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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.

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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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advertising, your bowels and your liver!

January 10th, 2015 · Comments Off · Uncategorized

Advertising is meant to inform people, to influence their decisions, and to make money for the company paying for the advertising! Travellers’ health needs are not immune (sort of a pun). I think that the advertisers’, or the manufacturers’ aims are to convince everyone going anywhere for any reason that they are at great risk, and that their products will be life or at least trip saving.

American Express – “don’t leave home without it”, or Imodium, is thankfully informing us of the dreaded bacterium, Campylobacter jejeuni. This food and water borne infection is indeed a significant cause of Traveller’s Diarrhea, especially the more severe episodes. I have had it, after too much salsa sauce in Nicaragua. It is not a lot of fun. Calling an English-speaking doctor in Manila or Cuzco might be a benefit. But I would suggest visiting your family doctor or a travel clinic prior to your tropical trip, so that you can not only learn about the ills of food and water borne disease – AKA Montezuma’s Revenge – before you travel, but also to obtain an appropriate antibiotic, such as azithromycin (Zithromax) or ciprofloxacin (Cipro), so that you can treat yourself without depending on the Amex doc! Having said that, it never hurts to carry your Amex card!

Dukoral, now distributed by Novartis, extols the dangers of travellers’ diarrhea through the use of humorous ads. I wish they would consult me about those ads. I have lots of experience! Dukoral provides pretty good protection against cholera, which thankfully is not a concern for 99% of travellers. It provides about 60-70% protection against Enterotoxigenic E. coli, which may cause about 50% of the travellers diarrhea out there, so that leaves us with a “risk reduction”, of about 25% (according to PHAC) for a pretty mild form of diarrhea which is quickly treatable with time or antibiotics, usually only with a single dose (see above), for a cost of about $100 (the Dukoral, that is). Many people are quite willing to pay that price, either because of the advertising, peer pressure, or the fact that they have drug plans which will pay for this mediocre protection.

Twinrix, sold by GSK,  in my opinion, has produced the most prolific and successful “travellers'” advertising. Countless people have received Twinrix, though they don’t know what it is for! Both hepatitis A and B are indeed a risk when travelling abroad. Hepatitis A is transmitted though food, water and food handlers. Hepatitis B is passed through blood (needles, tattoos, acupuncture, blood products (transfusions), and unprotected sex, with someone other than your traditional partner, and I suppose those dangerous spa tools, which I suggest you avoid. The risk for a sexually active and budget traveller going to the middle of nowhere for several months may be greater than for the couple married for 45 years taking a one week cruise with a ship doctor! Most young Canadians (born after 1978, at least in Ontario), have received hepatitis B vaccine in school, though many continue to receive the combined vaccine. Some travel health professionals recommend Twinrix for everyone … others are more selective. In the end, it is the traveller who decides what their “risk tolerance” is.

Vaccines and pills are popular, but remember that most travel related illness is preventable though common sense!

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year end 2014

December 20th, 2014 · Comments Off · Uncategorized

Well another year has passed for travel medicine and travel. Personally, I have been to Portugal, Apsley, Kingston, Winnipeg and Niagara on the Lake (stay at Demi’s Place). Not as far afield as in the past. I hope to return to all of these places … well perhaps not Winnipeg, where I saw the new Canadian Museum for Human Rights and enjoyed the buffet at The East Indian Trade Company, the forerunner of the restaurant which I have been to many times in Ottawa.

The world remains in a constant upheaval. The Ebola crisis in West Africa has certainly reduced the amount of travel to the affected countries, and I would assume to neighbouring countries such as Ghana and Nigeria. I have had two travelling patients go to Sierra Leone and Liberia, and thankfully come back healthy. Certainly Ebola is on the mind of almost anyone who goes to Africa, even to see the wildlife in far from the epidemic places such as Kenya and Tanzania, and South Africa, Botswana, Zimbabwe and Zambia. Egypt continues to be absent from most travellers’ itinerary. Nepal has had its usual disasters this year – avalanches and plane crashes. India seems very popular this year – a long way to go, but peaceful … perhaps. I always stress that one’s personal safety is the greatest priority for everyone, anywhere.

Yellow fever vaccine – whether to give it or not, continues to be the biggest “thorn” in the side for travel medicine professionals. The increased risk from this live vaccine in the elderly (over 60) has made us recalculate and rethink our recommendations for those two day visitors to Iguacu Falls and the Peruvian Amazon. More and more travellers are “complicated”! They have reached the moment where they have the time and money to take exotic trips, but they also have liver and bone marrow transplants, they are anticoagulated and immunosuppressed. Makes my job more challenging, as it does theirs. Much of the travel world has been “Twinrixed“, that is, immunized against hepatitis A and B. These vaccines are likely protective for life. The Public Health Agency of Canada, and CATMAT, published new guidelines for typhoid vaccine this year. It seems we are likely giving way more of the vaccine than is warranted. Most of it, they say, should be directed at travellers going to South Asia, that is India, Pakistan, Bangladesh, Sri Lanka, Nepal and the Maldives. I continue to recommend it for “higher risk” travellers to other destinations, based on their style and duration and purpose of travel.

The risk of malaria is falling in the tropical world. Sri Lanka is no longer considered to be a risk. In fact, aside from subSaharan Africa, the risk of malaria depends upon where within that country you are going. So, it takes a little bit more work for you and your doctor to figure out whether you really need to be on malaria prophylaxis. As well, many exposures, by virtue of their brevity (two nights in the Peruvian Amazon) or the time of year (New Delhi in January) present little or no risk, and the traveller who can accept “the little” can comfortably forego medication and just use personal protective measures. Malarone continues to be the antimalarial of choice. Unfortunate for some that it is so expensive. Hard to believe that I can buy two great date squares at Timothy’s for the price of one Malarone tablet!

Part of the attraction of studying tropical diseases was the joy of learning to pronounce them. Parasites like schistosomiasis, onchocerciasis, filariasis and trypanosomiasis are only a few of the mouthfuls we learned. This year, another one, this time a virus, was on the tips of many peoples tongues. That would be Chikungunya virus. It started in St. Maarten last December, and has now spread to most Caribbean islands and parts of Central and South America. Canadians craving the beaches of Jamaica and the Dominican Republic are having second thoughts, or at least taking along some insect repellent.

Dukoral, at least in Canada, continues to fly off the shelves. It is not cheap, nor that effective. At least a hundred bucks to provide about 25% (according to PHAC) protection against travellers’ diarrhea. Perhaps in the new year I will do my own study in travellers off to India, to see if it really makes a difference!

Personally, I am expecting my fourth grandchild in March. I finally managed to eke out a squash championship. And I am back studying the piano – songs like Over The Rainbow and Summertime. I continue to practice travel medicine as well as family practice. I wish you all a happy and healthy new year, and hope that you get the chance to travel and do everything else you dream of in the coming year.


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Frequently heard in travel clinics ….

November 16th, 2014 · Comments Off · Uncategorized

As mentioned in my last blog, I have been practicing travel medicine for more than 35 years. That’s a lot of travellers, trips, shots and Imodium! And while every traveller and their trip is unique, I do tend to hear some of the same “things” over and over again. The following are a few of them, along with my usual responses.

What’s the risk? Answering that question is one of the most important aspects of our job. Sometimes, the risk is low, very low, like the likelihood of getting Yellow Fever on your one day trip to Iguassu Falls. Japanese encephalitis is estimated to occur in 1 in a million visitors to Southeast Asia, though if you are the one sleeping out in the rice paddies from May to October, your risk might be a lot higher. Traveller’s Diarrhea, on the other hand, affects anywhere from 20 to 60% of tropical travellers, depending upon the destination (India is more diarrheal than Illinois). So I try to give my patients an idea of the risk, and some good ideas on how to eliminate or minimize the risk, and let them decide on what measures to take, be it a vaccine, a pill, a seatbelt or a condom!

What are the side effects? This applies to vaccines, antimalarials, antibiotics and other medications for conditions such as altitude sickness or jet lag. Everything has side effects … make that POTENTIAL side effects. Thankfully most side effects don’t happen to most people most of the time, and when they do, they are usually tolerable or self-limited. Having said that, travellers need to know that a Yellow Fever shot may in fact carry a higher risk than actually getting Yellow Fever for some travellers, or that ciprofloxacin, used for Traveller’s Diarrhea, may cause a ruptured tendon in 1 in 20,000 people. More commonly, it is just a matter of letting people know that they will be a little sore at the injection site for a day or two, and that their Diamox for altitude sickness will make them tinkle and tingle! Mefloquine, a less commonly used antimalarial these days, certainly deserves some discussion regarding its interesting neuropsychological side effects.

But my hotel has 5 stars!!! While I am very pleased for my patients who can afford hotels with numerous stars, it is rarely enough for me to feel confident or comfortable endorsing the local lassi in Nepal or the chicken caeser in Cambodia. You, and your bowels are only as safe as the quality of the food handler in the kitchen, who likely doesn’t live in the same 5 star hotel. So, everyone has their own risk tolerance, and some Imodium just in case. Malarious mosquitos probably can’t tell 5 stars from zero, though you may be safer in air-conditioned opulence rather than out under the stars.

Does it matter which arm I get the shot in? Usually not! There is probably room in most deltoid muscles to accommodate two intramuscular shots, though I generally prefer giving one in each arm. Many people have a preference depending upon which arm they use the most, but in answer to the question, vaccines do not come as “right or left handed”. As soon as the shots are done, the next round of questions is usually “Can I go the gym/have sex/have a drink/drive after the shot?” And the answer is usually “Yes, just not all at the same time.”

I have an iron stomach! We all do until we don’t!

What does it cost? This can be the most difficult part of the travel visit for both patients and the travel doctor or nurse. Many of the vaccines are quite expensive. Some require a series of two or three doses. There is the conception “that if you can afford the trip … then you can afford the vaccines”. Not always true. A family going to live in West Africa for six months might warrant yellow fever vaccine, hepatitis A and B (if not already immune), typhoid and meningococcal meningitis and rabies vaccine. VFRs (those Visiting Friends and Relatives) are the ones who are most frequently faced with an unaffordable situation. They will sometimes vaccinate their children rather than themselves, and often go without the recommended vaccines. We are the ones often in the position of helping them prioritize according to the cost of a vaccine, the likelihood of the illness and the severity of the infection.

What would you do? And the followup question is usually  “What if it was your daughter?” In this case I usually tell them … I wouldn’t bother with Dukoral/Yes, I think the Malarone is a good idea/ Yes I would pay for my daughter’s rabies vaccine, for example. But I do stress that what I might or might not do does not necessarily dictate what is right or wrong, or right for them. Again, everyone has their own risk tolerance, budget and personal behaviour.

Why are we taking this trip, dear? This question usually comes up after I have recommended three vaccinations, medications for diarrhea and altitude sickness, and warned them about dogs, dengue and Chikungunya! I then gently tell them that they will be fine, but that it is my job to at least make them aware of the risks, even if they are small (the risks, not the travellers).

But my sister-in-law’s boyfriend got the typhoid shot and Dukoral! This is referred to as “vaccine envy“. The reverse of this envious entity is “Why did you give me a typhoid shot? My bother-in-law’s girlfriend didn’t get it.” In spite of the fact that we have guidelines and wonderful resources to help us, not every travel doctor or nurse will recommend the exact same thing for every patient, every time. And again,  there is always the issue of the traveller’s  risk tolerance, budget and love of needles.

Oh , but I love dogs! I tell everyone to avoid dogs and monkeys. People born after the release of the movie Old Yeller are not aware that dogs transmit rabies, and that rabies is usually 100% fatal after symptoms develop. This love of dogs and lack of awareness of rabies is especially common amongst young females. Patients are usually quite thankful that I brought this to their attention.

Isn’t it better to let the bugs get out of me?   I suppose if you have the time, a decent toilet and more than one-ply toilet paper and no pressing engagements, then this strategy can work. Most infections are self-limited (they get better on their own). But I do recommend “feel better” medications such as Imodium, Pepto Bismol and probiotics, and antibiotics like Cipro and Zithromax, for those who don’t have the luxury of time, dislike cramps and frequent trips to the squalid toilet, and hope to visit Machu Picchu, the Taj Majal or the Great Wall of China the following day!

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Politics, infection and travel

October 26th, 2014 · Comments Off · Uncategorized

I have been practicing travel medicine, and medicine, and travelling since about 1978. In that time, approximately 36 years, I have seen a lot of water under the bridge. Now I am 64. I am thankful that I have a lot of the world travel under my belt.

I was fortunate to visit Machu Picchu in 1973. While I didn’t hike the “Inca Trail”, mainly because I wasn’t aware of it, we (my friend Howie Hamer and I) did manage to sleep on the terraces for free. The Sendero Luminoso succeeded in discouraging any tourism for many years. Now I think it is one of the world’s most frequented tourist sites. At least learn a bit about altitude sickness before you visit. Colombia was considered safe as well at the time, but subsequently enjoyed a reputation as the most violent county in the world. It is again popular.

In March 2001, I went to Nepal with my son Benjamin. We hiked the “easy” Annapurna trek. I suffered a bit of shortness of breath at 10,000 feet, but not true altitude sickkess, A few months after our trip, The Royal Family of Nepal was murdered by a disgruntled relative. This set back tourism for many years. More recently, Canadians have died from ill-conceived climbs of Everest, and most recently on the Annapurna Circuit from an avalanche. I have a feeling that the latter will discourage travellers from visiting one of the most breathtaking spots in the world for some time.

Ebola. This deadly virus has surfaced in West Africa for the first time, in the last several months. The outbreak is much more extensive than in the past, and has, as we well know, created anxiety in many other countries in the world. Its effect on the affected countries in West Africa is huge, but in fact, I would think that it is having a significant effect on all of Africa. While it is hopefully not a significant risk to tourists to Kenya and Tanzania, or South Africa and Victoria Falls, I am certain that many people are putting off Africa  for the time being.

Patients are calling me about the outbreak of Chikungunya virus in the Caribbean. This mosquito-borne viral infection, though usually not life-threatening, has affected thousands of tourists since the end of last year. While I wouldn’t advise people not to go, they do need to be aware of the risk, and use insect repellent during the day.

The annual pilgrimage to Mecca for Hajj is now over. Most people won’t be returning with meningitis (because vaccination is required) or MERS (Middle East Respiratory Virus). But before travelling for Hajj, or in fact, for any other reason, one needs to be aware of the risks involed.

There is always risk from staying home. You may not get to experience the world or cross off items on your bucket list. There is always risk from travelling abroad. Most of the risks from the latter can be ameliorated or minimized by picking your destination sensibly, and by seeking some reliable medical advice before you travel.


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What on earth is going on?

October 13th, 2014 · Comments Off · Uncategorized

Infectious diseases related to foreign, usually tropical travel, have always been a concern. Every year I immunize a few thousand people against common, and not so common diseases such as polio, typhoid fever, yellow fever, hepatitis A and B, rabies and Japanese encephalitis. Many reluctantly take malaria pills for prevention, though they worry about side effects. Just about everyone carries some Imodium or Cipro in case they succumb to Montezuma’s Revenge.

Currently, it seems, we are equally worried about the exotic infections that might find their way back here. The tragic Ebola outbreak in West Africa has claimed more than 4000 lives, and the virus has travelled in unsuspecting humans to nearby countries such as Senegal and Nigeria, and not so nearby ones like Spain and the USA. Despite endless assurances from CDC and others, the case in Texas was initially sent home with antibiotics, and a healthcare worker has become infected. There have been “scares” at several Canadian hospitals, including possible cases today in Ottawa and Belleville. Is it any wonder that this is a tremendously difficult infection to contain in a place like Liberia, when we see people falling through the cracks over here.

Chikungunya virus has been around for years in Africa and Asia. This mosquito-borne infection made its debut in the Caribbean in December 2013, and has since spread to other islands in the Caribbean, and to countries in South and Central America, including Florida! It is similar to dengue virus, and causes a high fever, headache and severe aches and pains. Some victims may suffer with prolonged arthritis.

Patients are starting to ask if it is safe to take their children down south for a vacation this winter. The answer is “pretty safe”, and make sure you use some insect repellent during daytime biting hours.

MERS (Middle East Respiratory Syndrome) is centred in Saudi Arabia, but has also been reported in most of the nearby countries in the Gulf. It is characterized by fever, cough and shortness of breath. The elderly and chronically ill,  and close contacts and healthcare workers are at increased risk. It has an incubation period of up to two weeks, so it not inconceivable that Muslims returning from October’s Hajj in Mecca might show up coughing in local walk-in clinics any day now.

I vividly recall my son Benjamin acting as our SARS screener in 2003, when my Toronto office was smack in the middle of the outbreak. We haven’t hired a screener this time, yet, but we do have “tools” to identify who might be carrying a serious infection, and the mask, gowns and gloves are within easy reach. Public health and our local hospital have been invaluable in keeping us abreast of the current situations.

So, do you travel abroad, and risk contracting “tropical” infections, or do you stay home, and wait for them to come to you? Thankfully, the risk to most of us, no matter which we choose, is very low. Keeping yourself informed and washing your hands (and putting on some insect repellent) will likely keep most of us healthy.

And, don’t forget to get your flu shot!


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Nezon aces 17 at CMO 45

June 14th, 2014 · Comments Off · Uncategorized


JEFFCHARMYFOURSOME1STERNFARRELLCLIFF FOURSOME3 GEORGE GROUP HUNDERTSSTERNWAKSCHARMY1History was made at today’s 45th Chocolate Milk Open, when Jeff Nezon made the first hole-in-one in our long history. It happened on Dentonia Park’s demanding 17th hole, unfortunately just one hole shy of the closest to the hole prize. An audible shout was heard on the course as the ball rolled into the hole, but it  took several minutes for the news to reach the other proud players. Along with the disbelief was the feeling “well, it’s about time”. Congratulations Jeff for making CMO history.

Not to be overshadowed by Nezon’s feat was the equally impressive winning score of 58 by now two-time winner Richard Fink. Fink, who may be better known as the coach of the Royals in the now defunct Saturday Afternoon Baseball League (SABL), will be tough to beat in the future.


Closest-to-the-hole honours went to the no longer lactose intolerant and past CMO champ Paul Axelrod. Fish and chips were again enjoyed at Charmy’s, who will soon be celebrating their 10th anniversary.




Finally, $1000 was raised for the Panov Program at Mount Sinai Hospital for Precision Chemotherapy.








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Shameless promotion – Demi’s B and B in Niagara-on-the-Lake

May 24th, 2014 · Comments Off · Uncategorized

Not everyone wants to travel to Africa and expose themselves to malaria, diarrhea, typhoid fever, Ebola and sleeping sickness. Some would rather stay close to home, which if you live in Toronto, or close to Toronto, might include Niagara-on-the-Lake. If you love wine, theatre, relaxing, biking,  hiking and fine dining, why shlep to Nepal when you have it all in NOTL. You can drink the water!

For the past 10 years in my Family and Travel Medicine practice, I have had the pleasure of working with Demi Nasello. She has made my patients feel comfortable and at the same time looked after all of their needs so efficiently. Along with her husband Ed, she has relocated to NOTL and opened a B and B …. Demi’s Place.

It is steps from the main street of NOTL. You might want to spend a few days there even if you detest wine and theatre. Aside from being a beautiful home with lovely gardens and a hot tub and breakfast to die for, you will find your hosts delightful and accommodating. My books and some of my African knick-knacks adorn their bookshelves and walls.

So, if you need to wind down from the craziness of New Delhi or Bangkok, think about a few nights at Demi’s Place. No shots are needed!



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Odds and Ends

March 23rd, 2014 · Comments Off · Uncategorized

Well apologies are due for not writing for some time. Life seems to have gotten in the way!

I was shaken yesterday when one of my long time patients arrived in my office wearing a neck brace.  A week earlier the reports of his neck surgery had emerged from my fax machine. So, it turns out he had not been in a car or snowmobile accident near Toronto during our winter from hell. Rather, he had accidentally jumped or dived into some shallow water in Cuba, where he broke a few of his cervical vertebrae. Thankfully, he did not suffer any serious neurologic injury.

After being moved from the beach in a less than safe manner, he was admitted to a local hospital near Varadero. While Castro boasts of the excellent, universally available health care on his island, my patient was less than impressed, and somewhat frightened. Barriers to treatment include being able to guarantee payment to the local hospital, and managing to contact one’s insurance company from a foreign country. After three days, he was evacuated by a Learjet and transferred efficiently to a major Toronto hospital, where they were waiting for him and operated on him successfully.

I love Cuba. I have been there three times and would go back in a minute. But the lessons from this story include:

  • not only do accidents happen abroad, but they are the most common cause of death in travellers. We fret about whether to take Dukoral for diarrhea before our trip …. much more important is to be careful, very careful … when you are away.
  • don’t leave Canada without VERY GOOD medical insurance
  • consider imagining the scenario of a serious accident or illness before you leave; it might make you better prepared should something happen
  • carry a list of your medications and medical history with you at all times
  • whether this is a reason for everyone to get immunized against hepatitis B (with TWINRIX – hep A and B) or hep B alone, I am not certain. But the risk of being exposed to local, less than ideal medical care when abroad is real.

CATMAT recently published their guidelines on the need for typhoid vaccine . Typhoid fever, to remind you, is a bacterial infection passed through food, water and food handlers. Typhoid Mary is the most famous vector of the disease in history. The vast majority of imported infections to Canada are amongst VFRs (those who are Visiting Friends and Relatives) to South Asia. More specifically, this includes India, Pakistan, Bangladesh, Afghanistan, Nepal, Maldives and Sri Lanka. The estimated risk to most other destinations is felt to be low, or fairly low. As in all of travel, and other medicine, there are many risk factors involved. For the affluent couple doing a ten day safari to Kenya and Tanzania, I agree, the risks are extremely low and I try not to immunize these travellers. But if they are going to volunteer for six months in The Cameroun, the risk is much higher. As always, it is up to the traveller and his/her medical advisor to decide the risk, as well as their risk tolerance and budget for vaccines.

Chikungunya virus recently made its debut in the Caribbean. This is a mosquito-borne infection characterized by fever, headache, a rash and joint pains. It is similar and related to dengue virus.  Islands such as St. Maarten, British Virgin Islands, Dominica and  Guadeloupe have reported cases. Thankfully, I suppose, the more common Canadian destinations such as Mexico, Cuba and Dominican Republic have not. But remember, that not only do people travel, but also the viruses and their vectors.



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