Trip to the travel doctor

Today, we paid a visit to the travel doctor. I’m of mixed feelings about the visit. I found that I trusted the Doctor’s advise, and that he really knew about the various things; but I also felt that he didn’t do a good enough job informing me about medications and shots. If I hadn’t done a bunch of advance reading and research, I think I would have been completely lost. He did provide two comprehensive handouts though, which we are still digesting.

I’m going to have to do a little more research and be prepared with questions for my second visit.

I decided to document his recommendations and other information I’ve found in my research, but IANAD (I am not a doctor). Please consult your family doctor or local travel medicine clinic for recommendations before using any of the information below.

I was also a little surprised by the doctor’s lack of excitement about our trip. In hind sight, I realize that he has seen so many people who go on interesting trips, that it probably didn’t seem that exciting to him.

Vaccinations

For this trip, the doctor recommended the following vaccinations:

• Tetanus, Diphtheria, Polio booster. This is a standard booster given every 5-10 years or so depending on your needs.
• Hepatitis A. This is recommended for everyone that travels anywhere, as it doesn’t discriminate; that is, it affects both budget travelers and those staying at luxury hotels. Hepatitis A infections are spread through contaminated food, water, and shell fish.
• Hepatitis B. This is recommended for anyone traveling to areas without adequate health care screening for any length of time. The message the doctor gave us, if you end up requiring medical attention while traveling (e.g. car accident, animal bite), you are at risk at being exposed. Ontario now vaccinates grade 7’s for Hepatitis B, so if you are younger than 24 and went to school in Ontario, you were likely vaccinated in school. Hepatitis B infections are spread through inoculation with a contaminated needle, blood transfusion, sexual contact, intimate physical contact, and indirect routes such as sharing razors.
• Pre-exposure rabies. There is a world-wide shortage of rabies anti-bodies (human rabies immunoglobulin), and it is hard to store. As a result, it may be difficult to get in some locations. The immunoglobulin is required for initial treatment if you are not vaccinated. If you are bitten without the pre-exposure, you need immediate to have five-shots over 28-days. If you get bitten after completing the three-shot pre-exposure, you only require two shots, three days apart. Because we are biking and as a result might come in contact with rabid dogs, we are in the at-risk category (along with veterinarians and children, among others). Rabies is fatal if it reaches the brain, so this is well worth doing, but is a very expensive vaccine ($170 x 3 doses).
• Typhoid. This is recommended for anyone who is an adventurous traveler or who are staying with locals in an affected areas, which are pretty much any developing country. Typhoid is transmitted by unclean water and food. The Typhoid vaccination is available as either pills (must be refrigerated) that give you 5-years immunity or a needle which gives you 2-3 years immunity. We’re taking the 4 dose oral vaccine (pills).

Scott and I both had to have the Tetanus, Diphtheria, Polio booster, the pre-exposure to rabies, and the Typhoid vaccines. Scott also had to have a Hepatitis A booster (he had a Hep-A shot several years ago) and the Hepatitis B vaccine. I did a Hepatitis A-B combo vaccination (Twinrix) several years ago that is still good (antibodies test was positive), so I had 2 fewer needles than Scott!

We did not need to get vaccinated for Japanese Encephalitis because we will not be in Southeast Asia at the time of year where it is prevalent (autumn). We also don’t need to be vaccinated against Yellow Fever for the biking portion of our trip, but it may be required for the freighter trip from Italy to Malaysia.

The doctor also recommended that we get pre-screening tests for Tuberculosis. This just validates that we do not have Tuberculosis before we leave. It helps them figure out where / how you were exposed if you do end up returning with TB.

Medications

The doctor gave us three prescriptions to take with us:

• Keflex. This is used for skin infections or respiratory infections.
• Cipro XL. This is used to treat either severe diarrhea when in the Middle East or bladder infections. An Internet recommendation to use chewable Pepto Bismol as a stool hardener is interesting. I’ll add it to our list of questions for our next visit.
• Zithromax. This is used to treat severe diarrhea in Asia.

In addition, we will pick up Dukoral in Montreal or Halifax just before leaving Canada. This vaccination is only good for 3 months. Although it was technically developed for Cholera, it helps prevent traveller’s diarrhea caused by E. Coli.

Sunscreen

The doctor recommend that we purchase sunscreen at home and bring it with us. He also recommended a good hat, and long sleeve shirts and pants. Locals typically do not need sunscreen. As a result, the cost of sunscreen is likely to be excessive. In addition, the effectiveness of foreign sunscreen is a bit uncertain.

Hydration

The doctor emphasized the need to keep well hydrated. He commented that he has seen several patients that have had to return early from a round-the-world tour because they didn’t stay well enough hydrated. Side effects of not enough hydration include gout, kidney stones, and bladder infections.

Staying hydrated is an extra issue when you are exerting yourself cycling. The doctor also pointed out the women are more prone to dehydration due to poor sanitation. Women tend to drink less to avoid having to use the washrooms, especially when they are not clean or familiar. This is something that I have some specific strategies for dealing with, include:

• Bringing my personal “pee bandanna” – used when toilet paper is not available, always carried with me, and cleaned regularly with filtered water. I carry several of them, in zip lock baggies. They can be washed in a rotating fashion, so I always have a clean dry one at hand.
• A woman’s Urinating Aid. This allows women to stand up while peeing. It makes peeing in an unpleasant public toilet a little more palatable.

Malaria

Malaria medication will not be required until we go to Southeast Asia. It is not a problem where we are traveling in the Middle East. The doctor recommended that we pick up Malarone in Singapore. Malarone is taken every day, starting 1-2 days before you enter an exposed area and continued until seven (7) days after you exit the exposure area. We should take the medication when in: Thailand border region with Vietnam, in rural Vietnam (tourist areas in Vietnam are not a problem), Laos, and Cambodia. Other options are Chloroquine (but in most places the protozoa are Chloroquine-resistant). Mefloquine is another option, especially if we were staying for a longer period. It has a bad reputation for side-effects, but the doctor’s comment is that he was on it for three years, it is the most well-studied of the anti-Malarials and the more severe side effects are extremely rare. It also has the benefit that it does not need to be taken as frequently.

The most important prevention for malaria and other insect-borne diseases is to avoid getting bitten. To that end:

1. Ensure sleeping quarters are screened or sealed (if air conditioned)
2. Keep your bed surrounded with mosquito netting (ideally a Permethrin-treated bed net). Our travel doctor sells these at cost, but we may just wait until Singapore so we don’t have to carry it until we need it.
3. Wear light-coloured long-sleeved clothing when outside after sunset.
4. Apply DEET to exposed skin

Malarial mosquitoes bite at night, but insects which transmit other diseases (dengue fever, yellow fever, leishmaniasis) bite during the day, so clothing and DEET are good measures all the time. Add to it that most of these countries, it is not appropriate to be uncovered anywhere other than the beach, so this shouldn’t be too difficult.

One note is that if any additional medication is required, Singapore is a good location for getting it. Medications in Thailand should be avoid, as many of them are fake.

Diarrhea

Yes, this is not the funnest of subjects, but a really important one when you are cycling around the world, and eating food from a variety of budget oriented places.

The key message from the doctor was “Boil it, cook it, peel it, or forget it”. This will reduce our chances of exposure. The good news is in many cases we’ll be cooking for ourselves, and as long as we avoid salads (I think Scott learned this lesson first hand while in Mexico) and other raw vegetables we should do fairly well.

Also “don’t feed your diarrhea!” Your bowels have been infected by something, they need to purge to recover, and clear fluids (with Oral Rehydration Salts if necessary) are what is needed.

There is a medication you can take for prevention of Enterotoxigenic E. coli (ETEC)-based infections. This is a vaccine that was originally developed against Cholera called Dukoral, which can be picked up in Canada without a prescription. He said it is only useful against ETEC for about 3 months, so we will get it in Halifax or Montreal before we board a boat. The doctor advised that it would be more useful in the Middle East, rather than saving it for the Far East. Looking at the Dukoral site, it appears that it could be useful for E. coli after three months with a booster. We might be able to get that in Italy.

The doctor also prescribed two types of antibiotics for moderate to severe diarrhea caused by Campylobacter bacteria. Ciprofloxacin is to be taken if moderate or severe diarrhea occurs while in the the Middle East, and Zithromax is to be taken if moderate or severe diarrhea occurs while in Aoutheast Asia, since the Campylobacter there is often Fluoroquinolone-resistant (especially in Thailand and Nepal). Some notes on treatment similar to his explanation are available from CDC and The Oregon Travel Clinic.