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Zikamania

January 19th, 2016 · Comments Off · Uncategorized

Every year or two a disease outbreak pops up that lights up our telephones. This week, it is the emergence of Zika virus in countries in South and Central America, Mexico and the Caribbean.

Rather than overwhelm you with details, let me give your five reputable websites so you can do your own research. Zika virus tends to cause a milder illness (fever, aches and pains, weakness, a rash, red eyes) than its cousins, dengue fever and Chikungunya virus. They are all transmitted by the Aedes mosquito, which prefers to bite during daytime hours.

For years we have been recommending personal protective measures against mosquitos – DEET containing repellents (there are alternatives) and clothing for travellers going anywhere in the tropics, so Zika should not present an alarming threat to travellers. While there is a new vaccine against dengue fever (not yet available here), there are no vaccines against Chikungunya or Zika virus.

The heightened concern, however, is that the Brasilians have noticed a marked increase of microcephaly (an abnormally small head), in children born of mothers who might have had Zika virus. So there is a suspected, though not proven, association between the virus and microcephaly.

What should travellers to these areas do?

If you are not pregnant, have a good time and use personal protective measures against mosquitoes.

If you are pregnant, consider not travelling to these areas.

And .. if you might be pregnant, or hope to get pregnant, you have two choices – postpone your trip …or go and  be religious about your insect precautions.

Here are the five reputable websites for you:

Public Health Agency of Canada

Centers for Disease Control (US)

World Health Organization

Pan American Health Organization

Society of Obstetricians and Gynecologists of Canada

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The telephone and me

January 8th, 2016 · Comments Off · Uncategorized

On March 10, 1876, Alexander Graham Bell made the first telephone call (albeit to the next room) to his assistant Thomas Watson. The first words spoken were ” Mr. Watson …come here. I want you“. We have come a long way since then. We can call from our cell phone (even better than Maxwell Smart’s shoe phone), and on the receiving end, we have such tools as call display, multiple lines, answering machines and headsets. And then there is e-mail!

Rather than hearing Alexander’s voice on the other end, you will probably be greeted by “Your call is important to us. If you know the extension of the person you are trying to reach, dial 1. If this is a medical emergency, proceed to the nearest emergency department.”

In all seriousness, my clinic and I give a lot of guidance, and advice, over the phone. Many travellers who call would like to get all of the information over the phone. “We are going to India for a month. What shots do we need?” It saves them the dreaded trip, perhaps with kids, into my office. The traffic is not to be underestimated in Toronto these days. It also saves them the cost of my professional advice!

As mentioned, we do guide, more than most clinics, over the phone. My staff, who have been with me for years, know travel medicine as well as I do. They diplomatically use phrases such as:

  • Dr. Wise might recommend this
  • Dr. Wise usually suggests this
  • it depends upon what shots you have had before
  • how soon are you leaving
  • are you climbing Mount Kilimanjaro
  • you should probably sit down with Dr. Wise and he will explain everything and answer your questions
  • it may cost this
  • there may be other issues, like malaria, dengue, safe sex, motor vehicle accidents, traveller’s diarrhea, and the fact that your medical history is as thick as Gone With The Wind
  • you could check out his website, and CDC and  the Public Health Agency of Canada.
  • and when push comes to shove, “Can I please put you on hold!”
  • feel free to call back and make an appointment

They DO NOT use the phrase “ Don’t worry. You don’t need anything. Have a nice trip.” While “What shots do I need?” is an important question, it is usually not the sole or most important information that you need. And, the answer to that question depends upon many factors, such as your destination(s), the duration of your trip, the “style” of your trip, your departure date, your past immunization history, your risk tolerance and your budget.

The downside or pitfalls of telephone advice include:

  • I do not get a full picture of your trip or medical history or particular concerns
  • you just seek advice regarding “the shots” and not the numerous other issues that are at least or more important
  • there is usually no record of your conversation if you are not seen in person
  • in spite of perhaps not needing any shots, you succumb to malaria or dengue  fever or Montezuma’s Revenge or motion sickness or altitude sickness or contract rabies or HIV or fall off your motorbike, or all of the above
  • you will feel badly if you get sick from something about which you weren’t aware
  • I might feel badly, and even liable, if I didn’t get the opportunity to advise you properly, in person, and document my advice
  • I, and all travel medicine professionals, enjoy and earn their living by providing up to date, appropriate travel medical advice … which in my opinion, can’t be given over the phone!

My tan, from Cuba, is slowly fading. I am now reading Red Heat. Conspiracy, Murder and The Cold War in the Caribbean. You might find it interesting. Today’s Globe and Mail also has a great column about modern day Cuba by Stephanie Nolen.

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Fidel and me

December 31st, 2015 · Comments Off · Uncategorized

Not much beats enjoying Cuba while watching your grandchildren swim, build sandcastles, learn salsa, snorkel and sail the turquoise ocean on a catamaran. Playing crazy 8s in the lobby bar and practicing on their Baby Grand also hit the spot. We stayed at the Pestana Resort in Cayo Coco. It was a twenty minute, not two hour, transfer from the local airport.

When I started to travel in my twenties, or in the seventies, I backpacked on less than 5 dollars a day. That was South America, which has been followed by most parts of the world for work and/or pleasure. I have done many of the same adventurous trips as my patients, and lived vicariously through countless others. This recent trip was the favourite of thousands of Canadians, an all inclusive family holiday to the Caribbean. I have been to Cuba three times before, and would keep going back.

So what did I learn as a travel medicine “expert”. The following are a few of my observations and my advice.

  • take bandaids – blisters from wet sandals and abrasions from rocks are common.
  • get immunized against hepatitis A, and consider hepatitis B vaccine. We didn’t require local medical care, but in spite of what Fidel claims, I would not be keen on too much of it. You may be at a resort literally in the middle of nowhere – go prepared – bandaids (as previously mentioned) Tylenol or Advil, Polysporin, Gravol, baby powder, antibiotics and Imodium for diarrhea.Whatever you have in your medicine cabinet at home belongs in your suitcase when you travel.
  • don’t skimp on your travel medical insurance. I learned that if you are over 65, your typical “credit card” coverage may be less than adequate
  •  consider using insect repellent – I got about 12 bites, about 12 more than everyone else. I am still  waiting for my dengue fever or Chikungunya to strike.
  • two out of six of us got sick, with vomiting and/or diarrhea. That is a 33% attack rate. This was not a double blind placebo controlled trial, so I am not sure if it reflects the reality of the other 994 people in the resort. The infirmary did not seem packed with dehydrated poopers. We did not take Dukoral in advance. I would probably make the same decision again.
  • we avoided the tap water, including tooth brushing. Otherwise, as a family, we probably made contact with every food group available. I am not sure what made my daughter and granddaughter sick – luck of the draw perhaps.
  • Cuba is much more than all-inclusive vacations. Learn the history. Spend a few days in Havana. Go to a ball game. Visit Vinales.
  • the Cuban people whom I have met on all of my trips have been friendly and helpful. The same can be said about those I have met everywhere else I have travelled.
  • a lot of people have tattoos and are overweight (an observation, not advice).
  • everyone says “I must get to Cuba and Havana before the Americans get there”. Probably not a bad idea!
  • I saw no shortage of bright red backs. Presumably, some of these burnees were quite uncomfortable and possibly sick. Sunscreen, a hat and some shade are priceless.
  • freedom from phones (cell and land), e-mail and faxes is one of the many benefits of vacations.
  • being in the Caribbean at an all-inclusive resort with your family is a pleasure and a privilege. Getting there is not. Airports, parking, security, waiting, lineups, transfers, customs, turbulence, check-ins, the Canadian dollar … but a pleasure and a privilege! I see many people travelling abroad who spend more time in airports than at their destinations. Not sure if I will ever make it to Southeast Asia.

VIEW I hope to return to Cuba and travel again with three generations of my family. I hope you get to do the same.

 

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Cuba and me

December 18th, 2015 · Comments Off · Uncategorized

Many of my friends and patients say “I need to get to Cuba before the Americans ruin it”. In that spirit, though I am not so pessimistic about future American influence, I am returning to Cuba next week. This will be my fourth trip there. Twice, I have been to Havana and close by beaches and Vinales, and once to Granada on the south coast. This time, I will be taking along my children Carrie and Adam, and my grandchildren Hannah (7) and Isaac (5). While I doubt that I can legitimately deduct the vacation as a business expense, I am certain that I will learn a lot that is applicable to my travel patients and my practice. Just to name a few issues that we have or may have to deal with:

  • hepatitis A vaccine for those not previously immunized
  • how careful do we have to be with Cuban food and water
  • better take some Imodium and antibiotics for bad diarrhea like Cipro and Zithromax
  • we didn’t take Dukoral
  • there is no malaria, but potentially dengue and Chikungunya, so lots of insect repellent
  • a fair skinned family and sunscreen
  • no jet lag, just tired from a long day of airports, flights and transfers
  • we will avoid motorbikes, alcohol, unsafe sex and diving into unsafe waters
  • the culture shock should be tolerable
  • medical insurance gets a bit more complex as one gets older
  • withdrawal (with pleasure) from my fax, phone and e-mail
  • which books should I take to read

So with all that in mind, I look forward to a lovely vacation. I wish all of you a happy holiday season and a healthy 2016. Mark

By the way, this past week’s Globe and Mail has a fascinating story about the plight, and opportunities for Cuban baseball players.

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Anthony and me

October 27th, 2015 · Comments Off · Uncategorized

In my more than 30 years of practising travel medicine, I have had more than my share of celebrities pass through my office and receive my advice. These have included professional athletes, politicians, philanthropists, musicians, ex-wives of Rolling Stones, writers and journalists, business legends and many more. Some of their pictures grace my walls, and their autographed books sit on my bookshelf. Unfortunately I can’t divulge their names, as it is confidential.

Speaking of confidential, perhaps you have read Kitchen Confidential, by Anthony Bourdain. Even better, maybe you watch his weekly show on CNN, Anthony Bourdain: Parts Unknown. It is a delightful and fascinating combination of travel, food, history, politics, wine and people. Last Sunday he was in Ethiopia, and his season opener was in Cuba. If somehow I could convince him to come to see me for pre-travel advice, it would make my day.

Considering that is unlikely to happen, what follows is a totally fabricated transcript of an excerpt from his recent mythical appointment!

Anthony: Nice office you have Doc. Where’d you get all this shit? (masks, photos and other stuff).

Me: Call me Mark!

Anthony: OK, and call me Tony.

Me: It’s a combination …a lot collected on my travels …. and a lot has been generously brought to me by my patients. Everyone wants my elephants. Don’t know what I am going to do with it all when I retire.

Tony: I know what you mean. I’ve got the same problem. Listen Mark, enough chat. I came to you cause if I get Delhi Belly or the Cuban Cruds or whatever you wanna call it one more time, CNN said they would have to cancel my show. How can I avoid shitting my brains out every time I go somewhere other than Luxembourg?

Me: Gotcha. I suppose you’ve heard the phrase “Be careful with what you eat and drink“, better known as “Boil it, bottle it, peel it, cook it …or forget it.”

Tony: Sure I’ve heard it a zillion times. Works in Luxembourg but not in the rural village in Ethiopia where you are visiting your host’s 90 year old parents for dinner. I do try to stick to what looks cooked, though I don’t always recognize what it is they are cooking. My crew brings along cases of bottled water, Coke and beer. Are they OK?

Me: Probably, though counterfeit bottled water, just like antimalarial pills, is not unheard of in many parts of the world.

Tony: What’s this Dulcolax stuff that some of my Canadian crew takes for the runs?

Me: Dulcolax is to make you poop. You are thinking of Dukoral. It’s  an oral vaccine against E. coli, a common bacteria that causes traveller’s diarrhea (TD). It also helps prevent cholera, though that thankfully is rarely a concern for most travellers. You might manage to be an exception! Did you catch a ball game in Havana?

Tony: No time. Tight schedule. Does the Duk-whatever stuff work?

Me: Yes, but not really that well. It lowers your overall risk of getting TD, from all causes, by abut 25%. Remember, that for many, perhaps not you, that risk might be pretty low to start with. So while I mention it to every traveller, I don’t highly recommend it. If someone has underlying health problems, say diabetes or kidney disease, or just can’t afford to get sick, it may make sense. Not cheap … more than 100 bucks!

Tony: By the way, your Blue Jays had a helluva run. Bautista, Pillar, Tulo …what a great bunch of guys. Next question … I hear that Imodium is bad for you, that it’s better for the little bugs to get out of your system. Whaddya think?

Me: Ya know, I think it’s OK in small amounts (the Imodium, not your stools), say just one or two pills. It will usually bail you out, with the small risk that you won’t shit again for a few weeks! Just kidding. Personally I avoid it. I prefer the antibiotic option, based on the fact that most cases of TD are caused by a bacteria (E. coli, Salmonella, Shigella, Campylobacter). If I so much as fart in the tropics … I’m exaggerating … if I get loose and crampy I will reach for a quick, and brief (1-3 days) course of an antibiotic, such as Cipro (ciprofloxacin) or Zithromax (azithromycin). In a particularly bad situation … shitting my brains out while on an eight hour bus ride in Bolivia, I might use both! In the States they have an antibiotic called Xifaxim (rifaximin), which can also be used to treat mild TD. You have a politician with bad verbal diarrhea there … not sure what to do about him.

Tony: Anything else I can do or take before I go away to the middle of nowhere? Did you see my trip to the Congo? We all got sick as dogs. Maybe that’s what made us sick in the first place. The stench. Oy vay!

Me: There a few things, like Pepto Bismol, probiotics, and something new …bovine colostrum (Travelan) if cowstuff turns you on, but I think that being careful and having an appropriate antibiotic are the keys. Some people say a daily glass of scotch or vodka will keep you diarrhea free. Have you thought of that? Just kidding. Gees you must get heartburn every night you are on the road. Take something for your stomach?

Tony: You shoulda seen me drink twenty years ago. Yes I take Tecta (pantaprazole) or Dexilant (dexlansoprazole). My doc gives me samples.. Haven’t had heartburn since I started it. Too bad it doesn’t prevent the hangover! Korea … now that was a challenge!

Me: By the way Tony, how do you manage to have clean white shirts wherever you go. Do you travel light? Carry-on? I suppose you could get your laundry done locally.

Tony: I wash them in my hotel sink and they’re wrinkle free. I carry three on each trip. You must have seen how good I look in a T – shirt too!

Me: Yes, you do look fit. Did they tell you that you become seven years younger when you’re in Ethiopia? Do you play squash? Anyways, Tony, it’s been great imagining that you were in my office. I know that I and millions of others live vicariously through you. Let me know if you are ever in Toronto. I’d love to meet you and put you on my wall.

Tony: My pleasure Mark. I will let you know if we need a travel doc on the road. What’s your e-mail?

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Hillary and Me

September 20th, 2015 · Comments Off · Uncategorized

me benny poon hill

Another weekend, another movie. Now that I qualify for seniors’ discounts, I can’t afford not to go! Everest! This 3-D epic documents the disaster that took place on the world’s highest mountain back in 1996. There have been other disasters since, some “man-made”, some caused by nature, and often an unfortunate combination of the two.

I went to Nepal with my son Benjamin in 2001. We trekked along the Annapurna Circuit and had a wonderful time. We also took “the flight over Everest”, which while not as treacherous as climbing Everest, does entail some risk. A few months later, nine members of the royal family were killed by a disgruntled relative. Tourism suffered for a few years after that tragedy, as it undoubtedly has again following April’s deadly earthquake.

I have been fortunate enough to meet Sir Edmund Hillary on a few occasions when he would visit Toronto on behalf of The Sir Edmund Hillary Foundation. Please visit their website to learn about the important work they support. His presentations were spellbinding – no script, just speaking from his heart. That was in the days of slides … before Powerpoint! Through good luck or a good eye, I have managed to amass a modest collection of Hillary and Everest memorabilia. Rather than reviewing the movie – there are many reviews to read online – I wanted to share with you some of my “stuff” – books, magazines, autographs, plates, T-shirts, trading cards and personal photos. I am aware that Hillary and Tenzing Norgay conquered Everest in 1953, so I imagine that many of my readers will be less than familiar with their amazing accomplishment.  

For some important information on altitude sickness, please visit my blog and the website of The CIWEC Clinic in Kathmandu.

While climbing Everest may not be on your bucket list, visiting Nepal should be. Enjoy! Mark

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Redford and Me

September 11th, 2015 · Comments Off · Uncategorized

In May 1970, I went on a canoe trip with friends in Algonquin Park. It snowed on us that first night on Burnt Island Lake. Being totally unprepared for such inclement weather, we spent the rest of the weekend at The Holiday Inn at Hidden Valley near Huntsville. One of our evenings, I, Elliott and Grant spent at the small theatre watching Butch Cassidy and The Sundance Kid, starring Paul Newman and Robert Redford. The movie changed my life. I suspect many of you reading this blog either missed that movie, or were born a few years later. To make a long story short …Butch and Sundance went to Bolivia to rob banks. So did I, a few years later while in medical school, and the trip influenced my decision to pursue studies in Tropical Medicine. What happened to the health of those in poorer countries concerned me and interested me. I did not rob banks, though I do recall making use of the “black market”. Fast forward to today, when I went to another movie, A Walk in the Woods, starring Nick Nolte and again, my idol Robert Redford. It  is based on the book of the same name by well known writer Bill Bryson. The movie is about hiking, this time the Appalachian Trail, a 2,200mile path stretching from Georgia to Maine. The movie is also about getting older, reconnecting with friends, finding happiness, being realistic, and hanging your food in a tree at night to avoid attracting bears. This is the first “hiking movie” I have seen since suffering through Martin Sheen schlepping along the Camino de Santiago in memory of his son a few years ago. I have been camping since the age of ten. I have at least twenty trips to Algonquin Park under my belt. Most of these involved “portages” rather than hikes, though a hike to The Synagogue of The Great White North on Joe Lake has been a regular highlight of many of these trips. When I went to Peru in 1973, as a prelude to Bolivia, we were not aware of The Inca Trail. This was due to the lack of guidebooks and internet at the time. Instead, we rode the “Indian train” to Aguas Calientes, and hiked up from there. This in itself was quite an experience, as most tourists now travel in a glass-topped train with a view and Chilean wine. I “trekked” the Annapurna Circuit with my son Benjamin back in 2002. I truly wish more people were doing the same now. I am not sure of the difference between hiking and “trekking”, though doing anything above 10,000 feet can be much more difficult. My joy was resting in the tea houses and eating unlimited quantities of dal bhat.

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Butch Cassidy and The Sundance Kid gave new meaning to the term “meaningless banter”, including such memorable phrases as “Boy, I got vision, and the rest of the world wears bifocals” (Butch), “Who are those guys” (Butch) and “You just keep thinkin’, Butch. That’s what you’re good at.” (Sundance). I don’t recall many memorable lines from A Walk in the Woods, and I only walked out of the movie an hour ago. Perhaps time will tell. There was no shortage of fuckin’ this and fuckin’ that, with Nick Nolte aka Stephen Katz getting in the majority of the four letter words. Strange, Butch and Sundance never uttered a swear word even though they had the entire Bolivian army firing at them. There was one moment in Walk in the Woods, with the two hikers trapped on a high rocky ledge, where Bill turned to Stephen and said, I think, “We’re fucked!” It was hauntingly reminiscent of when Butch and Sundance found themselves on an almost identical cliff. We are not made aware of their swimming prowess in the movie, unlike when Sundance (Redford) famously confessed “ I can’t swim!”.

Food! Certainly this is the essence of camping. After a long day of climbing up and down and narrowly averting an ankle fracture, a good meal is in order. The only time we saw Nick and Bob eating was in motels and inns. I must admit that two or three of my “camping trips” have been spent at Arowhon Pines, a Michelin rated, though rustic resort in Algonquin Park. Singapore grouper, exotic pastries (gluten free) and pate (with an accent) were the order of the day.On my most recent solo trip to Silent Lake Park, my all inclusive menu consisted of bagels with peanut butter and jam, salami and cheese, steak, reheated buttered chicken from the Copper Chimney on Avenue Road, hot chocolate, red wine and gorp.

I practice both family and travel medicine.I see patients of all ages with every conceivable medical problem travelling to every conceivable destination for every imaginable reason. Travellers’ willingness to put up with discomfort, limited leg room and customs constantly amazes me. Recently, I spent thirty dollars on a foam bed rest. It did not enhance my sleeping experience at all. Napping, though not sleeping, is one of my joys of camping.

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While Robert Redford may look like a million dollars, minus the wrinkles, Nick Nolte (Steve) does not look great.  I have not been privy to his medical records, and excuse me for my assumptions,  but he looks hypertensive, diabetic and may be harbouring a stent or two. He has one prosthetic knee, the other knee likely being deserving of the same. He is overweight. He should be admired for dealing with his alcoholism. But, I find it hard to believe that he hiked as far as he did.

Fortunately, we have never encountered a bear while in the woods, though Kenny and I never lacked for irritating raccoons. Having said that, our first order of business when arriving at a campsite, almost like a religious ritual, is finding a place to hang the food pack at night. This is not always as easy as it sounds, perhaps because of the preceding gin and tonic, but is well worth the effort. Regardless, I think that Bob and Nick ( Bill and Stephen) reacted quite admirably when approached by not just one bear, but two.

All in all, an entertaining and enjoyable movie that allowed me to reminisce about my past, and contemplate the future.

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Catching up!

August 29th, 2015 · Comments Off · Uncategorized

Writing a regular blog is a bit like sticking to a diet or going to the gym. We all start with the best of intentions, but following through is often a problem. My end of the summer goal is to write something of relative value at least every fortnight, also known as every two weeks.

As so often happens, the popularity of the various tourist destinations fluctuates with nature and politics. I have seen perhaps two travellers going to Egypt in the past year. Once one of the most diarrheal of destinations, it may be a little while before tourists start to trust Egypt, let alone the food on the cruises down the Nile. Certainly, Canadian journalists are wary.

Nepal, which I visited with my son Benjamin in 1999, has been the victim of almost regular disasters, both man (woman) made and otherwise. April 2015’s deadly earthquake and avalanche on Everest, as well as past political instability and less than enviable aviation mishaps continue to put a damper on tourism to this magnificent country.

A deadly bomb recently exploded in the middle of Bangkok. Something about Thailand … it seems to take a lot more than a bomb or a tsunami to discourage tourists from visiting.

Perhaps Peru, which for a long time was out of favour due to The Shining Path, is the most popular destination these days. I was there in 1973, at a time when one didn’t know about the Inca Trail, but also when you could sleep on the terraces of Machu Picchu without worry of being evicted and jailed.

Personally, my travel this year has been domestic. Ottawa, Quebec City, Kingston, Peterborough, Apsley and Silent Lake Provincial Park. Many people ask me “What is your favourite place?”. I have had many – Ghana, Guatemala, Cuba, Nepal – but give me a campsite, a fireplace, some salami and peanut butter, a beach and some hiking trails, and I am as happy as a lark. No time zones, security or exchange rates! DSC_0596

We are entering the rainy season in our hemisphere. Time will tell whether viral infections such as  dengue fever and Chikungunya virus will be prevalent again this season. By word of mouth, it seems that malaria in Punta Cana might be occurring more frequently. West Nile Virus, another mosquito borne infection, is once again being reported in our own backyards.

Travel medicine advice is now becoming ubiquitous. The only people not dispensing it are the staff at Tim Hortons. In my next post, I will talk about where you should be getting your advice … and why.

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When the dog bites!

March 15th, 2015 · Comments Off · Uncategorized

Most of my patients abroad don’t call me when they get diarrhea. They do call when they get bitten by a dog, usually after calling their mother in a panic. In the past week, I have received two calls from bitten travellers. The following  is what every traveller needs to know about RABIES (you can read more on the CDC website. dog guate 2

  1. Rabies is a viral infection of the nervous system, which is transmitted through the saliva (AKA bite) of a dog, and other furry animals, including cats, monkeys and bats. The virus travels via the nerve from the site of the bite up to the brain.
  2. If one develops symptoms of rabies, which is thankfully rare, you will probably die.
  3. I don’t usually go into the symptoms of rabies, as if you have them, it is a bit late to be on Google.
  4. Rabies is almost 100% preventable.
  5. DON’T PLAY WITH DOGS, OR OTHER FURRY ANIMALS. Not everyone who gets bitten has provoked the animal, but still, when you travel, humour me and avoid dogs.
  6. Most of today’s travellers have not seen the Walt Disney classic Old Yeller. Old Yeller did not look too good when he developed rabies. But, the bottom line is that you really can’t tell a rabid dog from a non-rabid dog, especially when that stray dog has run away after biting you.
  7. The most important thing to do if you get bitten is to thoroughly wash the wound for 20 minutes with soap and water and preferably an antiseptic. Then, you go for medical care… hopefully good medical care. While good medical care may be available, the proper rabies vaccine often isn’t.
  8. You can be vaccinated against rabies before you leave on your trip. This involves 3 doses of vaccine given over 3 weeks (days 0 – 7 – 21) at a cost of at least $600, and much more in the USA. For that reason, most travellers go without “pre-exposure vaccination”. If you are longer term traveller, or might be in a spot where decent medical care isn’t quickly available, or if you have some “dog-friendly children” you might consider getting vaccinated. If you have medical insurance to pay for the vaccine, that is certainly a bonus. If you will be staying in a country such as Thailand for an extended time, you could consider getting the vaccine locally for a fraction of our cost.
  9. If you have received pre-exposure vaccine (which is probably good for life) and get bitten, you still need to wash the wound and seek good medical care and get two further doses of rabies vaccine on days 0 and 3.
  10. If you have not received pre-exposure vaccine, then the standard of care would be to wash the wound, get good medical care, and then receive RABIES IMMUNE GLOBULIN (RIG) (which should in fact be injected right into the wound as much as possible) followed by 4 doses of rabies vaccine, on days 0 – 3 – 7  – 14. Travel medical insurance (please don’t travel without it) will usually cover the cost of rabies vaccine, but you will probably have to pay the cost up front. There are at least 4 different brands of rabies vaccine – they are all effective and interchangeable.
  11. Rabies, and deaths from rabies, in travellers are thankfully exceedingly rare. If you follow the proper procedures whether or not you have received the pre-exposure vaccine, you should be fine. If you screw up – don’t wash it, don’t get proper vaccine and/or fail to get the RIG, you may not be fine.
  12. At the risk of offending someone, the most anxious people at the time of a dog bite are the parents of the bite-ee, and the doctor back home. Local medical professionals may (though not always) minimize the need for RIG and even vaccine. The bite-ee would often like to spend the week in Halong Bay before seeking out their vaccine in Bangkok.How long do I have until I am going to die?” is probably the most frequently asked question. My answer is “You always have time, though it might involve some travel, a disruption of your itinerary or even a premature return home.” In Canada, post exposure vaccination is available for free through the local public health department.
  13. It is usually somewhat difficult and stressful to access proper post-dogbite care. Cell phones, e-mail, Facetime and colleagues from the International Society of Travel Medicine (ISTM) make it easier.
  14. DON’T PLAY WITH DOGS AND OTHER FURRY ANIMALS!!!!!
  15. DON’T PLAY WITH DOGS AND OTHER FURRY ANIMALS!!!!!

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Viruses have gone viral!

February 22nd, 2015 · Comments Off · Uncategorized

It’s been a wonderful winter, that is, if you’re a virus. Especially if you are one that we thought we had gotten rid of, or never had in the first place.

Chikungunya virus, which I have written about before, made its first appearance in this hemisphere back in December 2013. Saint Maarten was the first country to report cases. Since that time, it has spread to just about every other Caribbean island, as well as most Central and South American countries. Chikungunya is rarely fatal, but always unpleasant … a high fever, a headache, a rash and arthritis that may last  several months. The Dominican Republic and Jamaica, two of Canadians’ favourite destinations, have been particularly hard  hit. People ask me “Is there a vaccine?” “No” I say.  “Use your insect repellent during the daytime which is when the Aedes mosquito bites.” “Can I eat the chicken?” “Yes you may … well cooked!” For a detailed treatise on insect precautions, go to PHAC’s website.

This is the nicest time of the year to visit India, and it is a popular destination for tourists and Indians returning home alike. The risk of malaria, which is also mosquito-borne is very low this time of year. However a patient phoned my office last week asking about a vaccine against swine flu. Now I know why.  India is experiencing an outbreak that began in December, and which has affected and infected thousands and killed hundreds. Is it a concern to travellers to India? I would think so. Do we have a vaccine? I am not sure whether the flu vaccines used in North America this season provide any protection against the H1N1 strain circulating in India at the moment. But assuming you have already had the vaccine (we all realize it is not perfect), it would be advisable to avoid sick people (not easy in a crowded country of a billion people), wash your hands, and seek medical attention should you become ill. Antivirals such as Tamiflu may be of benefit if taken early in the course of the illness. Should everyone going to India carry their own personal antiviral? It is an option … which I will ponder this week.

Ebola has largely disappeared from the news, but not at all from West Africa. I have had a few very courageous patients travel there for humanitarian work. Their e-mails describe how difficult it is to live in these countries, let alone trying to fight against or suffer from Ebola. Is there a vaccine against Ebola? Maybe!

And then there is measles! Measles is a totally (well almost) vaccine-preventable viral infection, which traditionally claims the lives of hundreds of thousands of children in lesser developing countries. Why? Poverty is the answer. So why are we getting it here? Stupidity, rather than poverty may be the answer. The majority of the cases reported so far have occurred in adults and children who were never vaccinated. A few of the cases were in people who only received one dose of vaccine (two are recommended). And disturbingly, two cases occurred in adults who had received two doses of vaccine.

As travel medicine providers, we are particularly concerned about babies (6-12 months) who no longer possess their maternal antibodies, and happen to be travelling (usually as a VFR – Visiting Friends and Relatives – aka grandparents!) in far off countries with measles outbreaks such as the Philippines, Vietnam … and Disneyland in California. These children should receive an “early” dose of the MMR (measles-mumps-rubella) vaccine. This still needs to be followed by the usual dose at 12 months and a booster by the age of 5. For more information on measles and the outbreak, visit Public Health Ontario. For some further insights into the “measles madness” read Andre Picard’s column in The Globe and Mail.

Aside from the aforementioned threats, it sure was a helluva a flu season. And The Leafs ….

On a cheerier note, if you are reading this and live in Toronto or nearby, consider spending a cold afternoon enjoying “high tea” at After Queen. It is located at 7355 Bayview Avenue in Thornhill, inside the “Longo’s plaza. Great teas, scones and ambiance!

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