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Anthony and me

October 27th, 2015 · Comments Off · Uncategorized

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

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

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

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

Me: Call me Mark!

Anthony: OK, and call me Tony.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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Hillary and Me

September 20th, 2015 · Comments Off · Uncategorized

me benny poon hill

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

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

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

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

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

hilarycard Copy of mark nepal 2ghosts

autograph biognepal girl2white tdoctorlifehunt1plate



benny pokhara




ngcover1bookcoverblue ttenzing1ghosts


Copy of nepalese girl crop



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Redford and Me

September 11th, 2015 · Comments Off · Uncategorized

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

Copy of mark nepal 2


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

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

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


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

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

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

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Catching up!

August 29th, 2015 · Comments Off · Uncategorized

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

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

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

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

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

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

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

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

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When the dog bites!

March 15th, 2015 · Comments Off · Uncategorized

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

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

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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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