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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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What on earth is going on?

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!


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Nezon aces 17 at CMO 45

June 14th, 2014 · Comments Off · Uncategorized


JEFFCHARMYFOURSOME1STERNFARRELLCLIFF FOURSOME3 GEORGE GROUP HUNDERTSSTERNWAKSCHARMY1History 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.








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Shameless promotion – Demi’s B and B in Niagara-on-the-Lake

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!



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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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