House Call, MD: Health Carefully Explained

by Georgina Lee, PharmD 2011 | lee@myhousecallmd.com

With summer just around the corner, your dreams of traveling are very close to becoming a reality.  You open up your inbox and find ten unread messages highlighted in bold.  One of them may be from Aunt Sally but the rest have subjects like “$99 roundtrip airfare to Jamaica!”  Suddenly, a spark ignites and you start clicking on ads from Expedia, Jetblue, and Virgin and the next thing you know, you and five other friends are going to Timbuktu next week.

Before you start debating whether to pack your blue swim trunks versus the red ones, there are a few important questions you and your travel mates should ask:

•    Will I be going out of the country? If so, how many countries will I be visiting?

•    When will I be leaving and how long will I be staying at each destination?

•    What are my accommodations and what kind of activities will I be doing?

•    How am I traveling at my destination? (Hike, backpack, train, etc.)

•    What is my personal medical history including current medications, allergies, and other considerations or limitations?

When most people think of travel medicine, they think “vaccines” and “bothersome.”  In a 2003 U.S. airport survey, only 36% of travelers sought travel health advice.  73% of them went to high-risk malaria regions and, of those, only 46% brought along anti-malarial medications.  Most were traveling to regions where Hepatitis A was prevalent but only 14% of travelers were immunized.  Overall, vaccination rates were as low as 11% and 13% with respect to Tetanus Diphtheria (Td) and Hepatitis B.

For those who are asking “Well, how dangerous could it really be?”  Here are some statistics that might raise your eyebrows:

According to a network of specialized travel medicine clinics called GeoSentinel, the number of travelers with likely exposure ranged from less than 100 to over 1000 people in places like Mexico, South America, India, and parts of Southeast Asia.

Likely Country of Exposure in Patients Seen After Travel

(September 2009; n=43,216 Travelers with Known Country of Likely Exposure)

GeoSentinel and the CDC also collected data on large samples of sick travelers, specifically those who traveled to many countries, after they returned home.  Based on 17,353 travelers seen at 31 clinical sites on six continents, the following region-specific disease occurrences were found:

•    Febrile illness is most likely from Africa and Southeast Asia

•    Malaria is among the top three diagnoses from every region

•    Over the past decade Dengue Fever has become the most common febrile illness from every region outside sub-Saharan Africa

•    In sub-Saharan Africa, rickettsial disease (which causes a number of illnesses including Typhus and Spotted Fever) is second only to malaria as a cause of fever

•    Respiratory disease is most likely in Southeast Asia

•    Acute diarrhea is disproportionately seen in travelers from South Central Asia

In addition, 226 out of every 1,000 sick travelers had a systemic febrile illness, 222 had acute diarrhea, 170 had a dermatologic disorder, 113 had chronic diarrhea, and 77 had a respiratory disorder.  This doesn’t even include road travel-related deaths, falls, drowning, heat stroke, homicide, or altitude-related injuries.

Starting to sound scary?  The good news is that you and your friends can still go camel back riding in Peru or climb the Great Wall of China without fear, as long as you take the necessary precautions before traveling.  An ounce of prevention before you leave can make or break your trip.

Routine Vaccines

Tetanus-Diptheria (Td) and Pertussis

Everyone should get Td because you can get contract these illnesses almost anywhere, from countries like Russia and Eastern Europe to your own backyard!  It’s important to keep in mind that a routine booster is required every 10 years.

Influenza

This is also known as your flu shot, which is now available through both intranasal and injection routes of administration.  If you have a severe allergy to eggs or have other medical conditions, do not get the flu shot without consulting your doctor first.

MMR (Measles, Mumps, Rubella)

Did you know that most travelers should have 2 doses of MMR?

Update other routine vaccines

A pneumococcal vaccine is indicated for people who are 65 and older and individuals with certain medical conditions.  The Zoster vaccine (which protects you against chickenpox and shingles…note that they are caused by the same virus) is also indicated for people who are 60 and older so be sure to double check your immunization records before you hop on a plane.

Food/Water Borne Diseases

Catching a stomach bug while traveling is about as miserable as it gets.  Follow these simple tips to help prevent yourself from falling victim to the plethora of infections out there waiting to wreak havoc on your stomach.

“Cook it, peel it, boil it, or forget it!”

• Make sure all your food has been thoroughly cooked and comes out steaming hot.

• Avoid raw fruits and vegetables unless they can be washed in clean water and peeled by the traveler (think of the red apple from the movie Snow White).  If you can’t peel it yourself, you’ll have to trust that whoever brought it to you did a stellar job of washing it.  Are you willing to roll the dice?

• Drink only beverages made with boiled water (coffee, tea) or bottled water (double check the sealing)

• Avoid tap water and anything mixed with water or ice

Traveler’s Diarrhea

This is probably the most common travel-related health problem for our jet setters.   It usually occurs within the first 14 days of travel, especially if it is caused by bacteria (such as E. coli).  It’s defined as having three or more loose stools in an 8-hour period or four or more loose stools in a 24-hour period plus other symptoms like stomach cramps, nausea, etc.  Sexy, we know.  Typically, traveler’s diarrhea is self-limiting (i.e. goes away on its own) and will last 3-5 days.  So how do you prevent it?  Standard food and water precautions should suffice.  For the hypochondriacs in the room, antibiotics such as TMP/SMX (Bactrim), or ciprofloxacin and levofloxacin can be used.  However, because many diarrheas go away without medication, using an over-the-counter medicine like Loperamide (Imodium) which slows down your overactive bowels should suffice for mild to moderate diarrhea.

Typhoid

People usually contract typhoid fever from food and water contaminated with the bacteria, Salmonella typhi.  Typhoid vaccines are 60-70% effective against this critter and can be administered as a pill or an injection.  The pill form provides 5 years of immunity and needs to be completed 7-10 days before departure.  Alternatively, The injection is a single dose that lasts for 2 years and needs to be given 14 days prior to departure.  Note: the pill form needs to be taken every other day (three doses total) and the pill causes mild gastric discomfort (i.e. an upset stomach for a few days).

Hepatitis A

Hepatitis A isn’t nearly as famous as Hepatitis B but is a virus you will definitely want to avoid during your next trip.  Hep A is transmitted via contaminated food and water and person-to-person.  Morbidity increases with age and reports show 2% mortality in those greater than 40 years of age.  Countries like South America, Mexico, China, India, Africa, and even Greenland have an elevated prevalence of Hep A.  Vaccines are very effective and well tolerated and should be administered 2-4 weeks prior to departure.

Poliomyelitis

This is an acute viral infection that typically involves the gastrointestinal tract.  At the end of 2007, areas of polio risk included Sub-Saharan Africa, Southeast Asia, and the Middle East.  Food, water hygiene and vaccinations remain the best defenses against this infection.

Diseases you can catch via Person-to-Person contact (watch out snugglers!)

Hepatitis B and C

Hepatitis B is transmitted via blood, saliva and sexual contact.  Hepatitis C is transmitted via blood.  There is an excellent vaccine for Hepatitis B but there is currently NO vaccine to prevent Hepatitis C.  You Hep B vaccine options include two interchangeable Hep B vaccines and a combination Hep A and B vaccine.  Since the Hep B vaccine consists of three shots given at 0,1, and 6 month intervals, plan ahead so that you’re fully vaccinated by the time you leave for your trip.

Meningitis

This is an acute bacterial infection that is spread by respiratory droplets (i.e. saliva and those tiny drops of water that fly everywhere when you sneeze), close personal contact, and nasal secretions.  Saudi Arabia, where Meningitis is common, requires a vaccine for those who travel to Mecca during the Hajj pilgrimage.  Additionally, the “Meningitis Belt” includes Sub-Saharan Africa and Asia wher risk is especially high during the dry season (Dec-June).  There are two vaccines available, both of which take 7-10 days to take effect.

Tuberculosis

TB is a bacterial respiratory disease spread by airborne respiratory droplets.  Risks to travelers include areas highly endemic with TB such as Sub-Saharan Africa, Russia, and Asia.  The vaccine is given at birth in many developing countries but not used in the U.S. due to variable efficacy.  However, it’s important to get screened either via the PPD skin test or chest x-ray from your provider.

Vector-Borne Illnesses (i.e. disease you get from critters)

Although vampire movies are all the rage right now, mosquitoes are unmatched in their ability to suck blood and transmit diseases (only they’re not as good looking).  Enter the insect repellent arms race!  The most common types of insect repellants are:

•    DEET

•    Picaridin

•    Oil of Lemon Eucalyptus

•    Soybean oil

•    Citronella

(Bold = CDC Recommended)

DEET is considered the most effective insect repellant by the CDC.  Two important variables with repellents are Protection and Retention Time, both of which are concentration dependent (10-35% formulations provide adequate protection for 3-6 hours while 50-100% formulations increase protection time by 1 additional hour).  At the same time, more is not always better.  Using too much DEET in high concentrations can lead to DEET toxicity in the form of skin irritation, allergies and, in rare cases, encephalopathy (brain swelling) and seizures.  Another important tip is to avoid products that contain both DEET and sunscreen because the DEET can decrease the effectiveness of the sunscreen.  Therefore, you should apply sunscreen FIRST followed by DEET 1-2 hours later.  Yes, we realize this is a huge pain…but not nearly as bad as malaria.  Travelers can also use Permethrin spray (another insecticide) that can be applied to clothes and lasts for 2 weeks or 2 washings (whichever comes first depending on your personal hygiene).

Malaria

There are currently 500 million cases worldwide and 1 million deaths reported annually as a result of malaria.  Clinically, there is a 10-14 day incubation period followed by fever, malaise (i.e. you feel like poop), headaches, chills, diarrhea and sweats.  The risk of malaria after 1 month of travel with no preventive medications are as follows:

•    Oceania                                           1:5

•    Africa                                               1:50

•    S. Asia                                              1:250

•    SE Asia                                            1:2,500

•    Mexico and Central America      1:10,000

There are a ton of options for malaria-preventing medications depending on the species of mosquito in the region you visit.   The drugs are categorized as Chloroquine-sensitive P. vivax malaria, Chloroquine-resistant P. falciparum malaria (CRPF), and Mefloquine-resistant P. falciparum malaria (MRPF).  There are many choices within each category and your physician will choose the best option for you based on your current medical history (pregnant, psychiatric disorders, drug interactions, etc.) and your travel itinerary.

Dengue Fever & Chikungunya

This virus is the result of a marriage between an African virus and an Asian mosquito.  It can be self-limiting and is associated with fever and joint/muscle pain that lasts for 2-3 weeks.  It is also associated with a 30% mortality rate (not a good thing).  Unfortunately, there is NO vaccine and NO treatment available so the best way to prevent this disease is by using DEET and/or Permethrin.  Countries with a notable risk of Dengue Fever include Mexico, South America, Sub-Saharan Africa, India, and Southeast Asia.

Yellow Fever

Prevalent in countries including Brazil, Peru, Colombia, and the entire Sub-Saharan region of Africa, this viral disease is transmitted via mosquitoes (surprise, surprise).  The incubation period is usually 3-6 days and symptoms range from subclinical (i.e. you don’t ever notice it) to severe (i.e. multiple organ system failure).  There are roughly 200,000 cases per year, 30,000 of which are fatal, leading to a mortality rate of 15% annually.  Each dose of the Yellow Fever vaccine lasts for 10 years and needs to be administered 10 days before entering the country of risk.

Japanese Encephalitis

This virus is extremely rare.  You are at risk if you spend extensive amounts of time in a rural outdoor setting in the evening (we told you it was rare).  Incubation is typically 4-14 days and is associated with fever, chills, headache, nausea, vomiting, and neurological symptoms.  Of note, 30% of encephalitis cases are fatal but encephalitis is rare in most parts of the world (except for countries in Southeast Asia such as Indonesia).  A 2-dose vaccine is available that needs to be administered 28 days apart, so plan accordingly if traveling to a destination that has a high risk of Japanese Encephalitis both seasonal or year round.

Okay, I’ve consulted my provider and received the necessary vaccines for my trip, does that mean I’m done?

The answer is almost, but not quite!  Avoiding/preventing infection is a big part of staying healthy while traveling but not the only health aspect to be mindful of.  It’s important to pack a few basics for your trip including:

• Water – Your body has an uncanny ability to lose water while traveling.  The air (completely lacking moisture) on airplanes dries you out before you even set foot on foreign soil.  Once you arrive at your destination, you’ll notice that many parts of the word are extremely hot.  You can sweat multiple liters of fluid each day, all of which need to be replaced.  Make sure to drink plenty of water (as well as electrolytes) to stay hydrated during your adventure.  While traveling, bottled or purified water is always your safest bet.

• Sunscreen – As we all know our skin protects against heat, sunlight and infection, however, we need to protect our skin from skin cancer, aging, wrinkles, pigment discoloration, sunburn and heat rash.  The SPF on a sunscreen measures a product’s ability to screen or block UVB rays and is calculated based on the smallest dose of UV radiation (measured in hours) which causes erythema (i.e. inflammation in your skin affectionately known as sunburn).  The FDA does not like labeling sunscreen above SPF 30+ because there is not much protective benefit beyond that level.  The factors to take into consideration when choosing a sunscreen include the amount you need, broad or full spectrum, water resistance and formulation.  There are two types of sunscreen – chemical absorbers and physical blockers.  Chemical sunscreens have active ingredients that absorb, filter and reduce UV radiation penetration (examples include PABA, cinnamates, salicylates and octocrylene) and their strength is measured in SPF.  Physical blockers such as titanium oxide or zinc oxide reflect or scatter the sun’s UVR and are not measured by SPF.

• Insect Repellant – Another option besides DEET or Permethrin is Picaridin, which is equally as effective as 20% DEET and is non-greasy and odorless.  For those who prefer more natural products, 30% Oil of Lemon Eucalyptus (PMD) is equivalent to 20% DEET but requires more frequent application.

• Mosquito Net (if applicable)

• Anti-Diarrheal Medications – Other than rehydration, over-the-counter agents such Loperamide (Imodium) work fast to absolve diarrhea symptoms by minimizing loose stools and stomach cramps (it works like brakes on runaway bowels).  Bismuth Subsalicylate (Pepto-Bismol) can also be used as an antidiarrheal, antimicrobial and a mucosal protective agent, however, it can interact with certain antibiotics including Ciprofloxacin (such as for Traveler’s Diarrhea), and should be avoided in pregnant women.

• Pain Medications – Non-steroidal Anti-Inflammatory Drugs (NSAIDs) like Ibuprofen or Naproxen can not only help decrease generalized pain but it can also decrease erythema or sunburns.  Other agents that can be used for sunburns include aloe vera and vitamin E creams and gels.

• Allergy Medications – Pack some Diphenhydramine (Benadryl) or a non-drowsy alternative like Loratidine (Claritin) or Cetirizine (Zyrtec) in case you develop allergy symptoms such as watery/itchy eyes, runny nose, rash, or hives due to exotic foods or flowers.

• First Aid Kit – Most pharmacies sell pre-made kits you can easily purchase that include antibiotic creams (Polysporin and Neomycin), band-aids, gauze and alcohol wipes.

• Water Disinfectants & Hand Sanitizers

There are many resources available to travelers (for example, the CDC website, www.cdc.gov), which can be very useful and informative for important travel information.  It’s always better to be safe rather than sorry before hitting the road.  The last thing anyone wants is to end up in a hospital instead of showing off his or her cool tan lines.  An ounce of prevention goes along way when traveling.  As always, remember to seek professional medical advice before starting any new treatment.  Happy travels!

References

1.    Shoreland’s Medical Reference Guide

2.    Shoreland’s Travel and Routine Immunizations (“Blue Book”)

3.    Shoreland’s Travax/EnCompass

4.    TravelCare©

5.    Tropimed© by Astral, Switzerland

6.    CDC Health Information for International Travel (“Yellow Book”) – 2009

7.    World Health Organization (WHO). International Travel and Health – most current edition

8.    Rose S. and Keystone J.S. International Travel Health Guide. December 2005

9.    Dawood, R. (2002). Traveler’s Health: How to Stay Healthy Abroad (4th ed.).

10.    DuPont, H.L., & Steffen, R. (Eds.). (2000). Textbook of Travel Medicine and Health (2nd ed.).

11.    Jong, E. & McMullen, R. (2003). The Travel and Tropical Medicine Handbook (3rd ed.).

12.    Keystone, J.S., Kozarsky, P.E., Freedman, D.O., Nothdurft, H.D. (Eds.). (2008). Travel Medicine

13.    Leggat, P.A., & Goldsmid, J.M. (Eds.). (2002). Primer of Travel Medicine (3rd ed.). Brisbane: ACTM Publications. actm@tropmed.org

14.    Steffen R., DuPont H.L., & Wilder-Smith, A. (Eds.). (2003). Manual of Travel Medicine and Health (2nd ed.).

by Tania Houspian, PharmD 2011

There is a tried and true medical procedure that is minimally invasive and takes a few seconds to perform. This procedure will help prevent dozens of diseases and aide in making the entire population healthier. The more people that undergo the procedure, the better it is for the health of the entire population. Like any procedure though, it has its risks. Do the benefits outweigh the risks? Would you choose to undergo this procedure?

That’s a question you always have to ask yourself when choosing to undergo any medical procedure. The risks and benefits need to be weighed.  More importantly the true risks and true benefits need to be weighed. Grandma thinks that her blood pressure medicine gives her gas but, as her children and grandchildren can confirm, Grandma had some serious gas long before she began taking blood pressure medication. Just because two things happen at the same time does not mean that one caused the other.  Correlation does not equal causation.

So what was the procedure we referred to above?

Procedure: Vaccinating Children

Benefit: Vaccines are the single best public health measure ever implemented in our society. They have been proven to prevent many diseases that, in the past, were the leading causes of death in young children.  Think Polio, for example.

Risk: Autism?

One in four Americans believes that vaccines cause autism. When anything becomes that engrained in the minds of a society, it warrants deeper examination. There are two main theories that aided in forming this widespread notion.

Theory #1:

The first mention of vaccines being a possible cause of autism was in 1998 by British gastroenterologist, Andrew Wakefield. Wakefield, along with 12 others, published a paper in which they put forward the theory that the measles virus in the measles, mumps, and rubella vaccine (commonly called the MMR vaccine) caused a “leaky gut.” They concluded that the leaky gut allowed toxic substances into the bloodstream that eventually ended up in the brain. In the paper they recommend separating the three (measles, mumps, and rubella) into separate vaccines. Wakefield called a press conference to let everyone know about his discovery and consequently triggered a panic in Great Britain.

Since then, Wakefield has not exactly been what we would call a respected member of the medical community. Ten of the co-authors on that paper retracted their involvement and have said they do not agree with the conclusions that Wakefield drew in his paper. The General Medical Council is also investigating Wakefield for scientific misconduct, specifically falsifying data.  Oh yeah, and Wakefield also forgot to mention that he was working on introducing a new measles vaccines to the market to compete with the MMR vaccine. Can you say conflict of interest? Hidden motives aside, Wakefield’s research methods have been accused of not only being flawed but also unethical.

Taking into account the fact that Wakefield has been publicly discredited and his paper deemed invalid, you would think this theory regarding the connection between vaccines and autism would have fallen by the wayside…and it hasn’t.  This is because it’s not that simple.  Many people believed Wakefield was on to something even if the science did not match his conclusions. Due to the number of vaccines children receive in the first three years of life (14 vaccines to be exact) many parents felt that there could be a connection.  Once the idea of a risk like this has been introduced, it’s difficult to get the idea out of people’s minds. Simply said, it’s always easier to scare people than to un-scare them.

Theory #2:

In 1999 the US government published a report revealing three childhood vaccines (diphtheria, tetanus, acellular pertussis [a combo called DTaP]; Haemophilus influenzae type b (Hib); and hepatitis B) contained higher levels of mercury than previously thought. Thimerosal is the preservative used in these three vaccines and contains 49.6% ethylmercury by weight. An obscure medical journal took this finding and ran with it, publishing an article (without any scientific validity) saying that autism was a form of mercury poisoning.  This, of course, caused a huge uproar in the United States and propaganda like the image and chart included below (again, without scientific support; note the lack of references for the chart’s information).  In response, the Center for Disease Control reviewed numerous studies all finding that there is NO LINK between autism, vaccines, and mercury. Even though the CDC’s findings showed no connection between mercury and autism, the government still requested vaccine manufacturers to remove the mercury component from all childhood vaccines.  Since 2001, no childhood vaccines have contained mercury.  So let’s say the initial theory published by the obscure medical journal linking mercury and autism was correct (even though all the scientific evidence pointed the other way), then autism rates should have dropped dramatically after mercury was removed from all vaccines in 2001…and parents everywhere would be able to breath a sigh of relief. Well, it turns out that the exact opposite has happened. Autism rates have continued to rise since 2001. This simple fact should be enough to put the mercury-autism theory to rest yet many groups out there continue to vilify vaccines and anyone who dares step up to defend them.

Mercury – Autism Propaganda

Then why the controversy?

So why is it that, even though all the scientific evidence seems to point away from the connection between vaccines and autism, people still believe vaccines cause autism? Personal experience and temporal associations. One of the main driving forces amongst groups who believe vaccines cause autism are parents with children who have autism, which they begin to notice during the same period of time their children are receiving their 14 recommended vaccinations. Many parents first start to notice signs of autism when their children have developmental delays in speech. The MMR vaccine (which, by the way, never contained thimerosal) is given around 12-15 months of age, which coincides with the age most children begin to speak. So it seems that the most likely explanation is coincidence not causation. There are also many children who exhibit signs of autism prior to any vaccinations, further discrediting the link between vaccinations and autism.

What Now?

No one can belittle how difficult it must be for the parents of autistic children to witness their children’s developmental challenges. These parents need an explanation and, with so many people pointing the finger at vaccines, it’s a tempting to jump on the bandwagon. This approach, however, is not helping anyone. The focus of autism research has been and will continue to be on genetic causes of the disease.  This is the research that needs to be supported and perpetuated in order for real answers to be found and for meaningful interventions to be developed.

People seem to have become comfortable with how safe vaccines have made our society and forgotten that the illnesses they prevent can kill their children. These viruses continue to exist throughout the world and, without vaccination, we remain vulnerable to the epidemics they can cause. When Wakefield published his paper in 1998, parents in Great Britain stopped vaccinating their kids. The rate of vaccination dropped to 80% by 2003.  That same year, over 1,000 measles cases were reported in Great Britain. Similarly, in the United States there have been outbreaks of measles, pertussis, and Haemophilus influenzae Type B…all diseases that are preventable through vaccination.

References:

Fombonne,E. Thimerosal disappears but Autism Remains. Arch Gen Psychiatry. 2008 Jan;65(1)15-6

Gross L (2009) A Broken Trust: Lessons from the Vaccine–Autism Wars. PLoS Biol 7(5): e1000114. doi:10.1371/journal.pbio.1000114

Immunize.org, http://immunize.org. December 22,2009.

Miller L, Reynolds J. Autism and vaccination- the current evidence. J Spec Pediatric Nursing. 2009 Jul; 14(3): 166-72.

Thimerosal In Vaccines Questions and Answers. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/UCM070430#q5. December 26,2009.