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travelmedicine
by Dr. Rajiv Narula

Motion Sickness by Dr. Rajiv Narula

Motion sickness is a common problem encountered by travelers – whether by sea, air land, camel or elephant ! We all suffer from it, the difference lies in the level of discomfort- 5% suffer heavily, 5% suffer minimally and the remainder 90 % suffer moderately. According to the Medical College of Wisconsin from one third to one half of airline passengers experience some degree of motion sickness when encountering heavy turbulence.

The body has two pathways whereby it maintains balance, one is visually and the other is maintained by the inner ear. Both inputs are relayed to the brain. If the brain is sent conflicting messages, which is what occurs, when for example, one is below deck on a ship. Visually your eyes see very little motion, because one is unable to see the horizon , however the inner ear senses the motion. Both these in turn send the brain conflicting messages which results in symptoms of motion sickness.

Symptoms vary from person to person, these generally consist of malaise, cold sweating, abdominal discomfort, nausea and vomiting. Other symptoms may include drowsiness, salivation, hyperventilation, headache and flushing. There is also a major psychological component ; some persons develop some of these symptoms in anticipation of an air flight or a boat ride. Most people will adapt rapidly to motion, that is they will be able to tolerate the motion that made them sick at the beginning of their voyage. The French term for the debilitating effect of motion illness is Mal de Mar, luckily it is not life threatening, although the person suffering sure feels like they are in a bottomless pit. Women are usually more susceptible than men, this is worsened near menstruation and pregnancy. Factors that can predispose one to feel motion sickness include – alcohol, certain drugs, and as stated earlier, anxiety levels and sleep deprivation. An interesting study published in Aviation Space Environmental Medicine in 1993 showed that Chinese subjects were more susceptible than Caucasians.

There are many remedies that are used, ranging from use of behavior therapy – avoiding rooms without a view of the horizon, to eating ginger , to using wrist bands and also the use of prescription medications in oral as well as in transdermal forms. Yet others believe in avoidance of certain foods prior to and during the trip.

The first scientific study regarding the use of ginger was published in 1982. In this study 940 mg of ginger were shown to be more effective than Dramamine 100 mg. However other studies have shown it not to be effective in certain situations. Issues that remain to be looked at include the quality of the ginger preparation and the time that is required for it to produce it’s effect. The most common prescription medication is probably scopolamine, it comes in two forms an oral preparation and a transdermal format. The ‘transderm patch’ is applied behind one’s ear, 6-8 hours prior to departure. Medication is released in a fixed dosage, it penetrates the skin and is then absorbed. Absorbtion differs between different persons and unfortunately in some cases may be too much, the amount released differs from person to person. On the other hand the oral formulation can be taken an hour before travel, and is effective for 8 hours. The dose can be titrated to the person’s weight and individual needs. It would be advisable to try the oral preparation prior to the patch. Both these can have the side effect of causing some drowsiness, use of alcohol with them must be avoided. Alcohol is perhaps the last thing on a person’s mind when they have that dreaded feeling of mal de mar !

travelmedicine
by Dr. Rajiv Narula

Hepatitis A

Hepatitis A is a viral illness of the liver, which is primarily spread by eat­ing and drinking contaminated food and water. This includes eating raw seafood, uncooked fruits and vegeta­bles, or foods that are contaminated by food handlers. Intimate contact with an infected patient can also spread the disease. The virus is excreted in the stool, thereby spread by persons who do not practice good hygiene; this is another way to pick up the virus. Symptoms usually occur within 2 and 5 weeks of exposure and may include malaise, fever, headache, loss of appetite, nausea, vomiting and abdominal pain. Other signs that are seen are dark colored urine, light col­ored stools and jaundice. The disease can manifest itself over a wide spec­trum ranging from a mild illness last­ing 1-2 weeks to a severe disabling disease lasting several months. Mor­tality for people over 40 contracting the disease is 4%.Hepatitis A is an important risk for travelers to many areas of the developing world. Crowded living conditions and poor sanitation result in Hepatitis A being highly endemic in these regions of the world; it is pre­sent in the western world but is less endemic. The risk for travelers increases with the time spent in these regions either with long trips or with frequency of trips.

Each year in the US, about 100,000 cases of acute Hepatitis A are reported. This is responsible for about $200 million in economic losses and about 100 deaths in the US. Studies have shown that there is an aver­age loss of 27 days from work per episode. With the tremendous increase in business/leisure travel, getting the vaccination makes good medical and economic sense. Inactivation of Hepatitis A virus is achieved by boiling or cooking food or water to 85 degrees C for at least 1 minute; proper chlorination of tap water also inactivates the virus. Hepatitis A vac­cines have been available in the US since 1995, there are 2 vaccines with a reported efficacy rate of between 94-100%. The recommended schedule for both vaccines is a primary vaccine followed by a second dose 6-12 months after the primary one.

After the second one the project­ed protective antibody levels last for up to 20 years. Immune globulin, which is prepared from pooled plas­ma of several donors, also provides protection , but for shorter periods of 3-6 months depending on the dose used. Travelers less than 2 years of age are given the immune globulin because neither vaccine is licensed for this age group.

An easy rule to minimize food related illness is to — “boil it, cook it or forget it!”

travelmedicine
by Dr. Rajiv Narula

Malaria

Among the many diseases transmitted by mosquitoes, malaria is one of the most dreaded, and yet pre­ventable, causes of mortality among travelers. The geographic distribution of malaria covers most tropical regions and some warm temperate regions of the world. Risk of malarial transmis­sion decreases above 4,500 feet, how­ever in hotter climates, it may occur at heights above 9,000 feet. Last summer there was a big outbreak in Kissi, Kenya - altitude 6,000 feet.

Malaria is transmitted by the bite of the female Anopheles mosquito that injects the malaria parasite into the blood. These usually bite between dusk and dawn. Early symptoms are flu, fever, chills, muscle aches, headaches and sometimes vomiting and diarrhea Severe cases can rapidly progress to mental confusion, liver and kidney failure, convulsions, coma and death.

Making an early diagnosis is cru­cial to a successful outcome. You may have any of these symptoms from one week to several months after possible exposure to the mosquito. The period between the bite and the onset of ill­ness is usually seven to 21 days but can be several months.

There are four species of malaria which can infect humans and cause ill­ness, however only Falciparum Malaria can be life threatening; it can be treat­ed effectively in its early stages. Yearly about 300-500 million people contact malaria, out of that 2-3 million will die! One million people die yearly in Africa alone, the second biggest killer on the continent after AIDS, according to the United Nations.

Travelers can protect themselves by avoiding mosquito bites by minimiz­ing outdoor activities at night, wearing proper clothing, taking the correct anti-malarial medications, using repel­lents such as DEET and permetherine and mosquito nets. You cannot reduce the risk to absolute zero, but using this three-layer strategy will reduce the odds significantly.

The choice of anti-malarials is of paramount importance, as picking the correct one depends on the patient’s medical history- allergies, health status and itinerary. Studies done in Canada and Europe have shown that only between 11-27% of travelers were given the correct recommendations for protection.. This shows the importance of getting these recommendations from a reliable source. Vaccines for preven­tion are being developed and will hopefully be available in a few years. Until then, try not to make yourselves feeding grounds for mosquitoes.

Schistosomiasis
by Dr. Rajiv Narula

Schistosomiasis is a parasitic illness, which goes by several names, including bilharziasis and snail fever. It has been around since Egyptian times, mummies have actually been found with calcified eggs - dating back to 1500 BC. It is caused by one of five species of water borne flatworms, also called flukes. Fresh water snails are essential for part of the developmental stage of this parasite. The stage that causes human disease is called a cercaria. these are tiny, free swimming, pear shaped tadpole like objects. The cerceraie are stimulated by bright lights and warm day time temperatures, causing them to abandon their snail hosts and look for humans.

Survival time in the water is only 48 hours, so a human host is essential. The oily secretions of human skin attracts them to attach to the skin, they then release a substance that causes the 'cement' like substance that holds cells together to split, allowing the cercariae to burrow themselves into your body.

Penetration of intact skin takes between 30 seconds and 10 minutes, initial response is an itchy, rash - which may last for 1-2 days; this is usually followed by a period of six weeks during which worms enter the circulatory system and migrate to the veins of the abdominal cavity, where they reach sexual maturity and release eggs.

These eggs penetrate the walls of certain organs causing bleeding and obstruction. Over time this could leads to a chronic, disabling disease that can be fatal. Other symptoms that may be present include - fever (snail or safari fever), fatigue, loss of appetite, liver enlargement, cough and diarrhea. According to the WHO, in some African countries bladder cancer linked to the schistome is 32 times higher than that of simple bladder cancer in the US.

This incidence of disease is increasing among travelers, due to the increase in "off track" tourism. Infections in travelers are usually acquired by bathing, swimming, wading in infected waters, and also from drinking water. In a lot of these affected countries, local inhabitants swim, wash clothing and drink this very same water. Contaminated waters may include fresh water - lakes, streams - especially along the margins and slow moving waters. Risk is also increased in ditches and swimming pools that are inadequately chlorinated; also implicated is tap water that has been contaminated due to inadequate treatment or contamination.

Schistosomiasis is endemic in almost all of Africa, parts of SE Asia, parts of South America and some Caribbean islands. This affects 200 million people worldwide, out of this 1 million deaths can be attributed to it. Most human infections are caused by 3 species - Schistosomiasis Mansoni (53 countries in Africa, Eastern Mediterranean, Caribbean and S. America.)

Schistosomiasis Japonicum is endemic in seven countries in SE Asia and Western Pacific region. Schistosomiasis Haematobium is endemic in 54 countries in Africa and Eastern Mediterranean.

Diagnosis is usually by finding eggs of the parasite in urine or stool specimens. Prevention is by reducing the contamination of water. Worldwide demand for water has and is increasing; this requires more irrigation projects. Dams that are built for this purpose have been a big factor in causing spread of the disease. Almost half of the egyptian population is infected. The building of the Aswan Dam caused the propagation of S. Mansoni which causes schistosomiasis. W. Africa has seen a tremendous increase in infected persons around man made lakes.

Avoidance of contaminated water is the rule, but in case of exposure, studies have shown that using DEET (the mosquito repellant) can repel the cercariae. Vigorously wipe yourself with rubbing alcohol after exposure, has been suggested.