NOTE: The following information was written for clients of the Barrhaven Travel Medicine Clinic and the Riverside Travel Medicine Clinic. It is supplemental information intended to complement the in-person counselling we do at these two clinics. Other travellers are advised to see us or another travel clinic and should not rely on the information here unless they have been to one of our clinics. Recommendations may vary among clinics.
FOOD AND WATER
HEPATITIS B AND HIV
ODDS AND ENDS
PERSONAL HYGIENE SUPPLIES
When altitude is gained rapidly, travellers can feel unwell. Typical itineraries are Lima to Cuzco, trekking in Nepal and Mt Kilimanjaro. Symptoms can include headache, shortness of breath, nausea, vomiting, dizziness and poor sleep. There are measures one can take to minimize the effect of altitude.
The trip can be planned so that the traveller stays at an intermediate altitude for a period of time before continuing on to the high altitude destination. Taking it easy on the day of arrival at a high location seems to help. When trekking over many days to higher altitudes, it is best to "climb high, sleep low". Since most trips involve some ups an downs, it is best to stay and sleep at the lower altitude.
Diamox (acetazolamide) is a medication that can reduce the discomfort of high altitude when started 1-2 days before arrival.
Mt Kilimanjaro presents challenges because of its extreme altitude. Travellers need to know about HAPE (high altitude pulmonary edema) and HACE (high altitude cerebral edema), the proper treatment of these two life-threatening conditions and should have that treatment with them. We discuss this with travellers to such destinations at the clinic.
Cholera is a disease of severe diarrhea with loss of fluid at a great rate. The resulting dehydration placing infants and the elderly at the greatest risk. Cholera occurs rarely among Canadian travellers being found mainly where there is overcrowding and poverty. The vaccine is only rarely recommended. Refer to the section on food and water for information on how to avoid this and other diarrheal diseases.
This virus causes an illness similar to dengue fever (see below) with the addition of significant joint pain in many cases, which can go on for weeks, months or sometimes longer. The same mosquito carries both viruses. See Dengue below for details on how to avoid this disease. See the Dengue section as well to learn how to find out if there are reports of a chikungunya outbreak in the place you are visiting.
Dengue is sometimes known as "breakbone fever". It resembles malaria but is not usually as potentially life‑threatening. Victims are nonetheless quite ill often with an accompanying rash.
There is no vaccine, no preventative pill and no effective treatment for dengue. Dengue occurs in many tropical areas of the world, especially Latin America, the Indian subcontinent and southeast Asia. It tends to flare up in outbreaks and then die down. The virus causing this disease is transmitted by a mosquito which bites during the daytime. On a sunny day it bites particularly in the early morning hours and late afternoon. On a cloudy day, and indoors, it may bite more evenly throughout the day.
What can one do to avoid this disease? If you do hear of people coming down with it where you are or otherwise know that there is dengue activity in your location, minimize mosquito bites by wearing long‑sleeved and long‑legged clothing and use mosquito repellent during the day and particularly during peak biting times. See the separate section on repellents.
How can you find out whether there is much transmission of dengue, chikungunya or Zika at your destination? See the separate section titled ProMed.
FOOD AND WATER
Traveller's diarrhea is by far the most common "tropical" disease encountered. Forty to fifty percent of travellers will come down with it. It typically lasts a few days, is usually not incapacitating but can be quite unpleasant. If you develop diarrhea, replenish the lost fluids. Rehydration salts mixed with purified water are best. Diluted fruit juices, tea, bottled water, broth, or soft drinks are reasonable alternatives. Imodium pills will shorten the course of diarrhea, but should not be used alone where there is high fever or blood/mucous in the stool. In such cases of severe diarrhea, an antibiotic should be used.
A younger child who develops diarrhea should not use Imodium. Proper rehydration is especially important in the young and the elderly. Use rehydration salts or the following home‑made formula:
In one clean glass, mix 1/2 tsp corn syrup and a pinch of salt with 8 oz of clear fruit juice (orange or grapefruit juice best).
In a second clean glass, mix 1/4 tsp baking soda with 8 oz of boiled water. Sip or drink alternately from these glasses. The solution can be taken as thirst dictates. It will prevent serious dehydration, and speed recovery.
But how does one avoid diarrhea in the first place? It is a question of food and water precautions. The following is the "hard‑line", not applicable to all destinations. You may wish to ease up on these restrictions in areas where hygiene is better. For areas where you have reason to doubt the hygienic standard, here are guidelines:
Drink: Don't drink water from the tap. Don't drink water poured for you in a glass in a restaurant. Ask for bottled water (carbonated is better) and ask that the bottle be brought to your table seal intact. No ice in your drinks. Beer or soft drinks are usually fine and again, ask for the can or bottle to be brought to the table. Fruit juices poured from a pitcher are worrisome; better to have a can of juice, if available. Tea is usually safe, coffee often so. If you have facilities for boiling, 60 seconds of a rolling boil is considered adequate to purify tap water. Adding a pinch of salt or shaking the water will restore some of the taste. Where boiling is impractical, alternatives include Pristine water purification drops, iodine pills for short term travel or occasional use (not in pregnancy) and an ultraviolet wand such as Steripen. In general, avoid iodine in pregnancy.
Avoid dairy products unless you are sure the milk has been pasteurized. This is a big restriction: milk, butter, ice cream, yoghurt and cheese. In some countries, a particular brand is known to be good. Imported cheeses are usually safe. Canned or powdered milk is generally safe.
It is important to use clean water when brushing your teeth. The small amount swallowed is probably less of a concern than the fact that the water has a rather direct entry into your blood stream through the gum line, as you brush vigorously. If you have no clean water with which to brush your teeth you can use water from the hot water tap if it's too hot to touch.
Food: Don't eat salads in restaurants. You can picture a lettuce grown in possibly contaminated soil, picked, placed under tap water for 30 seconds, chopped up and served to you. You're liable to get sick. Have only cooked vegetables in a restaurant. On the other hand, fruit and vegetables bought in a market or store can be eaten raw, provided you peel them. Scrubbing them in clean water may be adequate. Leafy vegetables will need to be soaked in water to which iodine has been added. Fruit and vegetables are contaminated only on the outside, not usually the inside. The soil or people's hands are the culprits.
Meat should be thoroughly cooked and hot when served. Order meat well‑done. Pork is trickier than beef in general. Fish should be well‑cooked too. Shellfish is a particular worry. Some feel that it should be avoided altogether, as it is can be a common vehicle for hepatitis and diarrheal disease. However, if you are in an area specializing in delicious sea food, this may seem too much of a restriction. Try to ensure that the seafood has been well‑cooked, and eat in restaurants of good reputation. Shellfish should be cooked long enough that their shells are well open.
Rice, especially boiled or steamed, pasta, and bread products are usually safe to eat.
Try to avoid cold buffets, sauces, creamy desserts, and in general, street vendors.
Are you saying, 'There's nothing I can eat!'? As mentioned, these rules can usually be relaxed in four‑star restaurants, in establishments known to be hygienic, in resort areas, and in some cities within certain developing countries.
It is worth mentioning that antacids such as Tums and Maalox, should not be used unless necessary. Your stomach acid is a first‑line defense against germs, and antacids neutralize this protection.
The sun is strong in tropical regions. Wear a hat and use sunscreen. Wear loose‑fitting cotton clothing, covering most of your body during the first part of your stay. Avoid the sun between 10 am and 2 pm. If you plan exertional outings, bring lots of water to drink.
HEPATITIS B AND HIV
These are grouped together because they are transmitted the same way: by sex and needles. If there is any chance of sexual relations abroad, take condoms. You cannot always rely on those for sale elsewhere. Abstinence is safest.
The problem of unsterile needles and syringes can arise if you get sick enough to visit a clinic. If confronted with, "You're sick and will need a shot of penicillin', you should ask for penicillin pills instead. Most medicines that come in syringes are also available as pills. Try to insist on this.
Don't have ears pierced; don't get tattooed. Should you take needles and syringes with you? It depends on the chances of requiring an injection. For longer trips outside of major centers, or for people with illness liable to require medical care, this may be wise. Our clinic can provide you with a covering letter, and direct you to where you can buy appropriate syringes and needles. Alternatively, you can purchase a more comprehensive medical kit containing even suture material, intravenous needles and sterile lancets. Lancets can also be bought alone. These are very inexpensive, and worth having if you are travelling in malaria areas with sub‑optimal protection against this disease. Should a finger prick be necessary to diagnose malaria, you can ask the doctor to use your lancets.
Know your blood type if embarking on a long trip. This can be especially useful if you are part of a low‑risk group where everyone knows their blood type, and can thus act as donors.
Finally, if you think you have been exposed to a sexually-transmitted disease, seek medical attention.
This is an important part of travel preparation, which this clinic will be looking after.
This is a problem of east‑west travel across many time zones, usually worse travelling east. There are many proposed regimens to ease the fatigue, irritability and diminished attentiveness due to jet lag. Try to avoid alcohol while flying. Consider at what hour you will arrive, and consider trying to force yourself into the normal routine of your new time zone. Give yourself time to adjust before making important business decisions.
The tiny parasite that causes malaria is transmitted by the Anopheles mosquito. This mosquito bites mainly from sundown to sunup. In addition to any anti‑malarial medication you might be taking, you should try to avoid mosquito bites during these hours. Sleep in a well‑screened or air-conditioned room or under a bed net. Some travellers will take a roll of tape with them to easily repair any small holes or tears in a screen or net. When out of doors in the evening hours in malaria areas, long sleeved and long‑legged light‑coloured clothing should be worn and insect repellant applied to exposed skin. See the separate section on repellents. Try to avoid perfumes and scented deodorants as they attract insects.
What are the symptoms of malaria? Fever, sweats, chills, and headache. Sometimes backache, vomiting, abdominal pain occur. You might liken it to a truly severe flu. This is a serious, potentially fatal disease however, and medical attention should be sought immediately. Recall that a fever developing even months after a trip could be malaria.
Keep anti‑malarial pills out of reach of small children as even a small overdose of some can be fatal.
How extensive a kit should be depends on such factors as destination, duration of the trip, and one's state of health. Consider such items as scissors, thermometer, tweezers, alcohol or disinfectant, Bactroban ointment, oral rehydration salts and Imodium pills for diarrhea, antibiotics (for several conditions, including more severe diarrhea), band-aids, gauze, tape, sterile lancets for blood testing for malaria, iodine pills or other products like Pristine to disinfect water, Gravol, Tylenol or aspirin, and any medications you regularly take. The clinic has lists of suggested things to bring along depending on duration of the trip.
ODDS AND ENDS
Take an extra pair of glasses.
Remember to consider travel health insurance. OHIP coverage is very limited abroad. Have ready access to cash in the event of sudden illness.
For longer trips especially, it is a good idea to have seen your dentist before departure. Just as you don't want unnecessary injections, neither do you want dentists working in your mouth with possibly unsterile equipment.
When choosing a place for an ocean swim, try to ascertain that it is not a polluted area.
Sores heal with more difficulty in hot and humid climates. Cleanse cuts well, and apply Bactroban ointment
Carry medication in hand luggage. Consider taking a second emergency supply of important medications, packed elsewhere. Carry all drugs in their original containers. Carry a letter stating which medications you are on, using the generic name of all drugs.
Avoid placing clothes on the ground, and shake them well before putting them on.
If you become ill after you return, even months later, remind your doctor of where you have been travelling.
PERSONAL HYGIENE SUPPLIES
Depending on your destination, and length of stay, consider taking some of the following items, which may be in short supply abroad:
Tooth paste, soap, sanitary pads, dental floss, razors, toilet paper, washcloth.
We consider ProMed to be the best source for outbreak reports of all diseases, worldwide. The website can be a little difficult to navigate but once learned, it is a good source of information for the traveller who wants to know if there are reports of outbreak of dengue, Zika, chikungunya or other diseases at the destination. The URL is www.promedmail.org.
There is a risk of rabies in dogs in many developing countries. We have our share of rabies here but it is mainly in the woods. A proportion of the stray dogs in Bangkok are rabid. India has the highest percentage of rabid dogs of any country. Still, rabies is very rare among Canadians travelling. There has not been a reported case in many years.
Don’t pet stray dogs. If bitten, or even scratched, you must take this seriously. Wash the wound, no matter how trivial, with soap and water for 10 minutes. This can wash away much of the rabies virus if it is present. Then, you'll need rabies vaccine and an injection of a product called rabies immune globulin. You should set out at once to obtain these since rabies is always fatal. You may need to go to the capital city of whatever country you are in.
To find out where you can obtain proper treatment, you can first try the International Society of Travel Medicine’s web site at www.istm.org. Click on Global Travel Clinic Directory and see if there is a clinic near you. If you are a member of IAMAT, you can use their list of doctors and clinics. IAMAT is the International Association for Medical Assistance to Travellers, a Canadian non-profit organization. You can donate and join at www.iamat.org. You can also contact the Canadian embassy, the US or British embassy.
You will want to determine that you are receiving one of the modern rabies vaccines. A good rule of thumb: if the vaccine consists of four or five injections spaced out over a month or so, it is likely a modern vaccine. The older rabies vaccines have more frequent and worrisome side effects, and may be less effective.
Monkey bites and scratches are not rare in certain areas and these are a concern as well. In places where the monkeys have become more tame, they may jump on to a shoulder usually in the hope of finding food. In doing so, they can scratch, breaking the skin. It is best to not bring food to places where monkeys are known to be unafraid. It may be reasonable to not wear a backpack as the monkeys might recognize them as an indication of available food.
At the time of writing, Health Canada considers two insect repellents as providing acceptable protection: DEET and picaridin. Picaridin is the preferred one for children. DEET 30% and picaridin (also called icaridin) 20% both keep mosquitoes away for 6 hours when properly applied. The strength of repellents tells more about how long they work than how well they work.
Once indoors in a mosquito-proof room, repellent can be washed off.
When sunscreen us used, it should be applied first and the repellent on top of that. Waiting 15-20 minutes after sunscreen application before applying the repellent may be preferred.
This disease is not common in Canadian travellers but is prevalent in the people living in some developing countries. The tiny parasite lives in small snails in certain bodies of fresh water. It leaves the snail, making its way through the skin of swimmers, eventually residing in the bowel or bladder. It causes chronic problems there, with bleeding into the stool or urine. The general rule is: Particularly in Africa, don't swim or wade in fresh water while travelling . Slow‑moving water with weeds is more risky as are the areas near shore.
The risk varies considerably from place to place. Where you have reason to be concerned, consider these tips: travel in groups; do not wear expensive clothing or jewelry; don't have expensive cameras dangling from your shoulder; keep your cash in a money belt against your body; try not to be out at night, and stick to main byways. Women being followed within their hotel should resist the impulse to get quickly into their room if there is any chance of the intruder getting into the room too. A simple door wedge can be a useful thing to have while travelling.
The Peace Corps did a study of volunteers to find out which diseases were causing death or serious morbidity over the years. In fact, traffic accidents were the most important cause. They instituted two rules which cut down considerably on the frequency of accidents: don't travel at night and don't ride on motorcycles, mopeds, etc. One can appreciate that poorly‑marked roads, poorly‑maintained roads and vehicles, and daring driving practices constitutes a particular hazard at night. As a pedestrian be more careful than usual when crossing the street. Expectations about who will give way, driver or pedestrian, may differ.
This virus is in the same family as dengue fever and can cause similar symptoms, though is usually milder. In many cases it is so mild that the person is unaware that they have been infected. The seriousness of Zika arises from the devastating effect it can have on the developing baby during pregnancy, Pregnant travellers should not travel to areas where there is active Zika transmission. Pregnancy should be avoided after returning from travel for a defined period of time. See Health Canada's recommendations to know how long to wait.
There is no vaccine or medication to prevent Zika. See the section on dengue. The same mosquito transmits both.
Apart from possible traveller's diarrhea, the great majority of travellers enjoy a healthy trip. Following the advice given here should make this even more likely. Bon voyage!