House Call, MD: Health Carefully Explained

by Rebecca Shatsky, MD 2011 | shatsky@myhousecallmd.com

It’s one of the great paradoxes of life: what we perceive as beautiful has a tendency to be bad for us. Tan skin, while masking cellulite and stretch marks, is quite literally a sign of skin damage. Tanning is a fashion trend. Throughout history, tan skin has fallen in and out of fashion. Unfortunately, for the past forty or fifty years, since the days of fashion icon Coco Chanel, tan skin has been a status symbol that we equate with health, happiness and the lavish life the wealthy can afford filled with luxurious vacations.  Even now in 2010, after the dangers of sun exposure have been spelled out explicitly by dermatologic research, the tanning trend is stronger than ever.  Self-proclaimed “tanorexics” from the MTV series The Jersey Shore (particularly Nicole “Snooki” Polizzi) broadcast their love of tanning beds to anyone who will listen. Last month, Polizzi even slammed president Obama for imposing a new 10% tax on tanning beds that went into effect on July 1^st. Republican political opponent, John McCain, was quick to respond to Snooki’s criticism of Obama with a tweet supporting Polizzi’s “freedom to tan,” a fairly controversial move considering McCain’s recent struggle with the deadly skin cancer, malignant melanoma. Naturally, with tanning now in the political hot seat (both literally and figuratively), we at House Call think it’s only appropriate to re-educate our readers on the process of tanning and the dangers of skin caner with scientific research and medical literature leading the debate (instead of reality TV stars and politicians).

The Science of Skin Color:

A person’s natural skin color is determined by the concentration of a pigment called melanin in the skin. Melanin is produced by skin cells called melanocytes. While the number of melanocytes in the skin is fairly similar from person to person, the activity level of these cells when it comes to producing melanin varies greatly and is determined primarily by genetics. The activity of melanocytes is partially responsible for the wide spectrum of skin color that exists among humans.  Also, melanocytes can produce several varieties of melanin, which differ in chemical properties and color. Eumelanin, the most abundant form of the compound, can be either black or brown and is associated with darker skin tones and suntans. Pheomelanin is a yellow-red pigment present in abundance in people with red hair and fair complexions. Some individuals are unable to produce melanin at all due to gene defects or enzyme deficiencies that they are born with. These defects result in very light colored skin, hair and eyes (a condition known as albinism).

Melanin absorbs light and is a natural protectant for skin cells against UV rays that damage DNA.   Pheomelanin absorbs less UV radiation than eumelanin.  Since redheaded people produce more pheomelanin and less eumelanin, red heads do not tan very well and have a much higher incidence of skin cancer (in case you hadn’t noticed). Conversely, darker individuals have continuous production of eumelanin, naturally protecting them from UV DNA damage and lowering their incidence of skin cancer.

What Happens When We Tan?

UV radiation is a carcinogen; it causes mutations in your DNA that your body has to repair before new cells are made in order to prevent cancer from developing. When the skin is exposed to excessive amounts of UV radiation (with frequent sun or tanning bed exposure), the body can’t fix the mutations fast enough and skin cancer can develop. While the production of melanin in the skin is influenced primarily by genetics, it can also be revved up temporarily in response to UV radiation. Exposure to UV light causes an increase in Melanocyte-Stimulating Hormone (MSH), a hormone released from the brain. The release of this hormone into the blood stream revs up production of melanin by melanocytes in the skin, resulting in the golden brown skin color we call a tan. The extra melanin from a suntan is supposed to protect cells from further damage via UV radiation, but the melanin producing pathway takes time (it takes at least four hours to see a tan and then 5-7 days of repeated sun exposure to get the full effect).  In addition, extra melanin does not offer complete protection from DNA damage. Basically, while you spend time building up your base tan you are concurrently building up mutations in your DNA, predisposing yourself to skin cancer.

What’s Wrong With Tanning Beds?

Most people know that sunburns are bad. A sunburn is an immediate indication that the skin has been directly damaged by UV rays and is actively trying to repair that damage by increasing blood flow to the affected area (giving you a painful red hue).  If you are a fair-skinned individual that always burns (even if the burn “turns into a tan”), you are at high risk for skin cancer and every time you get burned you increase that risk.  What we are just learning, however, is that even people who tan easily are at increased risk for skin cancer, especially with repeat long-term exposure from tanning bed use. A landmark study that was published in the June 2010 issue of Cancer Epidemiology Biomarkers and Prevention determined that tanning bed users had a 74% increased risk of developing melanoma. The use of high pressure tanning devices was reported to be particularly dangerous, increasing the risk of melanoma to four times that of people who did not use tanning beds (3). Overall, the amount of exposure is thought to be the greatest risk factor for development of cancer and the cumulative number of tanning hours logged was a significant predictor of cancer development risk. This study is the largest ever to examine the use of indoor tanning as a risk factor for melanoma.  The results have instigated considerable debate amongst the FDA and other preventative health organizations about how to limit the use of tanning beds in the future. The new federal 10% tax on tanning beds instituted on July 1^st, 2010 may be the first in a series of steps to reduce the popularity of tanning beds.  There is talk of developing new laws to restrict use among those under the age of 18.

So What Can I Do to Prevent Skin Cancer?

If you are currently frequenting your local tanning salon or laying out and lathering yourself in baby oil, the best thing you can do is stop cold turkey.  Not only is frequent tanning quadrupling your risk of melanoma, it causes premature skin aging (i.e. wrinkles, sagging skin, and brown spots) and cumulative skin damage.  For serious “tanorexics” who still feel they need a golden glow to feel beautiful, the switch to spray tanning can be quite easy and painless.  More and more salons are offering spray tanning as a healthy alternative to UV beds and the array of self-tanning products in drugstores is mind-boggling. The quality of self-tanning products has also significantly improved in recent years.  If you’ve tried self-tanning in the past without success, you may just want to give lotions and sprays another go.  We bet that you will be pleasantly surprised with the results.

Unfortunately, despite the nonsensical banter from politicians and TV personalities, skin cancer remains a formidable enemy in the US, affecting over 2 million people each year (4). Research estimates that one in five Americans will develop skin cancer in their lifetime and, on average, twenty Americans die of skin cancer every day (1,6).  Don’t believe the myth that most skin damage happens during your teens.  Many people in their 20’s and 30’s who tanned in their teens continue to tan because they believe the damage has already been done. According to new data, every time you tan you put yourself at increased risk, no matter how old you are (7).

The Take Home Message:

• Wear sunscreen when you’re outdoors
• Leave the tanning beds to the cast of Jersey Shore (hopefully they save some of their new-found income for health care)
• See your primary care doctor or dermatologist once a year for your annual skin exam as well as your regular skin care.

• If you’re craving a summer glow, try tanning lotions or spray tans

Skin cancer is the most common form of cancer but it is also highly preventable.  We’ll leave you with a few words of wisdom from The Skin Cancer Foundation: “Tanning’s 15 minutes are over. Go with your own glow!”

Questions? E-mail the Author: shatsky@myhousecallmd.com

References

1. American Cancer Society. Cancer Facts & Figures 2009. Atlanta: American Cancer Society; 2009.
2. Kwon HT, Mayer JA, Walker KK, Yu H, Lewis EC, Belch GE. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol 2003; 46:700-5.
3. Lazovich, DeAnn, Rachel Vogel, Marianne Berwick, Martin A. Weinstock, Kristin E. Anderson, and Erin M. Warshaw. “Indoor Tanning and Risk of Melanoma: A Case-Control Study in a Highly Exposed Population.” Cancer, Epidemiology, Biomarkers & Prevention 19.6 (2010): 1557-568.
4. Melanoma of the Skin, Cancer Fact Sheets, National Cancer Institute, SEER Database, 2008
5. SEER Cancer Statistics Review, 1975-2004 (NCI)
6. Robinson JK. Sun Exposure, Sun Protection, and Vitamin D. JAMA 2005; 294: 1541-43.
7. Skin Cancer Facts. The Skin Cancer Foundation. July 15, 2010.
8. The Burden of Skin Cancer. National Center for Chronic Disease Prevention and Health Promotion. May 13, 2008.

by Leah Frankel, MS, RD | frankel@myhousecallmd.com

The sun is finally shining (at least in most of the country), but before you go outside you might want to reconsider your current sun protection routine. Hopefully you’re lathering up with sunscreen to prevent skin cancer but did you ever consider the idea that too much sunscreen could be detrimental to your health? Vitamin D, sometimes know as the sunshine vitamin, is the only vitamin that we can produce without eating anything since your body can create enough vitamin D by spending some time in the sun.  The question remains: How can you get your vitamin D without increasing your risk of developing skin cancer?

The Sunshine Vitamin

Vitamin D is a fat-soluble vitamin (meaning it is absorbed when consumed with fat, as opposed to water-soluble vitamins which are absorbed when consumed with water). Vitamin D helps with the absorption of calcium while also helping to regulate the levels of phosphorus and calcium in your blood stream. Unlike any other vitamin or mineral, vitamin D can be consumed from food sources or produced with exposure to the sun.  In line with the fact that there are two ways we can obtain vitamin D, there are two forms of the vitamin: the form that we consume in foods, ergocalciferol (vitamin D­₂), and the form that we produce with a little help from the sun, cholecalciferol (vitamin D₃). Vitamin D­_2­ or D₃ are then converted into the active form of vitamin D₃ by the liver and kidney.

How Much Sun Do You Need?

Most people can produce enough vitamin D with 10-15 min of sun exposure, 3-5 days a week.  However, these recommendations are based on the assumption that the person is not wearing sunscreen and some of the body, typically the face and arms, are uncovered by clothing and therefore able to receive direct sunlight. It is important to remember that the amount of vitamin D produced in response to sun exposure can vary depending on clothing type, the amount of melanin in the skin and the use of sunscreen. It is believed that casual exposure to sunlight without sunscreen will typically provide sufficient vitamin D to last through the winter months.  However, if you live in an area where there is little sun year round or you do not spend any time in the sun, it is important to consume adequate dietary sources of the vitamin or supplementation may be necessary.

Getting Vitamin D Without the Sun

As we discussed earlier there are two forms of vitamin D: vitamin D­_2­ and vitamin D₃. Vitamin D₂ is derived from dietary sources, mainly fatty fish, dairy products (including fortified milk, cheese, butter, cream, and margarine), fortified cereal or other enriched foods and multivitamins.

While there has been some debate regarding the amount of vitamin D that should be consumed, the Adequate Intake (amount that is necessary to maintain adequate health) recommended by the U.S. Institute of Medicine of the National Academy of Sciences is 5 micrograms (200 IU or International Units) daily for all individuals (males, female, pregnant/lactating women) between the ages of 18-50 years. For anyone 50-70 years-old, 10 micrograms daily (400 IU) is recommended. For those who are over 70 years-old, 15 micrograms daily (600 IU) is suggested. For infants, children and teenagers under the age of 18, 5 micrograms (200 IU) is recommended daily, however, recent studies suggest 10 micrograms (400 IU) may be beneficial.

While those recommended intake numbers sounds spectacular, they aren’t much help if you don’t know how much vitamin D is actually in the foods you eat…so we’ve included a list of foods that are high in vitamin D below:

• Herring, fresh, raw, 1 oz: 6.6 micrograms 

• Salmon, cooked, 1 oz: 3.5 micrograms

• Cow’s Milk, fortified, 1 cup: 2.5 micrograms

• Sardines, canned, 1 oz: 2.1 micrograms

• Egg yolk: 0.6 micrograms

Looking at some of these foods, you might wonder how you can reach your daily intake.  Do you really have to consume a can of sardines every day (which we do not recommend for social reasons alone)?  If you look closely at the serving sizes you’ll notice that, for example, 1 oz. of salmon provides 3.5 micrograms of vitamin D…and most people consume significantly more than 1 oz of fish at any given time.  The take home message: make sure to factor serving size into your calculation!

Consuming Too Much or Too Little?

Deficiencies in vitamin D result in rickets in children and osteomalacia or osteoporosis in adults; these diseases are characterized by defects in bone mineralization.  Rickets is a condition in which the mineralization of growing bones is impaired as a result of insufficient vitamin D, calcium and phosphorus, all of which are important for normal bone growth. Osteomalacia, which means soft bones (you can see the change in bone density in the x-ray to the left), is seen in adults with inadequate dietary intake of vitamin D, insufficient sun exposure or chronic diseases including kidney and liver disease. On the other hand, osteoporosis is characterized by calcium loss from the bones leading to increased risk of bone fractures.

As with most things in life, too much is never a good thing.  Too much vitamin D can cause your body to absorb too much calcium leading to calcium deposits in soft tissue. Since vitamin D is fat soluble, excess doses are stored in your body’s fat (as opposed to water-soluble vitamins which are excreted in urine when you consume too much).

Vitamin D and Aging:

As you age, your experiences a 75% reduction in its ability to produce vitamin D₃ as a result of less efficient production in your skin as well as reduced sun exposure, making the elderly particularly at risk for vitamin D deficiency (1). Since the elderly are at a higher risk for bone fractures and osteoporosis (for a number of reasons, many of which we are sure you can imagine), multiple studies have looked at the effect of vitamin D supplementation on bone health. A study by Trivedi et al, examined the effect of vitamin D supplementation on risk of fracture in the elderly (2). The study provided the 2,686 male and female subjects ages 65-85 years, with 100,000 IU of vitamin D, or a placebo, every 4 months for a 5-year period. The study showed a reduction in fracture risk in the hip, wrist/forearm and vertebrae by 33% in the group receiving the vitamin D supplementation. However, the RECORD (Randomized Evaluation of Calcium and/or vitamin D) trial compared the effects of 1000 mg calcium carbonate, 800 IU vitamin D₃, combined 800 IU vitamin D­₃ and 1000 mg calcium carbonate to a placebo on 5,292 men and women over the age of 70 years with previous a fracture, during a 2 year period (3). No significant differences were seen between the various groups in regards to bone fractures.  Very confusing, we know.  Science has a way of doing that to us.

So What Do I Do?

There are many ways to get your needed dose of vitamin D, whether through the sun, food or supplements.  The best plan of attack depends on your lifestyle, age and a number of other factors. Most of the population meets their body’s vitamin D needs from sun exposure alone.  If you are unable to spend 10-15 min in the sun without sunscreen, make sure you eat enough foods high in vitamin D. In the elderly or people living in areas with little sunlight, supplementation may be necessary to reach adequate levels.  Remember that you only need a little sunlight to get all of the vitamin D your body needs.  If you’re planning a day in the sun, don’t forget your sunblock!

Questions? E-mail the Author: frankel@myhousecallmd.com

References:

1. Palacios C. The role of nutrients in bone health, from A to Z. Critical reviews in food science and nutrition. 2006;46:621-8.

2. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ. Clinical research ed. 2003 Mar 1;326:469.

3. Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, Anderson FH, Cooper C, Francis RM, et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet. 2005 May 7-13;365:1621-8.

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.).