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More yellow fever stuff – please read!

June 27th, 2016 · Comments Off on More yellow fever stuff – please read! · Uncategorized

If you are coming to my office regarding a trip to parts of Africa and/or South America,this information is important to you. There continues to be a shortage of yellow fever vaccine. This may last several months. Yellow fever vaccine is protective for life. Please read my blog of May 29th.

If you have had a documented yellow fever shot, you are protected for life. It is unlikely that I will give you another, even if your previous one was more than ten years ago. I will “validate” your yellow card.

If you are going to Tanzania, it is felt that yellow fever is NOT a risk. There may be “bureaucratic” concerns. I will likely provide you with a yellow “certificate of exemption”.

For those with very brief, low risk exposure to YF, e.g Iguacu Falls or the Peruvian Amazon for 3 days, you will be offered the vaccine after a discussion of other risk factors, such as your age.

Studies have shown that using .1cc, or one fifth the usual dose, is protective against YF. This may be an option for some, after discussing the issue.

So, please make sure that you are aware of these issues before your appointment with me, or perhaps anyone else.

A list of all clinics attempting to provide YF vaccine is found on my previous blog.

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Me and Muhammed Ali

June 5th, 2016 · Comments Off on Me and Muhammed Ali · Uncategorized

ali
Cassius Clay, and then Muhammed Ali, was my idol. I was born in 1950, and when he won his gold medal in Rome in 1960, I jumped on board. I never boxed, but I loved professional boxing. His speed, his shuffle and his way with words to say the least, mesmerized me as a youth. I had other favourites, like Gordie Howe, Mickey Mantle and Elvis Presley, but Ali was my only idol.

Even before he became the champ, I remember being glued to my transistor radio to follow his fights.  When he won the title over Sonny Liston in 1964, I was the toast of my junior high school, along with the other three members of my Cassius Clay Fan Club. I took my own stab at poetry and sent it in to Sports Illustrated.

The odds were 7 to 1,

But when the fight was done

The people lost their money,

That is those who bet on Sonny.

Cassius Clay is the greatest by far,

A tomato red Cadillac is his car.

He came from the town of Louisville,

To prove that Liston was over the hill.”

There were a few more verses which I can’t remember. Today, I am rereading all of my Sports Illustrated magazines where Ali graced the cover.

I first met Ali at the gym on Ossington when he was training for his fight with George Chuvalo. He was sparring against his younger brother. I was there with my older brother, Joel. We ran into each other again a few years later (I suppose I was stalking him) in the lobby of the old Sutton Place Hotel. He was under suspension at that time, and was doing colour commentary for the Clyde Gray fight. Luckily, Joel was able to snap the picture of Muhammad and me.

For my sixtieth, I flew to Louisville to visit The Ali Center. I have been to more than a few museums during my life. This was one of the best. You should go to see it. For

so many reasons, Ali was and will remain “The Greatest”. I feel fortunate that he is my idol.

IMG_0129 photo 1 IMG_0149 IMG_0143 poster 3

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Yellow fever vaccine shortage

May 29th, 2016 · Comments Off on Yellow fever vaccine shortage · Uncategorized

If you are planning a visit to an area where yellow fever is a threat, you should read this. If you are one of my travel patients coming in regarding yellow fever vaccine, please read this! Some key points about yellow fever:

  • as mentioned in the previous post, it is a flavivirus, that is, in the same family as West Nile virus, Zika, dengue and Japanese encephalitis
  • it is transmitted by mosquitos
  • it may occur in both urban and rural areas
  • it is a very serious illness, affecting most of the body’s organs, with a mortality rate of about 20%, and no specific treatment
  • its distribution is limited to subSaharan Africa and parts of South America
  • it is the only infection for which there are international and national “requirements” for vaccination
  • the famous “Yellow Card” (not the one used in football) may be required to prove that you have received the vaccine
  • yellow fever vaccine is administered only in “designated” clinics
  • while it has been traditionally felt that the vaccine, which is 100% effective, provided about 10 years of protection, those in authority (WHO) have stated that it in fact provides lifetime immunity

For further information on yellow fever and the vaccine, you can check the following links: PHAC (Canada), CDC (USA) and the WHO (the world).

Unfortunately, the world is currently undergoing an acute and severe shortage of the vaccine. This was likely precipitated by a recent outbreak in Angola in West Africa. Cases of yellow fever were also reported in neighbouring countries, and not so neighbouring countries, like China. People and the viruses do travel. Uganda also has a local outbreak, unrelated to the one in  Angola. Vaccine production is not that simple, and it appears that production problems, which are not totally new, are also responsible for the shortage.

There is the very concerning and real threat that yellow fever could take hold in countries and continents that have always managed to stay free of the infection. There are apparently only four manufacturers of the vaccine worldwide (Sanofi Pasteur in North America), and I assume their priority is supplying vaccine for the affected and potentially affected countries.

So what does this mean for travelers planning to visit a “yellow fever” country?

  1. Those who have received the vaccine in the past are protected.
  2. You may have to call around (hopefully travel clinics can help) to find a clinic with vaccine in stock. (I assume most of us won’t have enough to meet the usual needs.)
  3. You may want to postpone your holiday to Angola, or any other potentially area of risk.
  4. The risk of yellow fever is VERY LOW for many of the destinations, especially brief ones, to which people travel (e.g Iguacu Falls, the Peruvian Amazon, Kenyan safari). We have already been using the vaccine much less, particularly in certain populations, dare I say “the elderly” = over 60!
  5. Using a DEET containing repellent or Picardin day and evening is important.
  6. There is good evidence that giving a smaller dose of the vaccine, 0.1 cc as opposed to 0.5 cc, might be effective and thus help stretch limited vaccine supplies. I am not  sure that this will contribute to the solution.
  7. There remains the logistical challenge of providing the yellow card, or perhaps a letter of exemption, where the vaccine is not available.

For further information on the situation, keep in touch with your travel clinic, and the above mentioned organizations.

If it helps, I have just returned from a brief trip to Newfoundland. I saw icebergs, but no mosquitos!

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It’s just a virus … a flavivirus!

May 14th, 2016 · Comments Off on It’s just a virus … a flavivirus! · Uncategorized

For most of us, “a virus” is just a cold, a runny nose, a sore throat, a cough, some aches and pains, or if we are lucky, some transient vomiting and diarrhea. When we travel, it may be the same, with the added possibility that you might contract dengue fever, Zika virus, Chikungunya virus, Japanese encephalitis, and Yellow Fever. All of these viral infections are transmitted through the bite of mosquitos. They belong to the family FLAVIVIRUS . Some of them bite during the daytime, and some between dusk and dawn, like malaria. It is probably best if you consider some “personal protective measures”, no matter where you you go and regardless of when you are there. For some guidelines, for yourself and your children, please go to PHAC.

Dengue fever has been on the upswing for many years, perhaps because of global warming, urban migration, poverty and smart mosquitos.  There is a new vaccine against dengue,  which is moderately effective, and which is available in only a few countries. Chikungunya virus became entrenched in our western hemispehere last year. It may have subsided, only to be replaced by Zika virus.

Zika virus, though it may only cause a mild illness, with a fever, joint pains, red eyes and a rash, may also be associated with much more concerning complications such as fetal abnormalities and Guillan Barre Syndrome. To stay up to date with Zika virus, please check my blog.

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Something for your kids or grandkids

May 7th, 2016 · Comments Off on Something for your kids or grandkids · Uncategorized

A bit of a change. Rather than discussing scary new mosquito-borne diseases, like Zika (please refer to my previous post for updates), I thought I would highlight one of my travelling friends and patients. Sarah Kraftchuk   recently climbed Kilimanjaro, but equally important to me, are the lovely and touching and meaningful books she is publishing.

I have given her beautifully written and illustrated book to all of my grandchildren, Hannah, Isaac, Jonah and Noah. I think you and your family will enjoy her books as much as my family.

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Zikamania

January 19th, 2016 · Comments Off on Zikamania · 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 on The telephone and me · 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 on Fidel and me · 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.

 

dadpiano pool1 VIEW1  wreckskyline

 

 

 

 

 

 

 

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Cuba and me

December 18th, 2015 · Comments Off on Cuba and me · 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.

baseball4 - Copy - Copy - Copy - Copy

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Anthony and me

October 27th, 2015 · Comments Off on Anthony and me · 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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