HEALTH & MEDICAL GUIDE

Ankara is generally a pleasant place to live and work. Travel and cultural opportunities abound and the Turkish people are warm and hospitable, especially towards children. This may be a very different environment for some people and those differences bring their own benefits and risks to health.

Much can be done to prevent health problems during your stay in Ankara. This handbook has been prepared to give you important information on

• looking after your health
• sensible preventative measures
• dealing with common health problems
• options for medical treatment

Read and familiarise yourself with the recommended emergency procedures. Please also keep a copy handy - perhaps by your telephone.

Introduction

Ankara is situated at an elevation of 850m in the relatively barren hills of the Anatolian plateau and has a population of approximately 5 million.

Climate: it is one of the driest areas of Turkey with cold snowy winters and hot dry summers.

Natural Hazards: Turkey is subject to earthquakes, although Ankara may not be as vulnerable as Istanbul or Izmir.

Utilities: Electricity 220V AC, 50Hz, European 2-pin, supply stable. Rubbish collection and sewage systems cope.

Food: wide range readily available. Local fresh fruit and vegetables of good quality

Toiletries, cosmetics, medicines: wide range of products but some vaccines and pharmaceuticals not available

Water: the risk to health is thought to be small from Ankara’s water supply but enough to suggest using reputable bottled water or a suitable filter.

Air: heavy air pollution can occur mainly in winter, up to date measurements of air pollutants can be obtained from (http://havaizleme.com/)

Transport: In 2005, Turkey had 86 motor vehicles per 1000 inhabitants, the lowest ratio of OECD countries. Because of the relatively low number of vehicles, the road fatality rate is misleadingly low at 62 per million inhabitants. The true danger of Turkey’s roads is revealed when considering the death rate per million vehicles. In 2005, road accidents caused 726 deaths per million vehicles compared with a UK figure of 103 per million. The risk of injury or death on the road is one of the most serious dangers faced by expatriates in Turkey.

Crime: petty street crime is probably less of a concern in Ankara than other capital cities, but burglaries are becoming increasingly common in Ankara. The threat of terrorism is of serious concern as in many countries.

Prevalent diseases: Infant and maternal mortality is higher and life expectancy lower than Western Europe.

Tuberculosis incidence is higher than in some parts of Western Europe with a prevalence of approximately 29 per 100, 000 in 2005.

Snake bites (not common in Ankara) are a potential hazard in rural areas. 10 of Turkey’s indigenous snakes are venomous.

Sexually transmitted disease: overall probably less common than Western Europe, with HIV at a relatively low and stable incidence. Commercial sex workers and their clients said to be the main contributors for the spread of HIV in Turkey.

Rabies: In 2001, Turkey reported 202 cases of Rabies in dogs. Stray dogs, foxes and bats are the main reservoir of infection. Vaccination provides good but not complete protection. There have been no cases of Rabies in Ankara for many years but the same precautions are advised and vaccination is recommended.

Hepatitis A: does occur in Turkey (vaccine advised) while typhoid is commoner in the south east region.

Hepatitis B: has a higher prevalence in Turkey than Western Europe and vaccine is strongly advised.

Malaria: 2,084 cases were reported in 2005, the risk is limited to south eastern areas of Turkey. Bite prevention measures should be taken and advice on prophylaxis obtained from health provider.

Avian influenza: Of the 12 human cases confirmed in Turkey between 2003 and 2007, 4 have been fatal.

Smoking: 50.7% of Turkish men and 18.6% of Turkish women smoke. Smoking in public places is widespread. It is suggested to ask for a smoke free place when visiting restaurants etc, if only to raise awareness of this serious public health issue.

PREVENTIVE MEASURES

Water:

Many problems can be avoided by consuming water from safe sources. Tap water in Turkey may not be safe to drink without additional treatment. All water used for drinking and food preparation, including ice cubes, should be obtained from purified sources. When you do not have access to filters/purifiers for home and office use the following measures should be taken:

• Filtering & Boiling: cloudy tap water may be filtered, and then boiled for 5 minutes. The flat taste will improve if left to cool for a few hours in the same container. Boiling is the most effective way of sterilising water.
• Chemical Disinfection: recommended where boiling or filtration is not available. Chlorine based tablets are commercially available, and manufacturers instructions should be followed carefully.
• Bottled Water: many brands are available in Turkey. Hayat, Pinar and Niksar are well-established companies. Not all brands are bacteriologically safe and some may have high levels of heavy metals or other toxins.

When travelling in areas where hygiene and sanitation are in question, travellers are advised that only the following may be considered safe:

• drinks made with boiled water
• canned or bottled carbonated drinks (be sure they are opened in front of you)
• beer and wine

Fluoride supplements: the amount of naturally occurring fluoride in Ankara’s water has not been established. Some local paediatricians or dentists recommend fluoride supplements while other authorities advise caution about this, as excessive amounts of fluoride have adverse effects.

Current UK-based advice for children’s dental care is:

• avoid sweets and sugary snacks between meals
• Brush teeth twice daily with a pea-sized quantity of fluoride toothpaste (supervised by an adult).

A fair selection of fluoride toothpastes suitable for young children is available on the local market. Contact your health provider or the Nurse for more information if concerned.

Food:

All fruit and vegetables should be rinsed thoroughly and ideally soaked for 10 minutes in chlorinated water (1 tablespoon of bleach in 1 gallon or 4 litres of water) and then rinsed again in clean water. Even fruit which has been peeled should be washed, so that fingers do not transmit micro-organisms from the peel to the flesh of the fruit. When eating out, a useful rule is 'if you can't peel it or cook it, don't eat it.'

Consume only pasteurised dairy products (Turkish: 'pastorize'). Avoid unwrapped products, especially in villages or local markets, which cannot be guaranteed to have been made from boiled milk. Diseases such as tuberculosis and brucellosis can be transmitted from unpasteurised products.

Eating out: Ankara has a wonderful selection of good restaurants. To spot the not-so-good, look out for the general level of cleanliness. An inspection of the toilet facilities may give a clue to hygiene standards in the kitchen. See if perishable food is kept on display for long periods at room temperature. This is especially risky in hot weather, when the incidence of food poisoning and gastroenteritis is much higher.

DIARRHOEA & VOMITING

Gastroenteritis is an infective illness of the digestive system with symptoms of nausea, vomiting, diarrhoea and abdominal pain. Food poisoning is a common name for gastroenteritis, since it is usually caused by eating or drinking something contaminated with micro-organisms (germs), or by toxic substances produced by these germs. Traveller's diarrhoea is a popular non-medical term for gastroenteritis occurring in someone who's away from home. It isn't a separate medical condition.

Diarrhoea is not uncommon in Ankara but tends to be more prevalent in the late summer months. Common causes are viruses, bacteria and amoebae. In most cases, diarrhoea will resolve in a couple of days without any long-term untoward effects. Less commonly, diarrhoea (especially if accompanied by vomiting) can cause severe illness.

Prevention is important. It begins with something we can do for ourselves: following commonsense precautions with food and water. This isn’t enough, though. It also depends on other people - particularly food-handlers – observing scrupulous personal hygiene.

• Be aware of the possible sources of contamination - tap water, ice, and uncooked food such as shellfish, unpeeled fruit, salad and partially cooked meat.
• Be careful eating out in very hot weather: avoid meals that may have been cooked several hours before. Prepared meals (sulu yemek) are usually prepared at lunchtime then sold throughout the day.
• Protect food from flies and insects
• Be wary of food sold by street vendors
• If a member of the household develops diarrhoea or vomiting, clean the bathroom (including taps, light switches and doorknobs) frequently with disinfectant. The patient should have their own soap and towel.

Hepatitis A and typhoid are also spread by food and water. Vaccines for typhoid are not available at present.

Treatment is centred on fluid replacement. Follow these self-help guidelines:

• If vomiting - small frequent sips of water or electrolyte rehydration fluids
• If only diarrhoea - drink plenty of water or electrolyte rehydration fluids (preferably not carbonated or caffeinated and definitely not alcoholic!)
• Do not take any medication to stop the diarrhoea unless advised by a physician or your health provider. Diarrhoea and vomiting are the body's ways of getting rid of what is making you ill, so it doesn’t make sense to suppress them!
• As a rough guide, an adult might need 10-12 medium-sized glasses a day plus one more glass for every loose bowel movement. Suitable drinks are:

• Water
• Sprite, ginger ale (shake the bottle or stir to remove all the carbonation)
• Commercial electrolyte rehydration fluids such as Electrolade, Rehidrat, or Dioralyte or in Turkey, Georal)
• Homemade electrolyte rehydration solution made with:

• 8 level or 4 heaped teaspoons of sugar
• ½ teaspoon salt
• One litre of clean water

• For the next 24 hours eat small amounts of easily digested, sloppy foods such as clear or cream soups, mashed banana, mashed potato, rice, apple puree, scrambled egg, jelly and yoghurt. Continue with a high fluid intake.
• If these are well tolerated, slowly reintroduce a normal diet, avoiding foods that require a lot of digesting like cereals, fruit or vegetables with a high fibre content. Also avoid spicy and fatty foods for several days.
• Some people develop temporary lactose (milk-sugar) intolerance after severe diarrhoea and for such individuals, dairy products may prolong diarrhoea or provoke cramps. In practice, this is not a common problem and for most people, dairy products play a useful part in the reintroduction of food as they are so nutritious. Some say live (or 'bio') yoghurt has the ability to repopulate the bowel with healthy germs and displace the nasty ones that caused the diarrhoea.
• Similar general principles apply to children and infants but in order to get adequate rehydration and nutrition into them, it may be necessary to let them eat or drink whatever appeals to them, within reason.
• Breast-fed babies should continue to be breast-fed.

CONTACT A DOCTOR, IF:

• A child younger than 1 year has vomiting and/or diarrhoea for longer than a few hours
• Vomiting, diarrhoea, and/or abdominal pain in an adult or older child show little sign of easing after 24-48 hours
• There is blood or mucus in the stool
• Fever of 39°C (102°F) or higher
• Signs of dehydration (particularly in a child): listlessness, lethargy, dryness of the mouth, decrease in urination, crying without tears
• You are worried about the condition for any other reason

Other notes:

• If you are taking antacids or other ulcer medication, you may be more susceptible to diarrhoea
• Women taking the oral contraceptive pill should be aware that diarrhoea and vomiting can reduce the effectiveness of this method

AIR POLLUTION

Due to Ankara's valley location, air pollution is a concern, especially during the winter. On days when the air quality seems particularly bad, limit or avoid outdoor exercise. The air is very dry so the use of humidifiers is recommended. Empty the reservoir daily and refill with clean water. Follow the manufacturer's instructions for cleaning the apparatus - otherwise it will begin to spew bacteria-laden mist into your room!

An additional source of air pollution is second hand smoke from cigarettes. Ask for smoke-free areas in restaurants and other public places - if only to raise awareness of this important health issue.

TRAFFIC

There are obvious traffic hazards in Turkey, with a very high rate of accidents. Expatriates should know that traffic accidents are one of the most serious risks to their health and safety in Turkey. Take extra care on highways outside the city. If you are in an accident you should not move your car but get yourself off the road and seek help.

It is safer to be in the front of a taxi with a seatbelt than the back without. Arsan taxi service, near to the BESG, usually provides rear seatbelts while other taxis tend to leave them trapped under the rear seats, rendering them unusable. Arsan taxi service no is 426 1010. It is very important that children wear seatbelts with the relevant car seat at all times, even if sitting in the back of the car.

In all but the most minor accident, the possibility of cervical spine injury should be borne in mind. If there is any question of a head, neck or spine injury, the victim should not be moved unless absolutely necessary until the ambulance service arrives. Neck or spinal injury should be suspected in all unconscious victims and also in any conscious victim complaining of neck pain or stiffness, direct injury to the spine, weakness, numbness or tingling in the extremities. Even if they are walking around unaided, they should be considered at high risk of cervical spine injury and should see a doctor immediately.

HEAT
The summer months in Ankara are hot and dry. Be very cautious during the summer months to prevent heat stroke dehydration and sunburn. Maintain adequate hydration, avoid the sun between 11am and 3pm, use a high factor sunscreen (but not in order to spend longer in the sun), wear a hat and use other protective measures to decrease your exposure to the sun. The Nurse has additional information on minimising sun risk. All pupils at the BESG are required to wear sun hats when playing in the sun and sun safety is an important part of our PSHE education.

HOME SAFETY

Balconies and stairways do not always have adequate safe-guards and lifts do not always have internal safety doors so take great care of yourself and children in lifts. Serious injury due to clothing or fingers being caught in lifts has been reported.

POISONING

Prevention is the key: keep household cleaning substances and other domestic chemicals and medicines out of children's reach and sight. Be sure your childminder knows what to do in the event of a child swallowing a poison. Medical advice should be sought IMMEDIATELY:

• Note what was taken, when it was taken and how much was taken
• If the situation appears critical, take the child immediately to the emergency department of the nearest recommended hospital
• If the situation does not appear critical, there are several options for advice

• Telephone the POISON ADVICE CENTRE - Ankara 433 7001 or 0800 314 7900/1/2/3. 24-hour advice service in English and Turkish - wait for an operator to answer.
• Telephone your health provider

Depending on the substance ingested, induced vomiting may be necessary or it may be dangerous. Act on medical advice.

If you need to take the child to hospital, take the original container with the offending substance along to aid identification.

RABIES

Rabies is almost invariably a fatal disease. Although there is a very low risk in Ankara, it is present in Turkey and must always be considered if scratched or bitten. There are many stray dogs and cats in Turkey and reports of bites are not uncommon. Keep away from them!

Immunisation: pre-exposure immunisation provides a high level of protection but does NOT eliminate the need for additional vaccination after a bite.  However, it does make it less likely that you would need immunoglobulin treatment (see below).  Pre-exposure rabies vaccination is available. If scratched or bitten:

• Immediately wash the wound with copious amounts of soap and water
  (VERY IMPORTANT)
• Have animal detained if possible for veterinary examination
• Phone your health provider immediately
• or go to the Rabies Vaccination Centre ( Kuduz Asisi Istasyonu)
• Ankara Egitim ve Arastirma Hospital (Ankara Hastanesi) - Cebeci, Ankara.
  Tel: 595 3000 or direct no is 5953503 or 04
  Go to the Acil (A&E) entrance, then check in at Bilgi Islemler which is directly in front of the door, then go to the rabies centre KUDUZ ISTASYONU by exiting through the main door and turning left and you will see immediately another entrance, proceed through here. Most doctors speak English but it may be helpful to take a Turkish speaker with you if you can.
  THIS IS THE ONLY APPROVED RABIES CENTRE IN ANKARA

The risk of rabies will be assessed and action taken according to:

• Severity of wound
• Species of animal
• What precipitated the attack
• Rabies prevalence in the area
• Current rabies and tetanus immunisation status

If you have not previously had rabies vaccination there is a possibility that you might need anti-rabies immunoglobulin, which is currently in short supply throughout the world. It is therefore essential that you seek advice if you are ever in such a situation

HIV/AIDS & HEPATITIS

HIV, AIDS and blood-borne forms of hepatitis (B&C) prevention :

• Avoid unsafe sexual practices and other high-risk behaviours.
• Avoid getting a tattoo.
• Ensure that you consult approved medical facilities
• If you go for a manicure or pedicure, check that all implements used are sterile, single-use disposable or (less satisfactory) that reusable implements are sterilised. These procedures can draw blood!
• Never share toothbrushes or razors
• Always wear gloves when handling blood and body fluids - for example, if you have to administer first aid.

If you feel you have put yourself at risk of HIV infection, the hospital dealing with HIV infection and centre for post-exposure prophylaxis (PEP) and other treatment is Haceteppe University Hospital Infectious Disease Department, Sihhiye, open 9.00am to 4.00pm, closed from 12 noon to 1.00pm. There is a good chance of finding an English-speaking doctor there.

A safe and effective vaccine against hepatitis B is available and is strongly recommended.

BLOOD SUPPLY

All blood donated in Turkey via the Red Crescent is screened for diseases. Hospitals may take blood from donors accompanying the patient if requested and screen it themselves. Quality control in small hospitals up-country is unclear. You should get in urgent touch with your own health provider in any situation where a blood transfusion is being advised.

DOMESTIC EMPLOYEES' HEALTH

Household employees who care for your children in any country should be supervised to ensure that they meet the standards of hygiene and food preparation you expect and that they have some knowledge of first aid and what to do in an emergency. You should be aware that there is a higher rate of tuberculosis, hepatitis B and other infectious diseases in Turkey than in some parts of western Europe. You may wish to arrange a pre-employment physical check-up which might include chest x-ray, clarification of immunisation status (especially Hepatitis B) and vaccination if necessary.

IMMUNISATIONS

The BESG will help you keep your child’s vaccinations up to date.  You are required to submit your medical clearance forms with your vaccination booklet on arrival so that the Nurse can keep a record of your vaccinations and when boosters are needed.  For children, additional immunisations to the routine childhood ones (see table below) may be needed for Turkey, depending on personal circumstances.

Vaccines in bold are recommended for all children regardless of travel.

The Nurse is happy to give fuller information on particular infectious diseases, risks and benefits of immunisation and any other information you may require. Children at particular risk (due to certain chronic illness, or immune-compromised) may be advised to have vaccination against influenza and/or pneumococcal pneumonia.

CHILDHOOD IMMUNIZATION SCHEDULE

The UK Department of Health recommendations for childhood immunisation, along with detailed FAQs and other authoritative resources, can be accessed at www.immunisation.org.uk. Other countries may have a slightly different immunisation schedule. The nurse is happy to discuss these differences and any general immunisation matters.

Please keep these numbers readily accessible at all times.

DISCLAIMER

BESG tries to ensure that all hospitals on the list are registered and suitable However, neither the BESG nor the British Embassy Ankara can accept any legal liability in this regard. Any complaint about a particular practitioner or hospital should be made to the Nurse, who will consider whether that person should remain on the list. Feedback following consultations is welcome - it helps the Nurse evaluate specialists.

EMERGENCIES

Department (Turkish: Acil). The hospital recommended is Guven Hospital, as it is nearest the school. MESA and Bayindir Hospitals can be used if you are in the Sogutozu area (next to the Konya highway). These hospitals have 24-hour paediatric cover.

MED LINE AMBULANCE SERVICE 444 1212.

They will take you to any hospital you wish and will charge the hospital that will bill you later.  This number can be dialled from anywhere in Turkey without having to use city code numbers.

HOSPITALS

Guven Hospital

Simsek Sok. - Kavaklidere
Tel: Switchboard 457 2525, Emergency Doctors Room 457 2500 (press 1 for ambulance or emergency service)

Please ask for Nahile hanim from the VIP&Foreign patients dept. if you require specific help with language or other matters.

MESA Hospital

Sogutozu (next to Armada shopping centre)
Tel: 292 9900 Press 1 for ambulance

Please ask for Seza Imamoglu from the Foreign Patients dept. for specific help with language or other matters.

Bayindir DAY Hospital (no in-patient beds)

Ataturk Blv 201 (almost opposite German Embassy) - Kavaklidere
Tel: 428 0808

Bayindir Main Hospital

Kizil irmak Mah 28 Sok No 2

Sogutozu ( it is just at the junction of Eskisehir and Konya road junction almost opposite Armada shopping centre. Its location is well known)

Tel: 287 9000 (press 2 for ambulance service and 3 for emergency dept. after call answered)

Haceteppe Children's Hospital

Sihhiye, Ankara Tel: 311 4963

This should be used only for major trauma or surgery as it is a state university hospital and difficult to access for minor issues. The school nurse may be able to help with establishing a specific contact there.

Ankara Hastanesi

Cebeci Tel: 595 3000

For rabies related cases only, this is the only official centre. Turkish speaker preferable and should call your physician for assistance if necessary.

Adli Tip Kurumu

Sihhiye Tel 319 31

This is the only facility dealing with rape or other medical/legal cases where a medical report can be used in court. Access for non-Turkish speakers is difficult. It is essential that an appropriate person is contacted in such a case. Post-exposure prophylaxis with anti-retroviral drugs may be required to minimise the risk of HIV infection.

PHARMACIES

There are many pharmacies in the Embassy area. Some will deliver for the price of the taxi fare. A particularly helpful one is SIMSEK ECZANESI, Simsek Sok, tel 467 8685 (ask for Beyhan Hanim).

Be aware that many powerful drugs and antibiotics are available over the counter in Turkey. If the pharmacist leaves an assistant in charge you may receive advice from an unqualified person. It is strongly recommended that you seek advice from your health provider for any medicines you require, as there have been cases of wrong advice being given, even by pharmacists. This especially applies to antibiotics which are frequently bought and used inappropriately, placing the patient and community at further risk. (Inappropriate antibiotic use is one reason for the rising incidence of antibiotic resistance in the Eastern Mediterranean. Antibiotic resistance is becoming a global threat.)

MEDICAL PRACTITIONERS

In Turkey, family practice is not a well developed speciality. Thus most people will directly visit the specialist of their choice in the private sector. In Turkey, a General Practitioner (GP) is a doctor who has completed their basic medical training while in the UK a GP is a doctor who has a specialist qualification in family practice. In Turkey, a GP as accepted in the UK would be called a family practice specialist and there are a small number of these in Ankara. In practice, most Turkish children in our community are seen and monitored by a paediatrician in the community.

The nurse is happy to discuss and help with referral to local doctors, although parents are reminded again that neither the BESG nor British Embassy Ankara accept any liability for the quality of services provided. Any feedback about specialists or hospitals is welcomed by the nurse, however.