Tomorrow I am off to Cuba with my wife Gayle, my children Benjamin and Ros, and their two lovely kids, Jonah, 4, and Noah, 2. We will be in Cayo Coco at the same Pestana resort we visited last year with a different set of kids.
So, from the travel medicine perspective, we are all protected against hepatitis A, the kids not yet B. No Dukoral for the family – just don’t feel that it is that effective or worthwhile or pleasant to take or cheap! I think Health Canada feels the same way.
I have packed some oral rehydration salts in case the kids get diarrhea, and a short course of Zithromax, powder and pills, in case someone gets a really bad case of the runs. In my mind, that might mean going to the washroom every 20 minutes all day, diarrhea associated with fever and chills, and diarrhea just not getting better after a day or two. On a very brief trip, I might be more prone to use the antibiotic, even just for a day, as there isn’t much time built into a seven day holiday for rest and rehab. You are welcome to unlimited probiotics! Small amounts of Imodium are also an option for mild diarrhea.
What else? Tylenol, sunscreen, insect repellent, Gravol, Polysporin, books, cashews, baby powder, puzzles, a hat, sunglasses and a passport.
Zika, dengue fever, chikungunya and even malaria are likely all a threat in Cuba. We will apply our DEET containing repellent, probably less than religiously. No more children or grandchildren on the horizon from this group, so the precautions regarding future pregnancy are not an issue. There is a new non-DEET based repellent called Icardin, or Picardin. It is now available at Mountain Equipment Coop, in Canada, for the less DEET-inclined.
These days, I tend to worry more about accidents and injuries in my patients than exotic infectious diseases. We will watch our steps, as I would advise you to do as well.
I have outgrown the need to shop for others on my vacations. My closet is full of colorful clothing from Burkina Faso and pillow covers from Rajasthan that have gone unwanted. But I do have a friend in need of some Cuban cigars. Nothing better than a trip with a mission!
February 19th, 2017 · Comments Off on a musical interlude · Uncategorized
When not talking about diarrhea and yellow fever vaccine shortages, I enjoy playing squash (singles and doubles) and piano. They have much in common with each other, and life. Here is a sample of my piano… Blue in Green, by Miles Davis, or perhaps Bill Evans.
February 1st, 2017 · Comments Off on Yellow fever vaccine shortage … again!!!! · Uncategorized
February 1, 2017
Dear Travel Patients,
There is currently a shortage of YELLOW FEVER vaccine, across Toronto, Canada and the world. This also occurred recently in the summer of 2016, due to production problems and outbreaks in Africa. There is a new outbreak in Brasil. At that time, WHO (World Health Organization), along with CDC (USA) and PHAC (Canada) developed the following regulations and recommendations:
Doses of 0.1 cc, rather than the usual .5 cc, have been shown to be perfectly effective in preventing yellow fever.
In the event of a shortage of YF vaccine, the smaller dose should be used in order to conserve supplies and to vaccinate and protect the maximum number of travellers.
In view of a lack of longer term studies, this smaller dosage, for the time being, should be considered protective for at least 1 year, rather than the lifetime duration of the full dose of vaccine.
Everyone receiving either dose of vaccine will receive the YELLOW CARD showing that you have been immunized.
Because of logistical reasons, it may be necessary to “clump” people receiving the YF vaccine together.
People who are not at risk of YF, or those with additional medical conditions or those over 60, should discuss with their provider as to whether YF vaccine is warranted.
Recall that it is now felt (by WHO) that previous yellow fever vaccine confers lifetime immunity.
Further information regarding this issue can be found on my website/blog (www.drwisetravel.com – May 2016), at CDC, WHO and PHAC.
Mark Wise MD DTM&H (London)
Comments Off on Yellow fever vaccine shortage … again!!!!Tags:
January 29th, 2017 · Comments Off on My family practice · Uncategorized
Travel medicine aside, here is what I have written to my family practice patients this new year.
I hope this letter finds you rested from the holidays and in good health. I realize, being your doctor, that this unfortunately might not be the case. My family is well, including my four wonderful grandchildren, now aged two to eight. When I am not in the office, I can usually be found at Tim Horton’s, the library, at a piano, playing squash or asleep in bed.
I hope you appreciate my staff as much as I do – Indi, Lilliana, Karon and Dolly. I think they are the kindest and best at what they do.
I wasn’t sure what to write this year. I also wasn’t sure if anyone reads these letters, as I get very little in the way of feedback. In any case, let me list for you the most commonly heard comments and questions that I get in my office. Next year I will provide the commentary on each one!
But I never had this before.
Why is it just on one side?
Is it my age?
Is it contagious?
I saw this on the Internet!
So you’re saying there’s nothing wrong?
My naturopath / chiropractor / massage therapist says I need all of this blood work / an MRI.
Shouldn’t I be on an antibiotic?
Do I really need all of these pills?
You know …the little green ones!
But I got the flu after the flu shot.
But I can’t afford it (physiotherapy, counselling, medications …).
What do you mean my appointment isn’t until May?
Are there any side effects?
Do I need to take all of these vitamins?
When are you planning to retire?
Can I e-mail you? (preferably not)
A reminder – please keep up to date, with my help, with your vaccinations (including shingles and pneumonia), and age (and sex) appropriate screening for colon cancer (FOBT or colonoscopy), osteoporosis (BDM), cervical cancer (Pap smear), and breast cancer (mammogram). There is no shortage of controversy regarding screening for prostate cancer (PSA) and everything else in medicine. I am happy to discuss these issues with you.
It is time to wax eloquently over the past year, with respect to travel medicine and otherwise.
It has been a good year.
While my travels are no longer far flung, I have visited Cayo Coco in Cuba, Apsley and Silent Lake Provincial Park, the Rideau Canal and Ottawa, St. Johns, Newfoundland, Kingston, and Paris. I am glad that I waited sixty-six years to see Paris. It made it that much more stunning. Playing the grand piano at the Gare du Nord stands as one of the highlights of my life. I plan to return to Cuba in March with my children and grandchildren, “before the Americans get there”, as so many of my patients say.
Travel medicine has not changed that much. We have run out of destinations and diseases, with the exception of new arrivals like Zika. Vaccine shortages have become a way of life. Mefloquine or Lariam has had a resurgence of bad publicity. No destination is immune to natural disaster or terrorism. Vaccine costs in North America continue to present a barrier for many travelers. The next meeting of The International Society of Travel Medicine is next May in Barcelona. I look forward to seeing that beautiful city, renewing old acquaintances and finding out what is new.
In Ontario, pharmacists have now been granted the right to provide travel medicine advice and vaccines. Needless to say, in spite of my obvious bias or conflict of interest, I don’t feel that this is in the best interest of the traveler. More to say about that in the new year.
I am also a busy family doctor. My aging practice, along with its aging doctor, is overwhelmed with high cholesterol, diabetes, heart disease, addiction, aches and pains, leaky valves, cognitive impairment, depression and cancer. Wait times for diagnostic testing and specialist consultations are usually, though not always, longer than I and my patient would hope for. Guidelines, drug interactions, side effects, natural remedies and patient demands are part of my daily life. I am blessed to lie geographically halfway between Sunnybrook and North York General Hospital. I am also fortunate to have a caring and superb staff, who look after and care for me as much as my patients. That would be Indi, Karon, Lilliana and Dolly. Lesson for young doctors – surround yourself with excellent colleagues (or work alone like I have for the past 15 years), but more importantly, staff.
We are in constant conflict with the Ontario government, with only imposed solutions rather than negotiated settlements. Our health minister, himself a physician, seems to despise us. The future will likely bring more bureaucracy, more scrutiny and less freedom. No surprise that the thought of retirement marinates in my mind.
I have lost many people this year, as we have all. Family, friends, colleagues and patients. Christy Afuwape, my Nigerian travel nurse and treasured friend, passed away unexpectedly this year. I subscribe to The Globe and Mail. While I wouldn’t call it my favourite section, the Obituaries is where I turn to first, to learn about the accomplished and loving lives that people have led.
I feel fortunate to have a wonderful family, with children and grandchildren that make me proud, thankful and happy. My spare time, or perhaps my primary time, is filled with squash (the racquet sport), piano, sample here, (jazz), coffee (double cream and sweetener), reading and dear friends. I dislike Toronto traffic and endless passwords.
I wish you a happy and health New Year, and hope some of that pleasure comes from travel.
November 19th, 2016 · Comments Off on Getting high! · Uncategorized
With the legalization of marijuana just around the corner, or already there, I thought I should write about getting high. Perhaps cannabis is a cure for altitude sickness, or perhaps one just wouldn’t care if he or she has a splitting headache and is vomiting incessantly on Kilimanjaro! The following is what I give to my patients. I hope you find it useful. Please refer to the links at the end.
The High Altitude Handout
Congratulations. You are about to get high! Here is some information regarding altitude sickness (AS).
Altitude sickness may occur at levels above 7,000 feet. Your likelihood of getting AS depends upon:
How high you go (especially how high you sleep)
How quickly you go high (are you flying to 12,000 feet or going by bus over a few days)
How well hydrated and warm you stay
The amount of exertion involved (i.e hiking vs taking the train)
Luck, or your personal predisposition – those who have had AS in the past are more prone; age and fitness have little to do with it
Most people will feel a bit unwell – short of breath with exertion, lightheadedness, loss of appetite at high altitudes. This should go away within a few days. Some people also experience “periodic breathing”, or trouble catching your breath at night. The types of altitude sickness include:
Acute mountain sickness (AMS) – headache, nausea, vomiting – usually beginning usually within 24 hours of arriving at your new altitude. Sounds a bit like a hangover!
If left untreated or if one continues to ascend with symptoms …
High altitude pulmonary edema (HAPE) – shortness of breath at rest, trouble lying down flat, cough and blood tinged sputum … this can be fatal!!!
High altitude cerebral edema(HACE) – headache, confusion, difficulty walking a straight line, coma (this can also be fatal!!!)
To minimize your risk of getting AS, either mild or severe, consider the following:
Getting to your destination gradually is preferable to suddenly flying to a high altitude. One does not always have this option!
Taking it easy when you reach your high altitude …. consider sightseeing around Cuzco for a day or two before you hike the Inca Trail. On your trek, go slow…go slow…go slow!
Drink lots of water (preferably clean water!)
Consider the local remedies such as coca tea in The Andes or garlic soup in Nepal.
Limit the change in your sleeping altitude to no more than 1,500 feet per day, and consider a day of rest every 3-4 days (applies to longer treks in Nepal)
Don’t continue to ascend with symptoms of AMS. Descend if you are very sick or not getting better.
Take along Diamox (acetazolamide) to use either preventatively (start the day before ascent) or if needed. It has three side effects – you will pee more often, you might experience some tingling in your hands, feet and around your mouth, and carbonated drinks might taste funny… It may be used just for the first few days, or continuously if you continue to climb higher.
Other meds, such as Decadron (steroids, for HACE) and Zofran (an antinauseant) and nifedipine (Adalat) (for HAPE) should be reserved for the minority of climbers on more dangerous expeditions, or those who are medically responsible for others.
November 5th, 2016 · Comments Off on Paris and plantar fasciitis · Uncategorized
As a doctor and parent and volunteer and adventurer and student, I have visited more places than most. Somehow Paris has escaped me. Last week I am happy to say that it was taken off my bucket list. Here are some of my thoughts and suggestions.
Airfares from Toronto to Europe are quite reasonable. If you are an Aeroplan member, however, the regular fare is about the same as the taxes on your “free flight”. So I used my Aeroplan miles for my hotel instead.
I used Uber for the first time. Truly a magnificent advance in service and at a lower cost. (I realize that there may be some downsides to it). Imagine if our medical system could be revolutionized in a similar way.
I stayed at the Best Western Anjou Lafayette, close to the Opera Garnier and Gare du Nord. Not the most trendy location, and I was urged in advance to stay on the Left Bank, but it was a relief to get away from the tourist areas at the end of each day.
Immerse yourself in the Metro as soon as you can. Between their extensive “underground” or “subway” and buses, you can really navigate Paris with little difficulty and quite inexpensively. I bought the carnet of ten tickets, which almost lasted me five days.
If you are asking for directions in a foreign country in your second language, it never hurts to get a second opinion!
There are several “passes” available, such as the Paris Pass, which will cover your transportation and admission (without the lineups) to most, though not all of the most popular attractions. I didn’t use one, and I think I came out ahead. If you do register on their website in advance, you will be blessed with daily e-mails encouraging you to sign up.
Much of Paris is free! The churches like Notre Dame and Sacre Coeur, the parks like Luxenbourg and Tulieres Gardens, walking along The Seine and sipping coffee or wine on the streets.
There is no additional GST and PST (aka taxes) on stuff in Paris, and tipping is not expected. So, while Paris isn’t cheap and the Canadian dollar is a bit anemic, it’s not as bad as you may think.
Try the Batobus for a day or two. It’s relaxing, not too expensive, and a good way to get from one end of the city to the other. Yes, Paris is great for walking and you can indeed walk most of the city, but a boat or a bus or the Metro might save you time and be easier on your plantar fasciitis!
Perhaps you enjoy playing the piano, like me! There are public pianos in all of the train stations, at Charles de Gaulle airport, and Shakespeare and Company’s bookstore. Along with the Eiffel Tower and the Arc de Triomphe, finding and playing the piano at Gare du Nord was a highlight of my trip, and life!
Try and find the statue of Montaigne by the Sorbonne. It is believed to be good luck for students to rub his bronze toe before an exam. The statue is not sideways in real life! From there you can visit one of the world’s great bookstores, Shakespeare and Company, to browse or tinkle their ivories or both. Next door is a pleasant café.
The fallafel at L’As du Fallafel in the Marais district is really as good as they say. Don’t miss it.
I borrowed Rick Steeves’ guidebook from my local library. I would highly recommend it.
I don’t sleep on airplanes, nor do I get HBO at home. So I was well entertained by a full season of Veep on the way over, and The Night Of on the way back.
If you are planning on picking up your own wine in Paris, take along a corkscrew or get one there. There really isn’t much in the way of screwtop bottles over there.
I saw seven SLR cameras in Paris. Everyone is using a smart phone. Selfies are the norm, and selling selfie sticks seems to be a common occupation amongst newly arrived French persons.
Speaking French certainly comes in handy. Remember to say “bonjour” when you address people.
I suppose the end of October is a bit off season. It still seemed like a very crowded city, though the lineups at most attractions were short. The leaves were turning colours, just like back home.
I have a fear of heights, probably dating back to trips to New York in my childhood, and aggravated by canopy walks in Ghana with my children. That saved me shlepping up the Eiffel Tower. There is a beautiful, and free, view in all directions from the seventh floor of the Galleries Lafayette (take the escalators up).
I have never before been a fan of fine art, but the Monets, Manets, Chagalls, Van Goghs, Cezannes, Rodins and much more enthralled me with their beauty, as did the museums and galleries where they were displayed.
You can go crazy before you go doing your research on Trip Advisor. Here you can find the best hotel, best restaurant, best crepe or croissant, piano bar, and I am sure much much more. Pretty helpful, but sometimes it’s best to stumble on your own finds, and then, if you must, review them on TA.
As the Travel Doctor, I am exhaustedly used to warning people about the food and water, the bugs and advising vaccines. None of that was necessary for Paris. I think it is the most beautiful place I have ever been.
And, below, the best pizza in Paris, at La Villa Andrea, close to the elegant Gare du Nord.
There are several people who advised me and encouraged me to take this trip. I thank you.
Please excuse the picture layout. I don’t find this program easy!
September 26th, 2016 · Comments Off on Whaddya mean that’ll be 2500 bucks! · Uncategorized
“Nice to meet you, Doc. From the looks of your office, you’ve done a lot of travelling.”
“That’s quite true, and I also get to travel vicariously through everyone else, like you two. What are you planning?”
“Well it’s our 40th anniversary, ya see, and we’ve been saving for a cruise to Southeast Asia ever since the kids moved out. We leave in three weeks and will be gone for two. Everything is first class!”
“Well let’s see. First, let me make sure you are up to date with your regular booster like tetanus. And it wouldn’t hurt if I gave you the pneumonia shot and the shingles shot. You’ve seen them on TV, and you are in your late sixties.”
“Is that all we need, Doc?”
“Oh God no. That just the start!”
“Well you’ll need a quick series of Twinrix, for hepatitis A and B, and typhoid for eating in the markets.”
“But we’re doing all of our eating on the ship. Maybe just some local beer on land. And isn’t hep B passed through sex?”
“I understand. Better safe than sorry, as the saying goes. Let me mention two other vaccines I think you should consider – rabies and Japanese encephalitis.”
“Oh, my wife loves dogs. Thanks for suggesting that. What about the Japanese thing? Is it common? We aren’t stopping in Japan, and we’ll be on the ship every night after five.”
“Estimated at one in a million travelers to the area. But it only takes one mosquito. Better safe than sorry, as the saying goes.”
“Hmmmmm. I appreciate your advice, Doc. Can give me an idea of how much all of those vaccines will cost us?”
“Well the tetanus booster is free. The others … let’s see …. for the two of you, it would run about $2500, and then of course there’s the consult fee, and you will need to come back two more times.”
“Any side effects, Doc?”
“Probably just a sore arm.”
“Thanks Doc. Sounds a bit pricey, and mostly unnecessary. You won’t be living vicariously through us! Adios.”
August 15th, 2016 · Comments Off on It’s all about the roads …. · Uncategorized
Zika, dengue, diarrhea, dogbites, sunburn …. these are a few of my favourite things, as Julie Andrews sang in The Sound of Music.
But what do I really worry about with my travelers?
Accidents … mostly of the motor vehicle variety.
With the Olympics and Donald Trump so pervasive in the press, probably most of you don’t notice headlines like this (bus accident in Nepal) or this (bus accident in Peru). While the traffic in Toronto and wherever you live is horrendous, and accidents happen everywhere, they are much more common in lesser-developed countries.
Why? Lousy roads, overcrowded, poorly maintained cars and buses and drunk drivers just to name a few reasons. I was in Peru in 1973, and Nepal in 1999. I’d bet that not much has changed. If I were to return, I might think twice before getting on the same roads and buses …. getting old!
Here are some suggestions for minimizing your road risks, realizing that all may not be practical, available, affordable or exciting!
stick to well-built vehicles with uncracked windshields, functioning rear-view mirrors and seatbelts
wear your seatbelt
avoid nighttime travel, especially in rural areas (I know it might save you money and a night’s lodging)
sitting in the back of the bus might be safer than the front (in Ghana, I recall being honoured with the front seat by the driver.. The goat went in the back!
if the weather looks really bad, stay put
the more expensive bus is probably safer
if you are the driver, don’t drink … or text … and drive
consider using a local driver
motorbikes are a lousy idea
if you have small children, car seats are a good idea
There is more to your personal safety than your mode of transportation, but this is a start.
By the way, the yellow fever vaccine shortage seems to have been resolved!
July 5th, 2016 · Comments Off on The Natural Way – a guest column · Uncategorized
Enough of yellow fever shortages and Zika. I think you will find the following information from my naturopathic friend and traveler of interest and benefit! Thanks Leena
Travel medicine has come a long way in the last few decades. People are travelling more than ever before which has dramatically increased travel-related health concerns. While conventional MDs are skilled in running lab tests, prescribing pills & injections to address these potentially fatal concerns, there are often missing pieces in the health puzzle which naturopathic medicine aims to put together.
While naturopathy recognizes the importance of accurate diagnosis and medical interventions, the naturopathic model incorporates prevention with a focus on strengthening your system and addressing the root cause rather than fixing the symptom. Naturopathic doctors are regulated in Ontario and have training in conventional medical diagnosis & natural treatments such as nutrition, nutraceuticals, Asian medicine & acupuncture, botanical medicine, supplements and other modalities.
The naturopathic approach to travel medicine is multifaceted. One aspect is prevention. What are ways to prevent you from getting sick in the first place ?
There are various ways to support your immune system to fight germs. Why is it that two people may be travelling, eating the exact same foods while one person gets terrible diarrhea and the other one is fine? Both were likely exposed to the same germ but one person had the ability to fight it off. By supporting your immune system, you can reduce your chances of getting sick on a trip. (Below are some suggestions to support your immune system.)
Naturopathic doctors in Ontario do not prescribe pharmaceutical medications, however they are trained in understanding their side effects and have access to a variety of natural options to choose from. For example, while Gravol is widely used for nausea, some people do not like the drowsy effect and may opt for natural options such as Ginger or Vitamin B6. Another aspect is to minimize the side effects of pharmaceutical medications. For example, there are many medications that target bacteria that causes diarrhea. Antibiotics can work well to kill that bacteria, however they also eliminate beneficial bacteria in the gut which can make you susceptible to re-infection. If antibiotics are prescribed, naturopathic doctors will often suggest specific probiotics to support healing.
Naturopathic medicine recognises the body-mind-emotions connection.
Travelling can increase anxiety – fear of flying or anxiety of new environments can put a damper on travel. Naturopathic doctors can customize herbal formulas to reduce anxiety. Herbs such as lavender, passionflower or lemon balm soothe the nervous system, however are best taken under guidance so as not to interact with medications you may be on.
Naturopathic Tips for Travelling :
Support your Immune System
Before your trip, it is advised to balance your immune system to help you fight unwanted infections.
Eat nutrient dense foods packed with antioxidants, such as berries, cocoa, chia seeds and whole fruits and vegetables.
Supplements such as Echinacea or Astragalus, Vit C & D, Zinc can be individualized based on your constitution and your health concerns.
Get sufficient sleep and rest before the trip.
Support your Digestive System
The digestive system is a complex yet delicate system in our bodies, and is most commonly affected while travelling when we are consuming new foods in new environments.
Electrolytes are a must when travelling in hot climates or when experiencing diarrhea, as they help rehydrate the body and provide mineral salts.
Digestive enzymes and herbal bitters can support digestion, assimilation and elimination of food.
Probiotics are critical in supporting intestinal flora – how much, when and which type should be customized based on your travel destination and your current state of health. There are many options of probiotics that are shelfstable which can remain viable on your trip.
To prevent or treat parasitic infections, herbs such as neem or black walnut have antimicrobial properties. Best to take under the guidance of a naturopathic doctor. In certain cases, your MD may also prescribe medications for you.
Other herbs such as slippery elm or marshmallow root can be taken to soothe the digestive tract if there is inflammation or irritation.
Naturopathic medicine can work in supporting your health needs in addition to conventional treatment at your travel clinic. Working alongside your doctor to ensure your health needs are taken care of before, during and after the trip, we can support your body’s innate ability to fight germs, adapt to new environments naturally and effectively so that you can continue to enjoy travelling.