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!
Tags:american express·dr. wise travel medicine·Dukoral·twinrix
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.
Tags:catmat·chikungunya·dr wise travel·Dukoral·ebola·malaria·typhoid
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!
Tags:chikungunya·wise travel blog
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.
October 13th, 2014 · Comments Off · Uncategorized
Infectious diseases related to foreign, usually tropical travel, have always been a concern. Every year I immunize a few thousand people against common, and not so common diseases such as polio, typhoid fever, yellow fever, hepatitis A and B, rabies and Japanese encephalitis. Many reluctantly take malaria pills for prevention, though they worry about side effects. Just about everyone carries some Imodium or Cipro in case they succumb to Montezuma’s Revenge.
Currently, it seems, we are equally worried about the exotic infections that might find their way back here. The tragic Ebola outbreak in West Africa has claimed more than 4000 lives, and the virus has travelled in unsuspecting humans to nearby countries such as Senegal and Nigeria, and not so nearby ones like Spain and the USA. Despite endless assurances from CDC and others, the case in Texas was initially sent home with antibiotics, and a healthcare worker has become infected. There have been “scares” at several Canadian hospitals, including possible cases today in Ottawa and Belleville. Is it any wonder that this is a tremendously difficult infection to contain in a place like Liberia, when we see people falling through the cracks over here.
Chikungunya virus has been around for years in Africa and Asia. This mosquito-borne infection made its debut in the Caribbean in December 2013, and has since spread to other islands in the Caribbean, and to countries in South and Central America, including Florida! It is similar to dengue virus, and causes a high fever, headache and severe aches and pains. Some victims may suffer with prolonged arthritis.
Patients are starting to ask if it is safe to take their children down south for a vacation this winter. The answer is “pretty safe”, and make sure you use some insect repellent during daytime biting hours.
MERS (Middle East Respiratory Syndrome) is centred in Saudi Arabia, but has also been reported in most of the nearby countries in the Gulf. It is characterized by fever, cough and shortness of breath. The elderly and chronically ill, and close contacts and healthcare workers are at increased risk. It has an incubation period of up to two weeks, so it not inconceivable that Muslims returning from October’s Hajj in Mecca might show up coughing in local walk-in clinics any day now.
I vividly recall my son Benjamin acting as our SARS screener in 2003, when my Toronto office was smack in the middle of the outbreak. We haven’t hired a screener this time, yet, but we do have “tools” to identify who might be carrying a serious infection, and the mask, gowns and gloves are within easy reach. Public health and our local hospital have been invaluable in keeping us abreast of the current situations.
So, do you travel abroad, and risk contracting “tropical” infections, or do you stay home, and wait for them to come to you? Thankfully, the risk to most of us, no matter which we choose, is very low. Keeping yourself informed and washing your hands (and putting on some insect repellent) will likely keep most of us healthy.
And, don’t forget to get your flu shot!
Tags:chikungunya·ebola virus·MERS·wise travel
June 14th, 2014 · Comments Off · Uncategorized
History was made at today’s 45th Chocolate Milk Open, when Jeff Nezon made the first hole-in-one in our long history. It happened on Dentonia Park’s demanding 17th hole, unfortunately just one hole shy of the closest to the hole prize. An audible shout was heard on the course as the ball rolled into the hole, but it took several minutes for the news to reach the other proud players. Along with the disbelief was the feeling “well, it’s about time”. Congratulations Jeff for making CMO history.
Not to be overshadowed by Nezon’s feat was the equally impressive winning score of 58 by now two-time winner Richard Fink. Fink, who may be better known as the coach of the Royals in the now defunct Saturday Afternoon Baseball League (SABL), will be tough to beat in the future.
Closest-to-the-hole honours went to the no longer lactose intolerant and past CMO champ Paul Axelrod. Fish and chips were again enjoyed at Charmy’s, who will soon be celebrating their 10th anniversary.
Finally, $1000 was raised for the Panov Program at Mount Sinai Hospital for Precision Chemotherapy.
Tags:chocolate milk open·dentonia park·panov program·the travelclinic
May 24th, 2014 · Comments Off · Uncategorized
Not everyone wants to travel to Africa and expose themselves to malaria, diarrhea, typhoid fever, Ebola and sleeping sickness. Some would rather stay close to home, which if you live in Toronto, or close to Toronto, might include Niagara-on-the-Lake. If you love wine, theatre, relaxing, biking, hiking and fine dining, why shlep to Nepal when you have it all in NOTL. You can drink the water!
For the past 10 years in my Family and Travel Medicine practice, I have had the pleasure of working with Demi Nasello. She has made my patients feel comfortable and at the same time looked after all of their needs so efficiently. Along with her husband Ed, she has relocated to NOTL and opened a B and B …. Demi’s Place.
It is steps from the main street of NOTL. You might want to spend a few days there even if you detest wine and theatre. Aside from being a beautiful home with lovely gardens and a hot tub and breakfast to die for, you will find your hosts delightful and accommodating. My books and some of my African knick-knacks adorn their bookshelves and walls.
So, if you need to wind down from the craziness of New Delhi or Bangkok, think about a few nights at Demi’s Place. No shots are needed!
Tags:Demi's Place·niagara on the lake·Shaw Festival
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.
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.
Tags:blog travel health·dengue florida·health.express.uk·typhim vi·typhoid fever
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
- 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.