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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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Accolades and more!

September 5th, 2013 · Comments Off · Uncategorized

Just a quick note to let you know that this site has been featured at health.express.co.uk as one of the top travel health blogs. I hope that more people will end up reading my articles, and perhaps this notoriety will encourage me to write more frequently, which I should be doing anyways! I appreciate the recognition and am confident that you will find their site of interest.

We are flush with Typhim Vi again, the injectable vaccine against typhoid fever. I believe that in Canada, Vivotif, the oral option, is not available. This will be welcome news to those off to high risk destinations and/or going off the proverbial “beaten path”. I am certain that I recommend much less typhoid vaccine than many travel doctors. Many travellers, though going to “exotic” locales, are doing  so in style. This, in my opinion, includes people taking upscale safaris in East and Southern Africa, and those sticking to the well travelled tourist routes of Southeast Asia and China. Having said that, for those who want to get vaccinated against typhoid fever despite their low risk, it is always OK with me. The injectable vaccine provides between 60-70% protection for up to 3 years.

Taking care with your food and water, the old “Boil it, bottle it, peel it, cook it …or forget it” is always recommended.

Dengue fever has apparently popped up in Florida, as reported by CNN. You don’t see Anderson Cooper reporting from the site. Perhaps too dangerous for him! This is a reminder that everything and everybody is travelling – people, mosquitoes and other vectors, and all sorts of infectious agents. So, if you are visiting Disney World or elsewhere in Florida,  not to mention India or Southeast Asia, don’t forget to dab on some insect repellent during the daytime hours.

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The Scoop on Yellow Fever Vaccine

June 8th, 2013 · Comments Off · Uncategorized

Most travel-related vaccines are pretty straight forward. Be up to date on your routine vaccines, such as diphtheria/tetanus/pertussis/polio and measles/mumps and rubella, flu, pneumonia, varicella, etc.

Consider getting vaccinated against infections for which you might be at risk, or high risk, such as hepatitis A, and/or B, meningitis, typhoid fever, rabies, Japanese encephalitis and diarrhea from cholera or E. coli.

Vaccination against yellow fever seems to be the most controversial subject in travel medicine these days. What is it? Yellow fever is a viral infection, more specifically a flavivirus (similar to dengue fever, Japanese encephalitis and West Nile virus), which is transmitted by mosquitoes. It may in fact affect everything – your kidneys, your liver, your bloodstream, and may have a mortality – i.e death rate above 20%. There is no specific treatment for yellow fever other than “supportive measures”.

Our offices are not teeming with returning travellers with yellow fever. It is rare in travellers. I have never seen a case in Canada, nor heard of one being imported. The best estimate of the risk, according to CDC, is  5/100,000 people travelling to South America for 2 weeks, and 50/100,000 per person travelling to West Africa.  That makes a 2 day trip to Iguassu Falls in Brasil, or a two day trip to Porto Maldonado in Peru a very low risk. East Africa, including countries such as Kenya, Tanzania and Ethiopia (woops, there has just been a report of a Yellow Fever outbreak in Ethiopia!!!) , is  probably much less of a risk, if a risk at all. The rationale for continuing to vaccinate travellers to these regions includes tradition, the fact that the mosquito vectors may still be present there, uncertainty about what the local authorities might “require”, and personal risk tolerance. We may also be sceptical of local reporting, as any mention of yellow fever may affect local travel and tourism. I often feel that the risk of travellers driving to my office exceeds the risk of some of  the illnesses against which I vaccinate them, or which they wish to be vaccinated against!

Another point worth mentioning is that yellow fever is prone to focal outbreaks, rather than something like malaria or typhoid which is continuously a threat. As my statement above regarding a recent outbreak in Ethiopia illustrates, you don’t know where there is going to be an outbreak until there is an outbreak!

Most vaccines that we use are “killed” or “inactivated”. While one can never say never, they are usually exceedingly safe and effective. Yellow fever vaccine is also exceedingly safe and effective. However, it is a LIVE vaccine, and it should absolutely not be used, or avoided, or used with the proverbial caution,  in travellers with the following medical conditions:

  • allergy to eggs
  • under the age of 9 months
  • pregnancy
  • immunosuppression – due to medications or medical conditions
  • people with multiple sclerosis
  • over the age of 60! (I am 63!)

This latter precaution, that is in those over 60,  applies to people who have NOT had a yellow fever shot before, or “primary” vaccinees. It is not a concern in those who have received a yellow fever shot before …. though the new WHO statement which I mention below makes us wonder whether anyone should be revaccinated!

The most contentious of these “cautions” regards the elderly, or those 60 and over. This is due to the fact that when the rare, and even fatal reactions to the vaccine have been reported, they have been more common in the “elderly”, and the more elderly, the more common.

For how long is a yellow fever shot protective or effective? Tradition says for 10 years, but a  recent statement by the WHO says that immunity is lifelong and that boosters are not needed. Having said that, it may take a few years before the countries requiring evidence of yellow fever vaccination, or “the yellow card” are in agreement with the WHO’s recommendation.

Yellow fever vaccine may be required or recommended under certain circumstances”

  • REQUIRED for entry regardless of from where you are travelling (French Guyana, and several African countries)
  • REQUIRED if you are crossing borders, especially if you are coming from  a country with ANY risk of yellow fever
  • RECOMMENDED if you are travelling to a country with risk of yellow fever, by virtue of past or present outbreaks of the virus, or the presence  of the responsible Aedes mosquito

To view the CDC Yellow Fever Maps, click here.The most common and controversial itineraries include Tanzania, whether or not you have travelled to neighbouring “yellow fever countries”, and South Africa, which rightfully or not, refuses entry to travellers who have visited Victoria Falls in ZAMBIA, though not Zimbabwe. Some people fly to South Africa via Rio (Brasil). This route also requires a yellow fever shot. It is often unclear whether just being “in transit”, that is just sitting on an Ethiopian runway on the way to Tanzania, might enrage the local authorities! And finally, some cruise lines will not allow you on board without the Yellow Fever certificate even though their planned itinerary does not warrant the vaccine.

There is no shortage of controversy amongst the travel medicine community as to whom to vaccinate, whom not to vaccinate, and to whom to issue a “certificate of exemption”. We are ever mindful that we do not want our travelling patient to get yellow fever. We also don’t want to be guilty of being responsible for a serious adverse effect from the vaccine in someone who was at a greater risk of such reactions. Hence, we do our best to advise our patients of the risk of contracting yellow fever (usually very small) versus the risk of a serious reaction (also usually very small). Some travel medicine practitioners are quite adamant that we should not be issuing “certificates of contraindication” or “waivers” in those who truly do not have a deserving medical condition … age not included. Rather we, and our travellers, should abide by the regulations of the country they are visiting, or go somewhere else … or get vaccinated!

For more information on yellow fever and the vaccine, go to CDC.

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vaccines come and go

April 14th, 2013 · Comments Off · Uncategorized

If you have been trying to get immunized against typhoid fever in the past month or so, I know it has been a struggle. Many travel clinics are out of both the injectable typhoid vaccine – Typhim Vi or Typherix, and the oral vaccine – Vivotif. This situation started several months ago when there was a “recall” on Sanofi’s Typhim Vi, over concerns that there wasn’t enough antigen in it … it might not be as effective as it should be. I assume that this caused a “run” on Crucell’s Vivotif, and they became unable to keep up with demand.

Typhoid fever is caused by the bacteria Salmonella typhi, which is contracted through contaminated food and/or water, or by being served lunch by less than hygienic food handlers. For travellers, it is most commonly encountered on the Indian subcontinent … India, Pakistan, Bangladesh. It is much more common in VFRs, that is, those travelling to “visit friends & relatives”. This category of travellers tends to stay for longer periods of time in more rural settings, live with local people, take more young children with them, and often tend to bypass pretravel vaccinations and counselling. Having said that, longer term, rural and budget travellers of any origin may be at risk.

Many expatriates or long term residents of lesser developed countries are diagnosed with typhoid fever. Considering that the vaccines are both only about 70% effective, it is possible that they may be getting infected with typhoid. More likely, however, is that they are diagnosed on speculation, or on the basis of old, inaccurate tests. Malaria is similarly overdiagnosed. Having said that, I don’t discourage my long term volunteers from accepting treatment for malaria, or typhoid, or both if the local doctor suggests that that is what they have.

In my humble opinion, typhoid vaccine is one of the more over-recommended vaccines. People going on cruises, luxury safaris and guided tours to many tropical destinations probably are at minimal risk. That is not to say that there is no risk, but when combined with a bit of “Boil it, bottle it, peel it, cook it, wash your hands, or forget it”, the risk is pretty low. I often offer such travellers a lovely dinner at the restaurant of their choice should they return with typhoid …that is, after it is treated with antibiotics.

Typhim Vi, the injectable vaccine, may be given to children over the age of two. Its protection lasts for 3 years, according to Canada, and only 2 years in the US.  Its advantage is that once it’s in the arm, it’s done. Vivotif, the oral vaccine, consists of 4 capsules taken over 7 days,which must be kept refrigerated and taken on an empty stomach. Not rocket science, but a few people screw up. It is recommeded for kids over the age of six, and is protective for 5-7 years. So each vaccine has its pros and cons.

There has also been a shortage or absence of rabies vaccine, which is mainly warranted for longer term travellers to countries where the appropriate rabies vaccine in the event of a dog (or other furry animal) bite might not be available. This shortage is now coming to an end to the best of my knowledge.

The shortages of vaccines mirrors the increasing number of shortages of other important pharmaceutical products.

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It ain’t all infectious

March 2nd, 2013 · Comments Off · Uncategorized

When reading my morning Globe and Mail (Canada’s leading newspaper), I usually check the obituaries first. There, I might discover the recent deaths of my patients, friends and colleagues. In addition, I am interested in the lives lived by others, even if I didn’t have a personal connection with them.

Today, I came across the obituary of John Driftmier, a 30 year old Canadian documentary film maker , who died tragically in a plane crash in Kenya earlier this week. The subject of the documentary he was working on? Dangerous flights.

Most people leave their travel clinics with an armful or two of shots against infectious diseases such as hepatitis A and B, typhoid fever, meningitis, yellow fever and more. These are usually quite costly, and the infections they protect you against can be quite rare and unlikely in most travellers. On the other hand, I’ll bet that most of you are not made aware of the greatest risk to your life when you are abroad - namely accidents. In particular, road accidents are the most common cause of death amongst travellers. That includes cars,buses,  motorbikes and even pedestrians. A British couple biking across Asia was recently killed by a truck, and its driver, in Thailand. A small plane carrying tourists over Everest went down killing 19 last September. A patient of mine recently had his arm mangled by a shark in Bora Bora.

In my travels over the past forty years, I have frequently ridden on those unsafe buses – the Peruvian Andes and the tro-tros of Ghana  immediately come to mind. I have played Russian roulette while attempting to cross the streeets of Kathmandu. And I have flown in missionary planes in Kenya, ten seaters in Guatemala and the aforementioned flight over Everest. I thank my lucky stars that I am still here to write about it! Let me not forget the ferry to Zanzibar, tropical ferries being another mode of transportation that makes my hair stand on end.

Why are traffic accidents the number one cause of death in travellers? (this does not inlude heart attacks and stroke) To make a long story short, and at the risk of generalising and insulting some people:

  • the roads stink
  • the vehicles stink
  • the drivers stink

Should we be advising our travelling patients to avoid all of these risky forms of travel on their adventures? Well that is one approach, but it is unlikely to deter most dangerous travel. More often than not, an unsafe bus, a small airplane or a ferry without lifejackets is the only way to get from point A to point B, assuming you really want to or need to get to point B.

You might want to glance elsewhere in my website to read some of my suggestions for staying safe while you travel. Some of the key points include:

  • avoid driving at night, especially in rural areas
  • at least look for a seatbelt when you enter a vehicle
  • don’t get on a motorbike, and at least wear a helmet if you do
  • look both ways, at least twice, before trying to cross the street
  • reconsider whether you really want to take that small plane or ferry to the middle of nowhere
  • say a prayer before getting on that small plane or ferry
  • stay sober, and avoid getting into vehicles with people who are not

Another excellent source of information is the CATMAT (Committee to Advise on Tropical Medicine and Travel) document on the PHAC website.

This posting is not meant to minimize the importance of avoiding infectious diseases. After all, who wants dengue and dysentery. But at least be aware of the non-infectious risks that await you when you venture abroad, and think twice before you do anything there that you wouldn’t do back home.

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a hodgepodge

January 27th, 2013 · Comments Off · Uncategorized

Welcome to 2013. I am a bit slow in writing, as I have been quite busy so far this year.

Vaccine shortages are topical, and sometimes tropical … and perennial, like some allergies … all year round.

A month or two ago there was a recall on single dose TYPHIM Vi, the killed, injectable typhoid vaccine. This vaccine provides about 70% protection for about 3 years. In the wake of that, travel clinics flocked to VIVOTIF, the live, oral vaccine which confers the same degree of protection, but for up to 7 years. Unfortunately, this vaccine involves swallowing capsules, 4 of them on alternate days, and is not licensed for kids under 6, or those who can’t swallow capsules!

With the Typhim Vi shortage, the “oral typhoid vaccine company” became a bit overwhelmed, which led to a shortage of their oral vaccine. Right now, it is touch and go with both typhoid vaccines. The people who suffer are those at the highest risk of contracting typhoid fever, namely, the VFRs (visiting friends and relatives) in places like India, Bangladesh, Pakistan and The Philippines. Much of the typhoid vaccine is “sucked up”, in my humble opinion, by travellers whose itinerary and style of travel puts them at very little risk of the infection. Last week I saw a young lady who had returned from India with typhoid fever. She had not considered taking any vaccine. They only work if you take it … if you can get it!

On another infectious note, Cuba has been reporting cases of cholera once again. As a reminder, cholera is a bacterial infection passed through food and water. It causes a severely dehydrating illness, which may prove fatal in the absence of proper treatment, namely rehydration. Allegedly, this most recent infection originated at the ballpark in Havana, the Estadio Latinamericano!

A year ago almost to the day I was at that same stadium with my son, Michael. We sat right behind home plate for 3 bucks. The game was much more exciting than our Blue Jays. And in restrospect, I am glad I stuck to the peanuts and Coke.

If you are travelling to Cuba, I would always suggest you visit Havana, and if you have the time, take in a ball game. But beware of the food and water. If you insist on eating the local food at the park, consider some pre-emptive Dukoral, a mediocre vaccine against E. coli, the usual cause of tourista, but in fact much more effective against cholera. On second thought, stick to the nuts!

 

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Year end thoughts

December 23rd, 2012 · Comments Off · Uncategorized

Firstly, let me wish anyone and everyone who reads this blog and visits my website and my clinic a happy holiday and a healthy new year. While I have not always been punctual with a new post every week, I have done my best to keep coming up with some topical posts. Some of my staff actually thought that they had missed Prime Minister Harper’s office visit last month!

Many travel medicine memories stand out in my mind from the past year, including, but not limited to:

  • my trip to Havana and Vinales with my son Michael in January
  • my trip to Poland with my daughter Carrie and cousin Susan in October
  • living vicariously through the travels of a few thousand patients in my office
  • admiring the efforts of countless humanitarian volunteers from all walks of life, going to a myriad of destinations
  • the work of CUSO International, for whom I am the medical advisor
  • the tragic death of Shriya Shah-Klorfine on Mount Everest
  • the endless flow of travellers going to other high altitude destinations, such as Machu Picchu and Mount Kilimanjaro
  • a two year old girl who returned from Jamaica with cutaneous larva migrans – an interesting rash
  • recurrent shortages of vaccines including rabies and typhoid vaccine
  • about a half dozen “dogbite” calls from the middle of nowhere
  • quite a few “cramps and diarrhea” calls
  • the reminder that not all illness that occurs during and after travel is related to travel
  • the wonder of Skype when trying to sort out people’s medical problems from afar
  • Malarone going “generic” at the end of the year
  • the continuing feeling that I/we are overimmunizing those who need it least and underimmunizing those who need it most
  • the tragic death of humanitarian Susan Wells in Tanzania less than a month ago
  • the numerous people who travel to exotic locations in spite of their complex medical problems
  • those who celebrate their “big birthdays” with trips of a lifetime
  • the contribution that the movie The Bucket List has made to international travel
  • the great stress of “tight connections”, such as mine between Krakow, Frankfurt and Toronto
  • the option to do it all on your iPad
  • the amount of business travellers enabling all of the outsourcing in India
  • and last but not least, the great enjoyment and satisfaction I get from helping people understand and minimize the risks of travel

Happy New Year

 

Mark

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The Return of Stephen Harper

November 11th, 2012 · Comments Off · Uncategorized

“Stephen Harper….?”

A slightly plump, though less-so than before (see previous post), silver-haired and somewhat green around the gills gentleman walked slowly into my office.

“How was India, Mr. Prime Minister? I enjoyed the picture of you playing cricket over there. I assume you have returned unscathed, though something tells me I am mistaken.”

“India went fine, a piece of cake. It was The Philippines that got to me I think. You never told me I still had to be careful with my food and water there.”

“Woops, your honour. In fact I don’t think you even mentioned The Philippines, though if you had, I would have advised the exact same precautions. In any case, whattya got?”

“Well doc, it hit me on the plane home two days ago. All of a sudden, chills, shakes, aches and pains, and then cramps in my lower tummy. And then, the diarrhea – I swear, every ten minutes all the way home. Never seen anything like it. We almost had to touch down in Newfoundland.”

“Did you have a fever, sir? Did you take the Cipro I prescribed you for such situations?”

“No time to check for a fever. Too busy running down the aisle to the can. But I felt hot. And no, one of my aides put out a call for Cipro on day three in India, and I gave him mine!”

“And I hate to get gross, Mr. Harper, but did you notice any blood or pus or mucous in your stools?”

“Ya know, those airline bathrooms aren’t exactly well lit, and I really wasn’t in the mood to lean over and look, doctor. Whoa boy, hear comes another cramp. Is there a washroom in your office?”

“It’s down the hall, Mr. Harper. Saves on toilet paper and plumber’s fees. While you’re at it down there, how ’bout putting some stool samples in these two different bottles. We can send them off to the lab to look for parasites, which I doubt you have, or for bacteria, which I’m pretty certain you do.”

A slightly relieved looking Harper returned to my office five minutes later.

“That wasn’t as difficult as I thought it would be, Doctor Mark.”

“I knew you could do it, Mr. PM. So, here’s the scoop on your poop. Common things being common, you’ve picked up an intestinal bacteria during your ITM (International Trade Mission). As you didn’t have to pay for it, we could call it a form of free trade! Another joke! It’ll take two days minimum to get a result on your stool culture – the one looking for bacteria. The common bacteria we see in returning travellers are E. coli (not the uncooked hamburger one), salmonella, shigella and campylobacter. My guess is that you picked up the last one. Here’s another script, let’s make it for Zithromax – once a day for three days. Along with that, I would drink lots of clear fluids – Gatorade, soup with salt, tea with sugar.

“You look like a milk kind of guy. Well I would skip it for the next several days as sometimes people get some lactose intolerance along with their traveller’s diarrhea. You can use an Imodium if you want, as long as you don’t see any blood in your stools, now that you have well-lit washrooms. Some people think Imodium is bad … keeps the bad stuff inside you. Whatever you do, don’t use much of it or you won’t shit again til the canal freezes over. Probiotics might help. You can find them over the counter. And don’t be surprised if it takes a little while for your bowels to return to the way they were before your ITM. And don’t forget, wash your hands and use your own towels. Wouldn’t want this to spread through Parliament Hill. I’ll call you as soon as I get your stool results. So might Public Health. Would you like me to Tweet you?”

“Just call my home and leave a message, and thanks for seeing me so quickly, Mark. I still really like your office!”

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Harper does Bangalore

November 3rd, 2012 · Comments Off · Uncategorized

“Stephen Harper?…”

A slightly plump and silver-haired gentleman with glasses rose from the corner of my waiting room and followed me into my office.

“This is quite an interesting office you have, Doctor Wise. Looks like you have been everywhere. Oh, there’s a picture of Mother Teresa on your wall. Did you meet her? And Romeo D’Allaire. Sir Edmund. And who is that guy with Muhammed Ali. Oh, that’s you with a full head of hair!”

“Yes Mister Prime Minister, that’s me and Ali, and yes I’ve been around, but let’s talk about your trip to India. When are you going? Whereabouts in India? For how long? Backpacking? Going to an ashram? Visiting friends and relatives? International trade mission? And call me Mark.”

“You got it, Doctor, I mean Mark. ITM as we call it in  Ottawa. Probably Delhi, the Taj Majal which I hear is breathtaking, and then down to Bangalore, to figure out my Bell bills …that’s a joke, Mark. Only there for five or six days. Back pack … ya right!”"

“Well I assume you’re staying first class, or even better. The best the taxpayer can afford, eh Mr. Prime Minister!”

“That’s right Mark. Can’t negotiate uranium deals if I have Delhi Belly, or would that be Bangalore Bombs?”

“OK. Let’s get down to business. You are NOT at the same risk of illness as would be the Indian family going to visit their loved ones for six weeks in a small village. We call those travellers VFRs – they are going to visit their friends and relatives. They are the ones I really worry about. Even the Eat Love and Pray gang is riskier than you. But, I would still treat you the same. So, here is my Indian advice.

“Don’t trust the food, don’t trust the water. Boil it, bottle it, peel it, cook it …or forget it! My guess is that you are taking a few zillion bottles of Canadian water with you. Don’t be embarassed, many of my Indian patients do too. You say your hotel has 10 stars? I say that is not enough. You are only as good as the last person who handled your food.”

“What if my hosts try and give me a salad, or something else uncooked?”

“Joke, and say “I have a Canadian stomach”, and then turn the conversation to something else, say cricket!”

“And when you get the runs, don’t screw around. Traveller’s Diarrhea is most often a bacterial infection. Imodium, Pepto Bismol, probiotics ….they’re all  nice. But if I were PM, I would quickly start an antibiotic like Cipro or Zithromax, even if just for a day or two. It’ll probably get you better the same day.”

“What about this Dulcolax stuff?”

“That’s Dukoral, Mr. Prime Minister, but you’re not the first one to make that mistake! Well, it’s not a bad thing, gives you protection against E. coli …not the one out in Alberta, a different E. coli. Overall, it gives you about 30-40% protection against all forms of diarrhea. Not bad. Not great. While you’re less likely to get diarrhea than that Indian family, the impact on a five day ITM might be substantial. Do you have a drug plan? Still have a decent pension?Just kidding! If so, it doesn’t usually have much in the way of side effects, and I agree, it’s tough to negotiate free trade deals when you’re on the can!”

“Gotcha, Mark. Now how ’bout malaria? And what’s this dengue thing? I hear some Bollywood legend died of it last week.”

“Well Your Honour, I mean Mister Prime Minister. Both are mosquito-borne infections, and both can make you sick as a dog – fever, headache, aches and pains, chills, shakes … Dengue probably wouldn’t kill you, but malaria, if it went undiagnosed in the midst of a massive flu outbreak in the nation’s capitol, could. By the way, hope the canal freezes over this winter. Gonna be a long winter with no Leafs or Sens.

So, use some insect repellent when you’re out during the day. That’s when the dengue mosquito bites. You’re a bit pale, so you might want to put on some sunscreen first, and then your insect repellent. The best ones contain DEET. DEET is not bad for the environment or Lauren’s skin. But keep it off your BlackBerry and sunglasses!”

“Sure am glad I just have to worry about Chinese oil takeovers and not the NHL. By the way, what about an antimalarial pill? I hear they make you go crazy.”

“Well, with all due respect, Mr. PM, some people think you are already. Just a medical joke! Having said that, your risk of malaria is pretty low, but not zero. Mefloquine, or Lariam, is the one with the weird side effects – insomnia, dizziness, anxiety, depression and bizarre dreams. Let’s not use that one. OK? I’d suggest Malarone – the day before India, daily while in India, and for seven days after you leave India. Doesn’t bother most people, though upset stomachs, mouth ulcers and weird dreams can happen.”

“Any shots, Doc? I’ve been pretty well shot before. Even had my flu shot last week … a bit of a photo op, you know.”

“Well, let’s look at your yellow immunization record. Hmmm, you’ve had the hep A and B series – that’s good for life, and you’re up to date with your tetanus-diphtheria-polio. I’d suggest typhoid vaccine – against typhoid fever, a type of salmonella. It’s passed through food and water. Your risk is awfully low, but what a great headline …  “Canadian trade mission struck by exotic fever. Parliament paralysed. Typhoid suspected.”

“OK. Gimme the typhoid vaccine.”

“Not so easy your Excellency. There is a shortage of the injectable typhoid vaccine. Sort of a recall. And you really don’t have time to take the oral typhoid vaccine as it is a series of four capsules over seven days and you are leaving tomorrow! You’ll have to take your chances on that one, but remember, don’t trust the food and water. If a trade deal depends upon it … well, it’s up to you!”

“Well you’ve been very helpful, Doctor Mark. So, I might say, was your staff. Anything else I should know?”

“Thank you Mr. Prime Minister. We like the fact that people enjoy our office. Oh, regarding that anything else …ya, don’t play with dogs, or monkeys. They’re all over. If you get bitten, wash it, go to my website, and call me, at ….  The jet lag is gonna kill you! Have a great trip Steve.”

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Fainting for the faint of heart!

October 23rd, 2012 · Comments Off · Uncategorized

It’s that time of year again where travel clinics are filling up with people planning on getting away from Canadian winters. Some of these travellers warrant pre-travel inoculations – AKA shots, needles, jabs …..  For most people, this is not a great problem. Their arm may be a bit sore for a day or two, there may be a  bit of pain during the injections, but for most people …that’s about it. Then there are the fainters!

Fainting, or vasovagal syncope, as doctors like to call it, can occur in many different situations, such as, but not limited to:

  • the sight of blood
  • some upsetting news
  • a severe pain, such as a needle or a bad cramp
  • being dehydrated
  • getting up too quickly
  • being on certain medications that lower blood pressure or dilate blood vessels, including  alcohol
  • wearing a hoodie and a scarf in the overheated waiting room
  • standing in line at the bank for too long  in the above mentioned hoodie and scarf

So to summarize, the typical person who faints or almost faints is someone who is young, overdressed, overstressed, underfed, medicated traveller …who then has an upsetting event like a needle and gets up too quickly!

In my experience, it happens most often in young adults and older teenagers, especially tall, lanky guys! And more importantly, PEOPLE WHO HAVE FAINTED BEFORE ARE MUCH MORE LIKELY TO FAINT AGAIN!

The main physiological problem when we faint is that our blood “pools” in our venous system, down in our legs, when it is up in our head/brain that we need it to stay alert and conscious. Fainters usually have a bit of a warning before they faint – they feel woozy or weak or lightheaded or sweaty or nauseated. They look pale as a ghost as their blood exits their head. If they don’t lie down, this will usually progress to fainting, or falling down and losing consciousness. It may resemble a seizure, with eyes rolled back and jerky movements of the extremities. In rare cases, one might lose bladder control. It also needs to be differentiated from other serious conditions such as allergic reactions, a stroke or a cardiac arrest. These latter things don’t usually happen in young, lanky guys!

The treatment of fainting is firstly, to anticipate it. Come to your travel clinic appointment well fed and hydrated. Take off your sweaters and jackets when you arrive at the clinic. IF YOU HAVE FAINTED IN THE PAST, LET THE DOCTOR AND NURSE KNOW. They can then give you your shot lying down, and keep a very watchful eye on you after your needle.

If you do get an injections and you feel “weak and dizzy” …tell the doctor/nurse, and then lie down, and get your feet elevated above your head so the blood comes back due to gravity. There is the temptation to deny one’s “faintability” and say “I’ll be ok!”  Well you won’t be. Lie down with your feet up. Cold washcloths and a sip of water and a sucker are all  nice touches, but the solution is in getting your feet up. Once the colour comesback to your face and your brain starts working again, you can progess to sitting for a while.

WE RECOMMEND THAT ALL INJECTEES STAY IN THE OFFICE FOR AT LEAST FIFTEEN MINUTES AFTER AN INJECTION, DUE TO THE RISK OF FAINTING, AND ALLERGIC REACTIONS. Both of these can be delayed. Sometimes people who faint stay a bit woozy for some time after their initial episode, so never be in a hurry to get out of the doctor’s office!

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