Travel-Related Illness: Montezuma's Revenge

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Travel-Related Illness: Taking Revenge on Montezuma's Revenge

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You have a great trip planned, but do you know what travel-related illnesses you might face and how they may be prevented? Before Montezuma takes his revenge on you, read what travel medicine expert Herbert L. DuPont, MD had to say about the latest prevention tips and treatment options. He joined us on July 15, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. DuPont. Is any vacation, no matter how close to home, worth planning with potential illness in mind?

DUPONT:
The issue is two things, really: How safe is the environment where a traveler going? Are talking about going to Portland or Wisconsin or Africa? The other major issue is whether the person is young and totally healthy. If they have medical problems then this too is a red flag to do special planning.

MODERATOR:
When traveling in the U.S. are here any special precautions a relatively healthy person needs to take?

DUPONT:
Traveling within the US is totally safe for individuals if they're healthy. My only concern would be to advise the person who takes medication that it's important they have at least two different supplies of the medication in case one of their suitcases is lost. Other than that, I think travel within the US is done very safely.

MODERATOR:
And what about travel to our neighbor, Mexico?

DUPONT:
Well, there are 17 million people who do that every year, and unfortunately there's a big problem! 40 percent of these people get traveler's diarrhea and it can wreck a trip. Being careful what one eats and drinks and being prepared for illness if it occurs are the keys.

There are other issues we could talk about. One of the things that's important is that non-seasoned travelers from the U.S. go to Mexico. They don't go to Katmandu or to Cairo, but they go to Mexico. That's problem number one. The other thing about travel to a developing place like Mexico is the regard for public safety that we are accustomed to in the U.S. is missing. There won't be guardrails, there will be huge holes in the sidewalk, wires stretched between buildings at eye level, cars drive too fast, and when you cross the street it's a challenge. Sometimes it even appears the cars are aiming at people. So the first thing I say to people is exercise extreme caution, because accidents continue to be the most serious problems we see in travelers.

There are some other medical problems in Mexico. Many of the cities are at high altitude and travelers from lower altitudes can have symptoms that include lightheadedness, tiredness, muscle aches and pains, and increased intestinal gas at the higher altitudes. Another problem is, surprisingly, constipation. The roughage in the diet in Mexico and many other countries is lacking. People don't drink as much fluids as usual, and the net result is constipation. I think these are the major problems in a country like Mexico for a traveler.

"I've made it a habit of going to pharmacies around the world and asking them how they would treat common problems and I haven't been very impressed with the quality of their advice as a whole."

MEMBER QUESTION:
When I was in Mexico last year I wasn't feeling well and went to the drugstore there to get some over the counter medicine. Is it as safe as what I would have bought here?

DUPONT:
The medication in Mexico should be as safe as the equivalent product in the U.S. The problem is whether or not the correct medication was obtained. In other words, if you know exactly what you're buying, in terms of the milligrams and name of the drug, I would be perfectly fine with purchasing that product in Mexico. But I wouldn't trust the pharmacist in Mexico to tell me what I needed for a medical condition. They probably are trained, but I think US people expect a higher level of help than might be expected at such a pharmacy.

I've made it a habit of going to pharmacies around the world and asking them how they would treat common problems and I haven't been very impressed with the quality of their advice as a whole.

MEMBER QUESTION:
I am going to Guatemala City this fall for a week. Some people say I need shots; some say if I'm only in the city I just need a box of Imodium and I'm all set. What do you think? Oh, and is the old "don't drink the water" adage still true?

DUPONT:
Terrific question. The major things to worry about in Guatemala City are twofold:

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The most important vaccine-preventable disease of travelers is Hepatitis A. The chance of getting hepatitis when a traveler goes to a country like Guatemala is 1-5/1000. There's a vaccine available for Hepatitis A that's taken in two doses, rendering protection for more than 20 years, so we recommend for all travelers to any developing country to take this vaccine.

The other problem, as you suggest, is diarrhea. It is actually not the water that's the problem, but it's contaminated food. Food in countries like Guatemala can be categorized as usually safe or often unsafe. The usually safe items are:

  • Those served steaming hot
  • Those that are dry, like bread
  • Those with high sugar content, like syrup, jelly, and honey
  • Any fruit that can be peeled or has been peeled
  • Items that have high acid content, like citrus

The often-unsafe foods are the ones that are served at room temperature that contain moisture. So this would be vegetables and things that haven't been properly washed and other foods that are sitting in warmers that are not maintained at high temperature. The causes of this common diarrhea are bacterial agents found in these food items.

While Imodium will treat the symptoms very effectively, it may not cure the infection. We have known for at least 23 years that antibiotics are the mainstay of treatment of this diarrhea. Probably the best treatment is to combine a drug like Imodium with an antibiotic, where you get the immediate effect of the Imodium and the curative effect of the antibiotic.

MEMBER QUESTION:
What antibiotic would you recommend?

DUPONT:
I think that's a real key question. We really have several possible medications we use that seem to work. The drug I favor right now is one that's just been approved by the FDA and will be in drugstores in the next week or two. It's called Xifaxan, which has a couple of advantages over other medications available. The main advantage is that it's not absorbed from the intestinal tract, which means it will not cause symptoms of headache, insomnia, vaginal infection, skin rashes, and the other problems with other antibiotics that are absorbed from the intestinal tract. So it's entirely safe with essentially with no side effects. It's very effective on the majority of the cases of diarrhea that occur.

Xifaxan is taken in a dose of one tablet three times a day for three days. This antibiotic and others are used for traveler's diarrhea, but not for cruise-related Norwalk gastroenteritis.

MEMBER QUESTION:
I'm planning the trip of a lifetime -- China and Tibet. What do I have to do to prepare for the altitude in Tibet?

DUPONT:
The key items, like everywhere else, are to determine whether the people going there are totally healthy people or have underlying medical problems. I would not advise anyone with heart or lung disease to travel to areas with such high altitude. For healthy persons there is a medication that can be taken to help prevent harmful effects of the high altitude. That drug is called Acetazolamide (diamox). It is taken twice a day during the early days after arriving in the region of high altitude. This drug will require a prescription from a physician.

"The people who get SARS essentially are those taking care of patients in the hospital or family members of active cases. The risk to travelers is very small, even during an epidemic."

MEMBER QUESTION:
I have a chance to travel to Hong Kong and mainland China. Do I still have to be concerned about SARS?

DUPONT:
Currently SARS is not a problem anywhere in the world. Even when SARS is at its peak it is really not a risk for travelers. The people who get SARS essentially are those taking care of patients in the hospital or family members of active cases. The risk to travelers is very small, even during an epidemic, and Southeast Asia right now appears to be entirely safe, without SARS cases occurring.

MEMBER QUESTION:
We'd like to take a cruise in the Caribbean, but hear reports of outbreaks of illness on ships. What is making people sick on these cruises? Can we avoid it? Would you take a cruise?

DUPONT:
Terrific questions. The chance of getting sick on a cruise is very small. Yes, I would take a cruise, and do take cruises. One suggestion, if you are worried about it, is to contact the cruise line and ask if a problem occurred in the recent past on that particular ship.

The problem on cruises is that a virus called Norwalk virus is spread between people onboard. It is hard to get it out of a boat once it's there. The bottom line, safe boats are safe and Norwalk-infested boats present a recurrent problem. If you are going to take a trip on a boat that has had a problem, my suggestion would be to load up on Pepto-Bismol, which appears to be useful in treating this virus infection.

MEMBER QUESTION:
Do smaller cruises with fewer people tend to be safer from outbreaks of viruses or food poisoning?

DUPONT:
I think in general smaller boats are going to have less of a problem, but the boats we were just talking about were large ships. When I say small, I'm talking 10 to 20 people. There's no reason to think a boat with 300 is any safer than 1500 people. I think when you have a larger number of employees and the need to bring water and food in from ports you're running the risk of these outbreaks.

I might also add that Norwalk virus that causes this problem does not cause serious illness, and this is really pretty trivial. Although no one feels that a 12- or 18-hour illness is trivial, it's not life threatening. I think we need to put it into proper context. It's pretty mild.

MEMBER QUESTION:
When we travel (usually islands in the Caribbean) we love to try the little out-of-the-way places where the locals eat. The food is amazing. We don't bother much with the hotels where the American tourists eat. Are we at any greater risk for illness by eating as the locals do? This is a fun part of travel for us. We are thinking of stretching our wings and exploring Asia. How about what we eat there?

DUPONT:
The risk of getting diarrhea in the Caribbean is island specific. If you're going to the U.S. Virgin Islands it's like going to New York or Dallas. If you go to Jamaica and some of the other less hygienic areas the chance of getting diarrhea when you eat at out of the way places is between 15 and 20 percent of cases, much lower than we see in countries like Mexico. You're running a slight risk by eating anywhere you wish if it's in an island like Jamaica, Dominican Republic, or Haiti.

In Asia, the traveler's diarrhea resembles more that of Mexico, in that the rate of illness approaches 40 percent. Here I would be more careful about the food that was consumed. You can eat at out of the way places if you eat the safe foods that I earlier outlined.

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MEMBER QUESTION:
My wife and I recently returned from Cancun and she contracted diarrhea that hasn't seemed to resolve. Do you have any idea why this might be?

DUPONT:
Yes. There are several possibilities. If the diarrhea has only been lasting for a week or two it is likely to be an infectious agent that can be treated with an antibiotic. If it has lasted more than a month an infectious agent probably will not be identified and I would recommend being evaluated by a gastroenterologist.

In this latter category we have found, in our studies, that approximately 10 percent of patients experiencing travelers diarrhea develop a condition known as irritable bowel syndrome, or IBS. Unfortunately this can last for months to years, and it's the most important reason why we want to prevent this illness from occurring in the first place.

MEMBER QUESTION:
My husband has diabetes. What precautions should we take before traveling to Europe (Spain, France and Italy)?

DUPONT:
There are a couple of issues here. One is to make sure that the proper insulin products are taken with you and put into two different separate places in case one is lost.

The other problem is the change in duration of days. When we go from the US to Europe the day is 6 to 7 hours shorter; it could be even longer if you come from the West Coast. Insulin adjustments for diabetes is critical, and the best advice is to stay on your time in the U.S. with regard to eating and insulin usage, and slowly adjust once you get into the local area and try to re-equilibrate with insulin dosages. It's tricky, and probably is something that your husband should work out with his doctor.

MEMBER QUESTION:
I have MS and have to take 15 days of shots (Copaxone) along. Does MS lower your resistance to infections?

DUPONT:
MS, by itself, and the treatment that's being taken should be okay for travel as long as the neurologic issues are sufficiently stable. I'm not particularly worried about increased risk of infection. Any increased risk of infection based on the presence of MS (such as a urinary tract infection) would not be a travel issue, but is an MS issue. In other words, these complications would occur with travel or with staying home.

The key for your travel is going to be to make sure you keep the medication at the proper temperature, and that it's taken on the proper schedule. If the MS is stable and you're doing well, I believe that sensible travel is possible.

MEMBER QUESTION:
I'm going on a tour of Finland, Sweden, and Norway in August. Any suggestions or problems with food there?

DUPONT:
You're traveling to some of the safest parts of the world. The only caution I would give you there is to not eat foods you wouldn't eat in the US, such as raw meats that might be served, but otherwise this is like traveling within the US and I'm not worried about anything special.

"Anyone traveling to a high-risk region of the world where diarrhea or malaria occurs commonly will need competent pre travel advice from a knowledgeable physician or travel medicine clinic."

MEMBER QUESTION:
Is it worth discussing any upcoming vacation with one's doctor?

DUPONT:
I'm going back to my original question and answer that there are two issues here: One is the safety of the place to be visited, and the other is the underlying health of the traveler. Certainly anyone with serious underlying medical problems should seek pre travel advice from their physician. Also, anyone traveling to a high-risk region of the world where diarrhea or malaria occurs commonly will need competent pre travel advice from a knowledgeable physician or travel medicine clinic.

Travel medicine clinics in the U.S. are the best places to go for travel advice and vaccine. They have something regular doctors do not have; they have regular weekly updated information from the Centers for Disease Control and Prevention (CDC) giving risks and recommendations for every place a visitor might travel, so travel- or itinerary-specific recommendations can be made.

MEMBER QUESTION:
What's the best first aid kit for packing on our upcoming car trip? We will be hiking and doing some lake swimming.

DUPONT:
I'm going to expand the term from first aid kit to medical kit. One takes all their normal medicines, plus medications they might need for anything that might occur in the US, such as colds, heartburn, or diarrhea. In other words, they need a mobile pharmacy, because in the wilderness the hours of the stores are pretty limited.

You also need to make provisions for safe water, which can be with a filter or with plans for boiling the water. Water can be brought to a boil and rendered safe during backpacking.

MODERATOR:
How much of a problem is malaria for the traveler?

DUPONT:
We have more than a thousand cases occurring each year, from the industrialized west to malarious areas, resulting in deaths. The most important areas for malaria are sub-Saharan Africa, Southern Asia, and South America. The most serious cases occur during travel to Africa.

Anyone going to an area where malaria is present must do three things:

  • Wear insect repellant every evening like after shave lotion or perfume.
  • You need to take medication, which you get from your doctor or travel medicine clinic, to prevent malaria.
  • If you develop any fever after that trip, you must report to a doctor immediately and indicate a potential exposure to malaria.

MODERATOR:
Dr. DuPont, before we wrap things up, do you have any final words for us?

DUPONT:
I think no one should be frightened of travel. Only rarely do medical conditions preclude travel, and we can prevent most of the illnesses by being careful what we do. The few illnesses that do develop can be adequately managed, either by the traveler or by a physician en route or at home. It is possible to travel safely and with health, but a little bit of knowledge goes a long way on this topic.

MODERATOR:
Thanks to travel medicine expert Herbert L. DuPont, MD, for sharing his expertise with us today. For more information, please be sure to visit our message boards to talk with others and ask questions of our experts. Links to some of the message boards are located on page 1of this transcript.



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Reviewed on 10/1/2004 4:30:59 AM

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