet and knees.
  • Avoid crossing of your legs.
  • Drink plenty of liquids.
  • Avoid alcohol – it dehydrates your body
  • Wear properly fitted graduated compression stockings

Are there any medications that can be taken to prevent blood clots while traveling?

Individuals with a prior history of blood clots or those at high risk for blood clots may benefit from taking medications prior to long flights.

Those individuals with 2 or more of the following risk factors and flying more than 8 hours at a single stretch should consider taking a dose of low molecular weight heparin (1mg/kg of ideal body weight) up to 12 hours before flight.

  • Major surgery within 6 weeks.
  • Hip or Knee replacement within 6 weeks.
  • Obesity.
  • Age greater than 65.
  • Hereditary Clotting Disorders.
  • Previous Blood Clot.

Check with your physician to evaluate your risk and take medication if appropriate.

Insect Safety


‘God in his wisdom made the fly and forgot to tell us why’
Ogden Nash

Insect borne diseases are a major cause of illness leading to death and disability in overseas travelers. They include malaria, dengue, chickungunya, encephalitis and yellow fever to name a few. Vaccines and prophylactic antibiotics are available for some diseases like malaria and yellow fever, but are not 100% effective. Also many travelers are not fully compliant with instructions to take medications on a fixed regimen. For many diseases like dengue or chikungunya, there are no preventive vaccines or antibiotics.

Therefore measures to prevent insect bites play a vital role in preventing illness and making your trip enjoyable.

Studies have shown that certain locations and patterns of insect behavior are associated with contracting bites; mosquitoes that transmit malaria are most active at night between dusk and dawn, mosquitoes that transmit dengue are most active in early morning hours and late afternoon. Ticks and mites are prominent in wooded and scrub bush areas, while kissing bugs are commonly found among cracks in mud dwellings.

Studies have also shown that some insect repellants are extremely effective in repelling mosquitoes, ticks, chiggers, fleas, gnats and some flies.

Therefore comprehensive measures to prevent insect bites should cover aspects of your activities, clothing, accommodation and insect repellant.

What precautions can be taken for timing of activities?

In general , avoid outdoor activities between dusk and dawn if possible; many mosquitoes are most active at these times. Specifically mosquitoes that transmit malaria are most active at night between dusk and dawn, mosquitoes that transmit dengue are most active in early morning hours and late afternoon.

Avoid walking barefoot or in open sandals to minimize risk of bites from spiders, scorpions and snakes.

Can clothing be used to minimize risk of insect bites ?

Wear long sleeve shirts and long pants, with pant legs tucked into socks to give insects as little exposed skin as possible to bite.  We have yet to see real cowboys be outdoors wearing tank tops and cutoffs !!  Clothing in developing countries is not just about modesty but health reasons as well.

Insect repellant (Permethrin or Etofenprox) impregnated clothing are available and effective, however repeated washing (5-10 times) might limit its usefulness.

One can also spray insect repellant containing Permethrin (Duranon, Permanone) onto clothing, sleeping bags, tents and mosquito nets.

What precautions should be taken in regards to accommodation?

Avoid staying in primitive accommodations with mud floors, walls and thatch roofs. There are safer ways to go ' native '

Stay in well built modern accommodations with net screens on windows, doors and eaves to decrease exposure to insects.

Fans and especially air-conditioning are helpful in keeping flying insects at bay.

Mosquito nets with a mesh size smaller than or equal to 1.5 mm that are tucked under the mattress are quite effective. If the nets are impregnated with the repellant permethrin, it is even better. These are available at camping and outdoor stores.

Special mosquito plugs INS are readily available in developing nations; these either accommodate a tablet containing insect repellant (bioallethrin) or liquid containing insect repellant (prallethrin). When plugged into an electric outlet it generates odorless, undetectable vapors that kill off mosquitoes and are effective for enclosed small rooms. These are not known to be harmful to human beings. They are available at pharmacies in the developing world.

What is the best insect repellant out there ?

  • DEET: The most effective and well researched insect repellant is DEET ((N, N diethyl-m-toluamide). It comes in concentrations ranging from 5% to 100%. The higher concentrations give you longer duration of protection, not more efficacy, but can increase the risk of side effects.
    Concentrations of up to 50% are safe and effective for up to 6-8 hours. Repellant effects lasts longer on clothing than skin, so long sleeve shirts and pants are helpful and it prevents toxicities since only a small proportion of exposed skin has DEET on it. We recommend that you wear long sleeve shirts and pants, spray insect repellant containing DEET to clothing and any exposed skin.
    Avoid spraying repellant on mucus membranes (eyes, mouth etc.) to avoid toxicity.
  • Picaridin: Picaridin is an insect repellant that may be as effective as DEET with less irritating side effects and preparations sold in Europe and Australia are effective for up to 8 hours. However the product sold in the US (Cutter Advanced) has lower concentration and is effective for 1-4 hours.

How effective are organic or ‘natural’ insect repellants?

Insect repellants made from eucalyptus – eucalyptol, lemon grass – citronella, catnip – nepetalactone are all effective to some degree. However independent studies show that for ecalyptol & citronella their effectiveness is very short lived; 30 -60 minutes and nepetalactone is ineffective once applied to skin.

What is the worry about DEET?

DEET may rarely, cause seizures in some people, especially children.To date there has been 14-46 cases, with 4 deaths reported. This risk works out to 1 in 100 million users in the United States; perhaps worth the benefit.

Jet Lag

Jet lag is the word used to describe a variety of symptoms that result when the body’s internal clock, which is set by exposure to light and dark, has not adjusted to the new environment and its pattern of daylight and night. The body’s internal clock lags in getting used to the new day & night cycles and one’s pattern of sleep and wakefulness are disrupted.

This phenomenon occurs when several time zones are crossed quickly, usually by jet travel, thus the term jet lag.

The body’s internal clock is primarily set by the hormone melatonin which is produced by the pineal gland. Melatonin is released by the pineal gland when it is dark outside and it makes one sleepy. Conversely day light suppresses production of melatonin and one is less sleepy.

What are the signs and symptoms of jet lag?

The symptoms of jet lag are include falling asleep during the day, difficulty falling asleep at night, repeatedly awakening during sleep, lack of energy, difficulty in concentrating, irritability, headaches, loss of appetite etc.

Is it worse going in one direction versus another?

Going eastward is generally far worse than going westward. Travelers going eastward will notice difficulty falling asleep at the new nighttime and trouble waking up in the morning. Travelers going westward will start feeling sleepy in late afternoon to early evening and wake up  early in the morning,way before sunrise.

How long does it take the body to adjust?

For each time zone that is crossed, it takes the body one day to adapt. Travelers returning from the east will generally take 2 days to adjust while those returning from the west will usually need 5 days to adjust to the new time zone.

What can be done to prevent jet lag?

  • Avoid large meals during flight and drink plenty of liquids to keep hydrated. Avoid alcohol, caffeine and carbonated beverages.
  • When you get to your destination, increase your outdoor activities to get maximal sunlight exposure. Bright outdoor light will help you shift your daily clock sooner.
  • Stay awake during daylight hours.
  • Adjust all your activities and meals to the new time zone.
  • If you absolutely have to sleep during the day, just take a nap for 45 minutes at most.

Are there any special diet’s that will help?

  • A high protein breakfast can increase levels of hormones that promote alertness and keep you awake.
  • A high carbohydrate dinner can increase hormones that promote sleepiness.

Is melatonin helpful in preventing jet lag?

  • Melatonin taken at a dose of .05 - 5mg may be helpful for some if crossing more than 5 time zones. It should be taken at the bedtime you hope to have at your destination; starting 3-4 days prior to travel. This may not be practical for many travelers.
  • The other issue is that the manufacturing process for melatonin is not standardized and dosages fluctuate widely in different preparations.
  • Its safety in those suffering seizures, children and in those taking blood thinning medications like Coumadin is not established.

What about other medications?

  • Sedatives like ambien (zolpidem) and lunesta (zopiclone) may be helpful in prolonging sleep at your destination.
  • Short acting benzodiazepine class of medication like restoril (temazepam) may also be beneficial.
  • The side effects of the above mediations may not be worth the benefit you gain, speak with you physician.
  • DO NOT combine melatonin with above medications.

What about ‘red bull’ and other stuff to keep me awake?

Stimulants like caffeine, amphetamines or amphetamine like products can interfere with sleep patterns, be habit forming and are not recommended.

So what is the bottom line in dealing with jet lag?

The best way to deal with jet lag is to be well rested prior to the trip, stay hydrated during the trip, avoiding stimulants (caffeine) and sedatives (alcohol) and adjust your activities, meals and sleep strictly to the new time zone with as much exposure to outdoor light as possible , and avoid day time sleeping.

Bon Voyage!!
Happy travels!!

Food Safety

How to make sure food is safe to eat

“Wash it, Peel it, Cook it or Forget about it”

You should ALWAYS:

  • Wash your hands with soap and clean bottled water or antibacterial gel before eating
  • Eat food that is cooked to order and brought to you steaming HOT!
  • Eat only well DONE meat, fish and eggs
  • Eat only undamaged fruit that you peel YOURSELF

You should NOT:

  • Eat food sitting out at room temperature at stalls, buffets, counters etc.
  • Eat raw or undercooked meat, fish or eggs
  • Eat ice cream, soft cheeses or custard
  • Drink cold milk, milkshakes or other dairy products
  • Eat salads, precut fresh vegetables and fruits.

Practical tips from Our Travel Experience!!

How does one pick a place to eat ?

First do a walk by and pick the restaurant that is most crowded. If the place is crowded the food is probably tasty, is turning over quickly and so is being freshly cooked.

Eat at the times when most of the locals eat, food is more likely to be freshly cooked then. This is usually between 11am – 1pm and 7pm – 9pm. Between 1pm – 7pm you are in the limbo time zone when leftovers are languishing and spoiling for a tourist.

What precautions need to be taken with cutlery and utensils ?

Dry surfaces do not promote bacterial growth; dry plates, cups, bowls, glasses and utensils are safer than the ones that were just sloshed up to impress you. If they are brought to you wet, dry it off first.

What about ice ?

In the developing world, ice is made with contaminated water and insisting on having ice in your drinks is a recipe for disaster. You can order a cold bottle or can, wipe of the cap or tab and drink directly from the bottle or can.

How does one select foods to eat ?

Foods that are dry do not promote bacterial growth and are safer than wet ones: breads, cookies, cakes, candy etc.

Deep fried foods are generally well cooked at high temperatures and are yummy!!

All food should be cooked to order, well done and brought to the table piping hot, especially in the developing world.

What are some habits to be avoided ?

Developing nations are not the place for you to insist on having green salads, precut fruits and raw vegetables. Just imagine who was washing and cutting these, yes the lowest guy on the totem pole; you will get sick on these. Have your ‘Caesar salad’ when your back home.

Avoid buffets anywhere, the food is kept out too LONG, is NOT kept hot enough to kill bacteria and they multiply in droves from the meats, fish and eggs, and will make you sick. This is true even for the most expensive and snooty places where they proudly serve with gloved hands.

In developing countries milk pasteurization is not reliable and eating ice cream, shakes or custard is likely to make you sick; save yourself for Blue Bells and Ben & Jerry’s when you get home.

Something Contrarian and lots of fun

As a general rule, everyone is advised to avoid open-air stalls and vendors. However, if you are impressed with the hygiene, the food is cooked to order in front of you, is given to you piping hot or deep fried it should generally be safe and is a wonderful local culinary experience.

What if  all of the above have failed ?

Always carry a small jar of peanut butter and crackers, just in case.

Water Safety

‘Water, water everywhere, but not a drop to drink’

How to make sure water is safe to drink

“Boil it, Filter it, Purify it or Forget about it”

You should ALWAYS:

  • Drink bottled water, from a bottle that has an unbroken cap seal OR
  • Drink water that has been boiled for 3 minutes OR
  • Drink water that has been filtered with an ‘absolute less than 1 micron’ filter and add iodine or chlorine tablets to kill viruses or drink water purified with a filter that removes viruses as well.
  • Drink bottled water, juice, soda and alcohol directly from the container.
  • Brush your teeth and wash hands before eating with bottled water.

You should NOT:

  • Drink tap water
  • Order ice with drinks, including alcoholic beverages
  • Brush your teeth or wash hands before eating with tap water

Practical Tips from Our Travel Experience!!

What is the most reliable method of making sure water is safe to drink?

Boiling water to an angry, gurgling and rolling boil (greater than 212 F/ 100 C) for a minimum of 1 minute but suggested up to 3 minutes is the single most reliable method of purifying water. Let it cool to room temperature on its own; please don’t dump ice in it!!

What is the most ‘practical’ way of making sure water is safe to drink?

Bottled water is readily available in most parts of the developing world, is cheap and the most practical way of drinking water safely. It should generally be safe, but be SURE the cap on the bottle is sealed when you buy it or else your karma will be let loose shortly!

When you have finished with the plastic bottle, CRUMPLE it thoroughly, so it will not be ‘recycled’ unscrupulously. Help your fellow vagabond stay healthy.

How good are water purification tablets in making sure water is safe to drink?

Water purification tablets containing iodine (Potable-Aqua, Globaline, Coghlans) if used according to manufacturers directions may be an alternative if you are unable to find bottled water and cannot filter or boil water. Make sure to take a new set of tablets with you, once the bottle is opened the shelf life is fairly short; don’t dig it out of your closet for the trip.

The drawbacks are that chemical purification of water with Iodine tablets can be affected by the pH, temperature and levels of organic material in water and therefore is not 100% reliable. Water purification tablets are not 100% reliable to kill giardia and cryptosporidium. It is not effective if the water is murky or muddy; you will have to filter the water first.

If the water is cloudy or extremely cold (<41 F) you may need to use more tablets and increase the treatment time to be effective, follow manufacturers instructions.

Those who are allergic to iodine and shell fish or pregnant should not use iodine tablets.

Are there non – iodine water purification tablets available to purify water?

Chlorine dioxide tablets (micropur forte, pristine, aquamira) are available and are effective against bacteria, viruses and protozoa, but treatment time can be from 30 minutes up to 4 hours to be effective against cryptosporidium. It is not effective if the water is cloudy, murky or muddy; you will have to filter the water first.

The drawbacks are again that chemical purification of water with Chlorine tablets can be affected by the pH, temperature and levels of organic material in water and therefore is not 100% reliable. Water purification tablets are not 100% reliable to kill giardia and cryptosporidium. If the water is cloudy or extremely cold (<41 F) you may need to use more tablets and increase the treatment time to be effective, follow manufacturers instructions.

How good are water filters/purifiers in making sure water is safe to drink?

Reverse osmosis filters are reliable against bacteria, protozoa and viruses but are bulky, expensive, prone to clogging and not practical for most overseas travelers.

Smaller traveler friendly microstrainer filters are more practical; those with an ‘absolute less than 1 micron filter’ are excellent in removing bacteria and 99.9 % effective in removing protozoa like giardia and cryptosporidia. You MUST add iodine or chlorine tablets to kill viruses.

Some filters come with an additional filter effective against viruses and some are combined with an iodine impregnated resin to clear viruses.

Filters that are designed to remove protozoa (cryptosporidium/giardia) carry one of the four labels verbatim on the package:

  • Reverse osmosis.
  • An absolute pore size of < 1 micron. (Typically 0.2 to 0.4 microns)
  • Tested and certified by NSF International Standard 53 or 58 for cyst removal.
  • Tested and certified by NSF International Standard 53 or 58 for cyst reduction.

Products with any other wording are not reliable to remove protozoa. Unless the product specifically states that it removes viruses, you need to add iodine or chlorine tablets or liquid as directed. Chlorine liquids will not be allowed on carry on luggage.

Proper maintenance and change of cartridges are essential to reliably purifying water.

What are some models of filters and purifiers that are effective?

Purifiers that remove protozoa, bacteria and viruses are:

  • First Need TravL-Pure water Purifier (pump)
  • First Need XL Purifier (pump)
  • MSR Sweetwater Purifier System with ViralStop (pump)
  • Katadyn Exstream XR Purifier Water Bottle (No pump bottle)
  • MSR MIOX Purifier (No pump bottle)

Filters that remove protozoa and bacteria; but need chlorine/iodine tablets for viruses are:

  • Katadyn Hiker Filter (pump), Katadyn Hiker PRO Filter (pump)
  • MSR Hyperflow Microfilter (pump), MSR MiniWorks EX Microfilter (pump)
  • Katadyn Microfilter bottle, MSR AutoFlow Gravity Filter (no pump bottle)
  • Sawyer 2L Water Treatment System. (No pump bottle)

How effective is ultra violet light in making sure water is safe to drink?

Ultraviolet light can kill bacteria, viruses and protozoa. The advantages are the lack of any after taste or prolonged wait time before drinking. In addition the devices are compact, lightweight, run on batteries and are easy to use. One can purify individual drinking containers; for example in hotel rooms or restaurants.

Make sure all the water in the container is exposed to UV light; it will not kill microbes above the light line – on the lip of the container for example. It does not work with muddy or cloudy water; you have to filter it first.

A product called Steri PEN is available and is effective if directions are followed closely; you can purify 32 ounces of water in 90 seconds. The SteriPEN’s have a prefilter; a screw on cap for water bottles with a 4 micron filter and can be used if the water is cloudy or muddy.

The products are;

                SteriPEN Adventure Water Purifier

                SteriPEN Classic with Pre-Filter

                SteriPEN Journey with LCD Display

Does alcohol in beer, liquor and wine kill bacteria, viruses and protozoa?

Unless your drink has alcohol content greater than 70% it will not help in killing bugs. However it can potentially make you act silly and still have the runs. Cooling your drink with ice made from unclean water is not wise either.

What are some common mistakes that are made when it comes to safe drinking water?

Pouring a drink into a glass that was washed in dirty water with unclean hands is a common mistake. Drink directly from the container (can, bottle, and carton). If the container (can, bottle, and carton) is wet, dry off the outside and clean all surfaces that will come in contact with your mouth.

Brushing your teeth with tap water is another mistake; always use bottled, boiled or purified water.

Washing your hands before eating with tap water and not bottled or purified water is also a common mistake.

Swimming in local swimming pools (inadequate chlorination), rivers, lakes and oceans is also a mistake. There is absolutely no point in drinking bottled, purified, filtered or boiled water, only to gulp water contaminated with sewage while swimming.

What if I am staying in a 5 star facility with lots of snootiness?

Yeah! Yeah! You must take these precautions even in expensive (5 star, blah-blah, hoity toity) restaurants, hotels, spas etc in developing nations. The places are not expensive because the local labor is exorbitant; trust us on this one!

What is the bottom line, best practical advice?

If your overseas travel is limited to places where bottled water is readily available, you can drink it straight from the container or use the SteriPEN to purify water for extra caution. If bottled water is not available but clear running water is available from taps in hotels and restaurants, use the SteriPEN to purify water.

If your overseas travel involves outdoor activities like camping, trekking and hiking where water needs to be obtained from rivers, streams and wells, take a water purifying microstrainer device or filters with ‘an absolute less than 1 micron pore’ filter but add chlorine or iodine tablets to kill viruses. Devices that pump water are convenient for purifying larger quantities of water and are practical for cooking, cleaning etc; especially for more than 1-2 people. Alternatively, one could use the SteriPEN’s prefilter screwed on to a compatible water bottle to remove particulates and use the SteriPEN as directed. One may have to repeat the dose of UV light once or twice for caution.

Sun Safety

Slip on a shirt, slop on sunscreen, slap on a hat’
                                                                     -Aussie sun safety slogan

Sunlight contains ultraviolet (UV) rays that can damage skin and cause conditions ranging from sunburn to photoaging to cancer.

UV rays are divided into A and B according to their wavelength. UV – A rays constitute 95% of the sun’s radiation and penetrate into the deeper dermis layer and are responsible for tans and wrinkles. UV- B rays are typically absorbed by the outer epidermis layer of skin and causes sunburn. However both can over time lead to skin aging, wrinkling and cancer.

Snow and light colored sand reflect UV light and thus one can get exposed to UV rays from the sun above and ground below.

UV light penetrates clouds and one can get sun damage even on cloudy overcast days.

Where is sun light most intense?

Countries near the equator, closer to the north and south poles or places at higher altitude have the most intense exposure to UV rays.

What part of the days is worst for UV exposure?

Ultraviolet rays are most intense at midday, between 10am – 4pm.

How soon after exposure does one develop signs and symptoms?

Signs and symptoms start 4-6 hours after exposure and are worst 24 – 36 hours later.

What are the signs and symptoms of sunburn?

In mild cases the symptoms are of redness of the skin, warmth and tenderness to touch. In severe cases one can see large areas of blisters with clear fluid in it and intense pain.

If large areas of the body are involved one can develop fever, fatigue, headache, nausea and vomiting. One notices the skin beginning to peel after 3-5 days.

What is the treatment for sun burn?

Treatment is supportive with fluids, rest, Tylenol or Ibuprofen. Gentle cool soaks or moist cloth on affected skin provides relief. Moisturizing creams like aloe and hydrocortisone creams are also beneficial.

What can be done to prevent sun damage?

Slip on a shirt

  • Wear LONG sleeve tops and LONG pants; clothing is more UV protective than any sun screen. Have you ever seen a cowboy riding in tanktops and speedo???
  • Darker colored clothing with tight weaves is superior to lighter colored loosely woven ones. Newer garments with high SPF ratings are beneficial.

Slop on sunscreen

  • You should lather on sun screen with a sun protection factor (SPF) of 30 or greater on to exposed areas at least 20 minutes before exposure. You may need to reapply it every 2-4 hours. Use water resistant products that will not easily be removed by sweating or swimming.

Slap on a hat

  • Wear a wide brimmed hat, many of which are now made with SPF materials and put on 100% UV-protective wrap around sunglasses.

What is the skinny on Sunscreen?

Sunscreen is commonly labeled with its Sun Protection Factor (SPF). SPF refers to the amount of time that a person will be protected from having sun burn. A sun screen with an SPF of 15 allows a person to be out in the sun 15 times longer than someone without sunscreen before suffering a burn.

SPF however only refers to protection against UV-B rays and not UV-A rays. Products containing zinc oxide, avobenzone, ecamsule, titanium dioxide and mexoryl block UV-A rays as well.

We recommend that you use Sunscreen products with a minimum SPF rating of 15 and that protects against both UV A & B rays.

Some examples include Aveeno Continuous, Bull Frog Quick Gel, Coppertone Sport, CVS Sunblock, Neutrogena Healthy Defense and Sea & Ski Advanced Sunscreen.

How is sunscreen best applied?

Make sure you use enough, at least 30 ml to cover the whole body. It should be applied at least 20 -30 minutes before exposure and need to reapply it every 2-3 hours.

If you are swimming, snorkeling or sweating heavily you may need to apply sunscreen every 1-1 1/2 hours.

Are there problems with Sunscreen and insect repellants containing DEET?

Sunscreens may not be fully effective if DEET is applied afterward and so some people use DEET first. However there have been recent experimental reports that sunscreens increase absorption of DEET and could increase toxicity.

The toxicity has not been commonly reported in adult travelers, so if the risks of insect bites are high, we would recommend applying insect repellant containing DEET first and then Sunscreen. Wear long sleeve shirts and pants so that the amount of DEET exposure to bare skin is minimal.

Can some medications cause or make sunburn worse?

Birth control pills, anti-malarial medications, non-steroidal drugs and certain antibiotics can have this side effect.

Slip on a shirt, slop on sunscreen, slap on a hat

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