drwisetravel.com

I apologize for having been a bit lazy on the posts as of late. We have recently changed over to electronic medical records in our office – lots of new machines, training, aggravation. That’s my excuse!

By now, everyone who has planned a trip down south somewhere for the holidays should be prepared. Health Canada’s website clearly states that the risk of malaria to travellers to the Dominican Republic / Punta Cana is very low. In spite of that, GSK continues to advertise over the radio in order to scare Canadians into taking their antimalarial for such low risk trips.

Dukoral is undoubtedly flying off the shelves faster than Ferarro Rocher chocolates.

This, in spite of its limited efficacy. But, alot of people are of the mind that almost anything is worth it to lower one’s risk. As you recall, I am a bit of a minimalist.
The floods in Thailand have not dampened the number of travellers going over there. Almost nothing keeps people from Thailand! Egypt, on the other hand, must be receiving very few tourists these days judging by what I see in my clinic.

I’ll stop there. I would like to wish all of you travellers who visit my site a safe and healthy New Year, and hope that you have some exciting travels to look forward to next year.

Mark

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This week’s CMAJ highlights The Canadian Task Force on Preventive Health Care’s “Recommendations on screening for breast cancer in average-risk women aged 40-74 years”. These guidelines, which I believe were last published in 2001, make some dramatic new recommendations, such as, it is no longer worthwhile for doctors or women themselves to perform breast examination.

Why is this pertinent on a travel medicine website? Well, you might have wondered what guidelines travel medicine professionals adhere to. Why does one travel doctor suggest a typhoid shot for travel to China, and another not. Does everyone need Twinrix vaccine (hepatitis A and B)?

How about the pricey ones … do I need Japanese encephalitis and rabies vaccine for that five week trip to Asia? Which antimalarial is best?

Well, we do have several sources of reputable guidelines. These include the Centres for Disease Control (CDC), the Public Health Association of Canada (PHAC) and the World Health Organization (WHO). In fact, these three sources are not always in agreement with each other. But that is the way things are with guidelines. They are not etched in stone. They reflect the opinions of those who publish the guidelines, and their perspectives may differ from a geographic, political and economic point of view.

The Europeans don’t recommend antimalarial medications for travellers to India … rather, use personal protective measures, and seek medical attention if you develop a fever during or after travel. We here in North America do. The Americans are still suggesting antimalarials for tourists to the Dominican Republic. Canada, to the best of my knowledge isn’t.

Likely more important than any guidelines are the opinions of the traveller and his or her medical advisor. Some travellers won’t accept any risk at all – “Give me all of the shots! What’s the downside?” Others might say ““The risk is low. I can use my common sense, and use my vaccine money for a month’s woth of meals!!” Some travel health professionals may recommend the “whole enchilada! I don’t wanna take any risk on your behalf … and in fact, I am making a profit on the vaccines which you take“. (a bit controversial).

Others might also say “Your risk is low. Be careful and use the loot to pay for your youth hostels for a month.”

That’s probably how it should be. A mixture of guidelines, combined with the traveller’s and their health advisor’s opinions. That’s how it is in the rest of medicine, and perhaps life. Here are the guidelines … here’s what I think. What do you want to do?

A plug for one of my children, Carrie, who is a social worker in Kingston, Ontario. She has opened her private practice for counselling, with a special interest in eating disorders. If you are in the Kingston area and could use her services, check out her website.

Movies are what dreams are made of. They make you laugh, they make you love, and they might make you want to travel.

I say this with conviction as my life was changed by a movie, namely Butch Cassidy and The Sundance Kid. In that classic, Butch and Sundance (Paul Newman and Robert Redford) ran out of American banks to rob, so they moved, or perhaps fled, to Bolivia. In 1973, inspired by their exploits, I too travelled to Bolivia, with a bit of backpacking through Colombia, Ecuador and Peru on the way. This led me to the study and practice of tropical and travel medicine, and eventually to this website and blog.

Many other movies must have been people’s impetus to travel. Sideways probably enticed a lot of wine lovers to California. Out of Africa sparked interest in the games reserves of East Africa. Gandhi and Slumdog Millionaire attracted travellers to India and Seven Years in Tibet to, you guessed it, Tibet! Eat Pray Love must have boosted tourism to Italy, India and Bali.

Today I went to see The Way, starring Martin Sheen, the former American president, and his son, Emilio Estavez. To make a long story short , (I wish someone had made the movie a bit shorter) the movie  is about Martin’s hike along the El Camino de Santiago trail in Northern Spain, to complete the dream of his son, who had tragically died in an accident on the same adventure. Understandably bereaved, Martin manages to cast a pall across almost the entire movie, though he does manage to shed some of his moreoseness towards the end. Hopefully his apparel supplier, The North Face, will not suffer from the exposure. He accumulates three hiking partners. An overweight but friendly Dutchman, a gaunt, Canadian chain smoker, and an initially psychotic Irish writer. While I would have thought the plotline would have allowed some insight into the less than ideal relationship between father and deceased son, very little time in fact dwelt on that potential aspect of the story.

Most of it had to do with the rugged scenery, the inadequate sleeping facilities, the abundant wine, and Martin Sheen rolling his eyeballs! Perhaps if Martin had become romantically involved with the much younger cigarette-addicted Canadian, things would have been a bit more exciting. Probably the greatest health risks encountered in this movie would be blisters, hypothermia and hangovers. But, if the silver screen entices you to India, Asia or Africa, malaria, dengue, diarrhea and much more await you.

So, there are many reasons why we travel. What we see in the movies is one of them. Check this one out if hiking, Spain, wine and father-son relationships intrigues you. My suggestion is that you rent or download The African Queen, even if you don’t plan to go there!

“To everything, turn…turn…turn

To every season, turn…turn…turn …”

Well it seems to be the season for dengue fever. If you Google dengue fever (conflict of interest … my son Benjamin now works for Google) you will find many useful medical sites, as well as the musical site for the band Dengue Fever. My son Michael’s band is called The Midway State, but how I wish they would have adopted a “tropical name” such as Tickbite Fever, Delhi Belly, Aleppo Boil, Creeping Eruption or Ciguatera Poisoning!

Anyways, back to dengue fever. I have seen and heard of a few patients with this viral illness in the past week. Dengue is transmitted by the Aedes mosquito, which likes to bite during daytime hours, and often in urban areas where there are small collections of water to breed in such as empty tires, planters, construction sites, etc. Dengue has a short incubation period (3-7 days), which means it is going to make you sick fairly soon after your exposure, rather than weeks or months later which might be the case with malaria, typhoid or hepatitis. This infection is on the increase worldwide, as opposed to malaria which is experiencing a decline. Perhaps this is due to factors such as global warming, urban migration and lack of mosquito control programs.

The classical symptoms of dengue are:

• a high fever
• a severe headache, usually behind the eyes
• miserable aches and pains in the bones, hence its nickname “breakbone fever” (another good name for a band)
• a rash towards the end of the illness

Of course, these may overlap with the symptoms of several other tropical and non-tropical infections, such as malaria, typhoid fever, hepatitis, pneumonia, infectious mononucleosis, kidney infections … and much more. The laboratory can be quite helpful in the diagnosis of dengue – the white blood cell count (WBC) may be a bit low, the platelet count (the little cells that help you form a blood clot) are usually low, and the liver function tests may be elevated. Again, many of these lab abnormalities might be present with the other possible diagnoses. Tests which detect antibodies to the dengue virus are the most important way to diagnose dengue, though by the time you receive the results of these tests, the patient / you may be all better, and hopefully hasn’t succumbed to something else.

Perhaps the most important point for you, the  traveller with a fever, is to make sure that you are seeing a doctor with experience in tropical, and non-tropical medicine. They should know where there is dengue, where there is malaria … and where there isn’t, what else should be considered, what tests to do, and how to treat whatever it is that you may have.

As with malaria, there are four strains of dengue fever. They may not all be circulating in the same place at the same time. The concern is that if you, or anyone else (such as a local 7 year old boy) is exposed to a second strain of dengue after a previous infection, a more serious illness called dengue hemorrhagic fever may develop. This can cause severe bleeding problems and may prove fatal without adequate supportive care.

As with most, though not all, viral infections, there is no specific treatment for dengue fever. Symptoms such as fever and pain can be treated with acetaminophen (not aspirin due to the tendency to bleed). Dengue usually resolves after about a week, though fatigue and depression may persist for some time. Dengue hemorrhagic fever may require more sophisticated treatment involving the replacement of clotting factors.

So, if you are travelling to the tropics, consider putting on some insect repellent during the day. If you are a doctor or nurse seeing patients returning from the tropics, don’t forget about dengue, or malaria for that matter.

I was away camping in Algonquin Park over the weekend. A bit colder than my recent trip to Nicaragua. Hence, I really haven’t had time to write my blog. Fortunately, I have come across a  guest blogger! In the words of Julie Vance ….

I write articles for http://mphdegree.org/, a website dedicated to providing
students with the information and tools needed in order to pursue their MPH
Degree.

I think you’ll find Julie’s article, A Public Health Primer to International Travel helpful and relevent. It is written from the American point of view, which public health / travel wise, is not much different than ours. You will find equivalent Canadian references and links in my site.

Have a goood week. Thanks Julie.

Mark

Another week … another disaster involving tourists. This tragic incident involved a Bhudda Air flight from Kathmandu over Everest, which crashed on its return to Kathmandu. Sixteen people were killed. Again the thought “Gee, that could have happened to me.” I took that same flight in 2001 with my son Benjamin. The weather was perfectly clear for our flight, and Benny and I were the lone North Americans amongst a planeful of Japanese tourists. When we deplaned after seeing Everest, we were presented with our official certificate. Four months after our return home, the royal family in Nepal was massacred. Tourism to this beautiful country, according to the travellers I see in my office, has still not recovered. This tragedy will certainly make people think twice about taking the once in a lifetime flight over Everest. Here you see  our brief view of the world’s tallest mountain.

On a nearby note, it seems this is the ideal time to visit India. The monsoons are over, and the bugs and the infections they transmit have disappeared … or have they. Dengue fever and chikungunya virus are two mosquito-borne infections that are probably most prevalent in the summer monsoon months, especially in the south. But they do get up to more northern parts of India. The question becomes … when does the risk disappear?

Malaria, a more serious mosquito-borne infection, occurs throughout India. However it is probably less of a problem in urban areas, further north, or in their “winter”. I recall landing in New Delhi many years ago in January to the sight of people wearing shawls and scarves and sitting around fires. Being Canadian, I only wore a T-shirt. But there were really no mosquitoes. I believe that the recommendation stemming from European travel medicine experts is not to prescribe antimalarials to travellers to India, as the risk is low. Insect precautions are encouraged, and of course people are advised to seek medical attention should they develop a fever. In North America, we tend to have a “zero tolerance” attitude towards antimalarials and India. We/I recommend them, though as the cooler weather approaches and many of my patients only go to Rajasthan, I tell them the risk is quite low.

If I were to rank all of the world’s countries according to their risk of traveller’s diarrhea, India would be at the top, perhaps tied with Egypt and Cameroun! All of the Dukoral in the world doesn’t seem to be able to stop the inevitable. Neither does the usual “Boil it, bottle it, peel it, cook it …. or forget it“. Part of the reason the latter phrase doesn’t do it, is that people don’t do it! Their hotels are five star and not inexpensive. Hence they think the food is safe, regardless of how it has been prepared, stored or handled.

The usual treatment of traveller’s diarrhea, or Delhi Belly as it is affectionately known as there, is clear fluids, perhaps a shot of Imodium or PeptoBismol, and when necessary, an antibiotic such as Cipro or Zithromax. One of the bacteria responsible for TD is Campylobacter, and it is becoming increasingly resistant to Cipro, especially in Thailand and Vietnam, but also India and Nepal. The $64,000 question (does anyone still remember that program) is when is that antibiotic necessary. The obvious answers are when you are very ill with fever and chills, if there is blood or mucous in your stools (dysentery), when your trips to the john are very frequent, or when you aren’t getting better in a day or two with steps one and two.

Other options for using an antibiotic a bit more promptly include, but are not limited to: I have no toilet paper, I can’t get up from a squat, this bus has no toilet, the train has one but I don’t want to use it, and last but not least, I just want to feel better more quickly! I tend to be an early user of antibiotics – even just for a day – when my bowels go wonky in a hot climate. I realize that others are more concerned about the adverse effects of such drugs than I am. To each their own.

Mefloquine (Lariam) has been one of the mainstays of antimalarial prevention since the parasite (P. falciparum) developed resistance to chloroquine. It has been available in Canada since the early 90s, and has been the subject of controversy ever since. A major part of that controversy stems from the behaviour of  a Canadian soldier in Somalia. If you want to read more about that incident and its investigation, click here.

Travel and tropical medicine frequently find themselves the subject of our entertainment – books, movies and the like. Who can forget that slow motion infectious sneeze in the movie “Outbreak“, and the new movie Contagion is currently raking in the dollars at the box office. A recent novel I read by Ann Patchett, entitled State of Wonder, works in the mefloquine controversy. In the novel about a pharmaceutical company doing questionable research in the Amazon, the protagonist, Marina, reminisces on her frequent trips to India to visit her father. Neither the trips, nor her relationship with her Dad worked out very well, though it wasn’t until several years later that she attributed this to the mefloquine which she would take each time for malaria prophylaxis.

So what is the place of mefloquine these days considering we have Malarone (atovaquone/proguanil) which is allegedly almost free of side effects (though at least five bucks a pill?).

Keeep in mind that mefloquine is relatively inexpensive (now that it is generecized) and only has to be taken once a week, rather than daily. It needs to be continued for four weeks following exposure, and is best started two to three weeks in advance in the hope that adverse effects will show themselves early …. though this is not always the case. Kids do not usually suffer the neuropsychiatric side effects, though they will get tummy aches if the don’t take it with food. People who have taken mefloquine in the past with no or minimal side effects are also great candidates to take it again. It is the only antimalarial that is considered safe in pregnancy, and is the least likely to interfere with blood-thinning drugs or anticoagulants.

From my “scientific” research amongst longer term volunteers, the commonest side effect from mefloquine was “crazy dreams”, or “vivid dreams”. At times, these could be disturbing and frightening, and would warrant stopping the medication.  Most of the time they were just more memorable, or rememberable. Anxiety and depression was much less common, though more concerning.The only episodes of psychosis that I have seen have been in those overdoing their alcohol or other drugs. I continue to recommend mefloquine for past users, young users, and those without a past history of anxiety or depression who are looking for an inexpensive, convenient antimalarial. I avoid it when possible in teenage/young adult first time travellers, especially women. Doxycycline is another good alternative, as long as its potential adverse effects are kept in mind.

So, I would recommend the book State of Wonder, and I plan to see Contagion, and if I went to Africa again for a few weeks, I would probably take mefloquine again!

One of my first trips to Africa was about 15 years ago. At that time, VSO (Voluntary Service Overseas – now CUSO-VSO) Canada, of which I was, and still am, the medical advisor, sent me over to visit our Canadian volunteers. This took me on a three week whirlwind trip around Kenya and Tanzania. Two of my fondest memories were visiting the islands of Lamu, off the coast of Kenya, and Pemba, an island off of Tanzania, and taking the ferry boat to Zanzibar for a day’s visit.

Two disturbing headlines this week have brought back those memories, and made me once again realize how unpredictable life can be. An overcrowded ferry sunk off the Tanzanian coast while travelling between the Zanzibarian islands of Unguja and Pemba. 200 people were lost, and thankfully 600 were rescued. To quote the BBC … Survivors said it was dangerously overloaded with passengers and cargo and was
listing when it left port.

Today, it was reported that Somali gunmen killed a British tourist and his wife was kidnapped from a luxury resort on the coast of Kenya, quite close to Lamu. This apparently was not the first such kidnapping in the area.

In most travel clinics, including mine, we dwell mostly on the infectious risks – what can be prevented by vaccines, antimalarials and treated with Imodium and Cipro! But we should be paying at least some attention to the huge issue of personal safety. I have read more than my share of “sinking ferry” stories over the years, and I cringe a bit when my patient tells me they are taking the local ferry over to their idyllic island. One also went over not long ago in Halong Bay off the Vietnamese coast. This is not to discourage you all from taking ferries. But just as I say with buses, if they look dangerously overcrowded and are tilting off to one side, you might wait for another, better-looking one to come by. I really don’t know whether this particular ferry was the same quality as the one I took many years ago.

With respect to the killing and kidnapping on the coast of Kenya by Somalian gunmen, you might want to read the book The Pirates of Somalia, by Jay Bahadur, for a little more insight into what may go on in that part of the world. I certainly wouldn’t discourage trips to luxury resorts on the coast of Kenya, or almost anywhere for that matter, but do keep in mind that tourists, because of their “relative wealth”, will always be a target for those with a disregard for human life and well-being and wishing a shortcut to some money.

My advice has always been to use your common sense, be aware of your surroundings, understand the risks of local transportation and follow the “travel advisories” which highlight places to be avoided or visited with caution.

On a more posittive note, my son Michael’s band, The Midway State, played the national anthems at the Toronto Blue Jay – Boston Red Sox game this week. The Red Sox won 14-0, making the national anthems the obvious highlight of the evening!

It is pretty easy for me to look after the “high-risk” traveller, that is, one going off to the middle of nowhere for a long time with very little money, medical support and perhaps common sense! I recommend most of the shots (though they often can’t afford them) and REALLY stress the importance of one’s personal behaviour when it comes to culinary choices, insect avoidance, dogs and sex and vehicle exposure, and much more. But what about the person going on one of the following:

• five days to Nairobi and Mombasa to deliver a lecture
• a two week cruise with excursions in urban spots of southeast Asia or the Caribbean or Central America
• a week at a 5 or more star resort in Costa Rica
• a two night stay at Iguacu Falls in Brasil
• a honeymoon in Bali
• a trip to South Africa with 3 nights in Kruger National Park
• a week in Rajasthan (northern India) in January when the mosquitoes are few and far between
• 3 nights in the Amazon at Puerto Maldonado after visiting Machu Picchu in Peru

Certainly all of the above mentioned travellers are entitled to the whole enchilada – shots against yellow fever, hepatitis A, B, typhoid, Japanese encephalitis and rabies, antimalarials and Dukoral for traveller’s diarrhea. But there is a time and place to minimize what you recommend to low risk travellers. Of course, that is after you have explained how to minimize the risks (Boil it, bottle it, etc., cover up at night and use insect repellents, don’t play with the dogs, or anything for that matter …).

When I counsel the “low-risk” traveller, I take into account several factors, such as:

• what will be the impact of illness upon their trip (a  day of diarrhea on a four day business trip is not a great thing)
• how careful will they be able to be
• what is their risk tolerance
• are they aware of what to do if they become ill – either abroad or back at home
• who is paying for their preventative shots, etc.
• how low is the actual risk – often it is very low
• what is the risk of giving that shot – for example, the risk of a yellow fever shot in an 80 year old might actually exceed the risk of the infection
• what does their spouse want them to do

After a bit of discussion, we usually arrive at an approach that makes me, the patient and their spouse, and perhaps their employer, happy and comfortable. Some patients are willing to take a small risk, others will ask for every precaution regardless of their risk. Remember …. The doctor / nurse advises …. but the patient / traveller decides.

I try to live vicariously through my travelling patients. That is, I don’t let them do all of the travelling, but I hope that I don’t also get their medical problems. Didn’t quite work this way following my recent week in Nicaragua!

About 5 days after I returned, my bowel movements, how shall I say it, turned a bit funny. Diarrhea would be the proper word. No fever, not too frequent, no blood or pus in my stools. But in order to be better able to relate to my patients, I decided to do a stool test. Surprisingly to me, I was infected with Campylobacter, a bacteria usually transmitted through contaminated food (often chicken or dairy producuts). By the time I got the result, I was really all better. Hadn’t even stopped eating.

I consider my self quite lucky, as this bacteria really can cause quite a wicked illness, with fever, chills, aches and pains, and dysentery (diarrhea with blood and pus). You don’t need to  travel to get this, though it helps. It is usually treated with ciprofloxacin or azythromycin. I am not always the most careful eater when I travel, though I tell all of my pateints to be scrupulously careful! So I suppose that the onions or tomatoes that I spread over my burrito might have been the culprit, as I am pretty careful with what I drink – bottled water, beer, Coke and wine.

I have had a few other sick travellers return home this week. Two of them had a fever, which turned out to be from paratyphoid fever and pneumonia respectively. In both cases, other infections such as malaria, typhoid fever and dengue had to be considered.

So, will I be more careful next time I travel to the tropics? Maybe. We’ll see. I have some time to think about it before my next trip!