Last week, Mexico’s top epidemiological official reported a rise in the number of cases of dengue hemorrhagic fever (DHF) throughout the Gulf coast state of Veracruz.  The disease is moving towards Tamaulipas state and is getting closer to the United States border.  The recent flooding in Mexico has been a factor in the increased number of cases, with some 1,900 cases and 16 deaths being reported so far this year.

DHF was first recognized in the 1950’s and is a more dangerous version of dengue fever.  DHF frequently requires those infected to be hospitalized, and if not treated properly, the fatality rate for DHF can exceed 20%.  The CDC cites symptoms of DHF as similar to dengue fever, but ratcheted up to include persistent vomiting, severe abdominal pain, and difficulty breathing.  Bleeding from the nose, mouth, and gums can also occur.  As with dengue fever, there are a variety of medications used in the treatment of DHF.  If detected early, it can be treated with fluid replacement therapy.

As we reported in an earlier post, dengue fever is also on the rise in dozens of countries.  Since our last post, we’ve discovered that Thailand, French Polynesia, Indonesia, Cambodia, Nicaragua and Venezuela all belong on the list.  Dengue fever and DHF are both spread by mosquitoes, so travelers should do their best to protect themselves from mosquito bites.  Symptoms begin about 5-7 days after an infected bite.  DHF can be deadly, so it is important that travelers who suspect that they may have DHF see a doctor immediately. We will be keeping a close eye on this growing epidemic.

Author: Christie Erdman
Christie Erdman, a guest contributor to the Healthy Travel blog, is a recent graduate of the University of Richmond with a degree in Economics and Marketing.  She enjoys traveling, and had the opportunity to spend a semester studying at Universita Bocconi in Milan, Italy during her junior year.

Photo by James Jordan

My eyes were opened to the threat posed by multi-drug resistant tuberculosis (MDR-TB) when I read about Dr. Paul Farmer’s evangelical efforts to raise the world’s consciousness in Tracy Kidder’s book Mountains Beyond Mountains.  Years later I’ve learned the threat continues to grow. The World Health Organization works very closely with Farmer’s Partners In Health organization to monitor and combat MDR-TB around the world.  The WHO’s 2010 report is cause for alarm but also offers some seeds of hope.

First some worldwide statistics from the report:

• In 2008, there were estimated 440,000 MDR-TB cases and 150,000 deaths
• Only 7% of all MDR-TB patients were diagnosed and notified
• 60% of those enrolled in treatment programs were cured
• In 2010, only 22% of the $1.3 billion needed to fund MDR-TB control is available
• In 2015, funding required to control MDR-TB will be nearly $4.5 billion

How did we arrive at this dangerous place?

Tuberculosis thrives in the poorest neighborhoods and in prisons and hospitals that house the poor.  Treatment with antibiotics is effective, but the course of treatment is long, and the side effects can be serious.  Therefore, it is not unusual for patients to abandon their antibiotics too early, giving rise to the MDR strain.  Today the prevalence of MDR-TB is growing, and so is the risk of encountering it on your travels, especially if you are visiting any of the 27 countries with a high burden of TB.

See the chart below for the prevalence of MDR-TB in these countries and the number of cases annually.  Travelers should also note that MDR-TB has a significant foothold in Jordan and Peru.  Further, only 22 of 46 African countries provide data to the WHO.

On the hopeful side, treatment efforts seem to have turned the tide in Estonia, Latvia, Hong Kong, the U.S. and certain parts of Russia. Twenty of the 27 high burden countries are strengthening their efforts by scaling up access to diagnostic tests.  As is so often true, sustained progress depends on increasing resources, expertise and coordination around the globe.  The price tag to control MDR-TB is relatively affordable when compared to global expenditures to combat HIV and H1N1, but until the problem reaches crisis proportions, adequate funding may not materialize.

And don’t bet against the microbes.  They have continued to evolve to elude even more forms of antibiotics.  The Extensively Drug-Resistant (XDR-TB) strain has now appeared in 58 countries, and the WHO estimates there are 25,000 cases annually.

Although rabies is rare in the U.S., it is still a risk in both rural and urban areas.  A recent New York Times article, Taking the ‘Wild’ in Wildlife Seriously, reminds us that rabies can occur anywhere and is a very real threat to health and safety.

Outside the U.S., rabies is even more common.  According to the World Health Organization (WHO), 55,000 people die of rabies each year; 95% of these fatal cases occur in Asia and Africa.

Rabies is most often transmitted to humans through a bite from an infected animal. Simply petting or being licked by an infected animal does not generally cause disease. Modern rabies therapy has an extremely high success rate, so it is imperative to get help immediately if bitten, especially because once the flu-like clinical signs of rabies develop in a human, the disease is almost always fatal.

Travelers should be aware of animals wherever they are, particularly those behaving with unusual boldness around humans.  Because any animal – wild or domestic – can pose a threat, contact with any unfamiliar ones should be avoided. 

Although the rabies vaccine is not necessary for most travelers, it is available for high-risk individuals such as field biologists who expect to be handling animals.  It may also be appropriate for those traveling in areas where rabies is still a problem in domestic animals and where prophylactic care may not be readily available, such as for hikers exploring remote rural areas.  If you’re not sure whether you need the vaccine, check out the CDC recommendations for getting the rabies vaccination before traveling.

Author: Melissa Haertsch
Melissa Haertsch, a guest contributor to the Healthy Travel blog, is a freelance writer specializing in healthcare, travel and fine food. She favors outdoor-related journeys, which she launches from her home in the Endless Mountains of Pennsylvania.

Photo by bartmaguire

Mononucleosis – better known as “mono” or “kissing disease” is a common viral illness that afflicts thousands of young adults each year.  Although usually a benign condition, with symptoms of fever, headache, sore throat, fatigue and swollen lymph nodes – particularly in the neck – mononucleosis can occasionally lead to much more serious problems, and rarely even death, particularly in those with compromised immune systems such as people with HIV/AIDS or those taking drugs to suppress immunity after an organ transplant.

Students abroad seem to be particularly susceptible to contracting mononucleosis.  Over the past two months, HTH Worldwide has had two study abroad participants experience severe symptoms of mono.  One student developed significant abdominal tenderness with an enlarged spleen and hepatitis (liver inflammation), along with anemia (a low red blood cell count), and difficulty swallowing.  Her condition prompted transfer from a rural area with marginal medical facilities to an urban hospital, where she did not start improving until given very high doses of steroids.

The second patient developed dehydration from an inability to swallow, along with “ataxia” (loss of coordination) due to inflammation of the cerebellum (the part of the brain responsible for balance).  Indeed, patients with mononucleosis have been diagnosed with a number of other neurological complications, including Guillain-Barre syndrome (loss of motor strength similar to polio), meningitis, encephalitis, and seizures. 

Other rare conditions seen with mononucleosis include pericarditis (an inflammation of the lining of the heart), thrombocytopenia (a drop in platelets – the small cells responsible for blood clotting), and airway obstruction due to extraordinary tonsil enlargement.  Although some enlargement of the spleen is quite common in mononucleosis – almost fifty percent of all patients who are diagnosed with mono have some splenomegaly – life threatening splenic rupture may also occur either spontaneously or as a result of minor trauma, in a small number of cases.

Mononucleosis is extremely contagious, and seems to have a predilection for groups in close confinement.  In addition to kissing, the virus spreads easily from shared drinking glasses and utensils.  Rarely, the virus can be contracted from a blood transfusion.  Mononucleosis can remain contagious for weeks after the onset of symptoms, or even after most of the symptoms have resolved. 

Although there is no cure for mononucleosis, symptoms seem to improve with steroids.  Other measures that help alleviate symptoms include salt water gargles and anti-inflammatory medications such as acetaminophen (Tylenol) or ibuprofen (Advil).  Aspirin should be avoided, as its use has been linked to the development of Reyes syndrome – a liver disorder- particularly in those under 21.  Those infected should avoid heavy lifting or contact sports to reduce the risk of injuring the spleen.

The test for mononucleosis is not universally available, and the diagnosis is often missed outside of the United States, so maintain a high index of suspicion if you are a young student heading abroad for studies or leisure.

Photo by: hipposrunsuperfast.com

A recent post on the Wall Street Journal’s Health Blog by Katherine Hobson brought to light a fascinating new study on the Quality of Death around the world. The Singapore-based philanthropic Lien Foundation commissioned the Economist Intelligence Unit to study forty countries in depth to gauge how much suffering accompanies the final few months of life. Researchers interviewed doctors and experts on palliative care to help measure four sub-indices: 1) basic end-of-life healthcare environment; 2) availability of end-of-life care; 3) cost of end-of-life care and 4) quality of end-of-life care. The results and rankings are shown below.

Predictably, most of the richer nations scored relatively well. But the biggest findings do not seem to be driven so much by a nation’s GNP as by the “culture of curing” and the scarcity of painkilling drugs. The study notes that medical professionals are trained to implement curative rather than palliative strategies–so much so that of the 100 million people worldwide who could benefit from palliative care annually, only 8% receive it. Likewise, regulations to stop illicit use of opiates often make them unavailable for clinical use. The result is that availability of painkilling drugs is “woefully inadequate” all around the world. Taken together, the authors conclude, these issues cause an “incalculable surfeit of suffering” for patients and their loved ones.

Still, in relative terms, you are much better off in the U.K. and Australia than China, Brazil or India when your candle is burning low. Once we all admit that death is a part of life, we can begin to appreciate the importance of the availability of quality palliative care and unflinchingly incorporate quality of death into our happiness index.

As if budget woes are not enough, last month the State of California officially declared a statewide whooping cough epidemic.  With recorded cases 400 percent higher than last year, including almost 1000 cases in 2010 with five infant deaths, state officials now believe that California is headed for the highest incidence of  pertussis, commonly known as whooping cough, in over 50 years.

California is not alone. The CDC notes that the number of reported cases in the United States tripled between 2002 and 2004.  Although still a far cry from the 175,000 annual cases diagnosed prior to the introduction of the vaccine, the incidence of whooping cough reported annually in the last decade still represents an alarming increase from the less than 3,000 yearly cases in the 1980s.

The dramatic rise in whooping cough is not limited to the United States.  The World Health Organization estimates there were over 17.6 million cases of whooping cough and 300,000 deaths last year alone, making this easily preventable disease one of the world’s leading causes of illness and death. The greatest increase has been in wealthier countries with widespread immunization programs.  The rarity of the illness, coupled with concerns about side effects of the vaccine and the use of vaccines with poor efficacy (Canada, Sweden), has led to an increase in the number of inadequately immunized, or unimmunized children, in developed countries.  In addition, the whooping cough vaccine does not confer lifelong immunity, which means that adults immunized in childhood are susceptible to the illness.  Indeed, almost 25% of whooping cough cases in Europe and the United States are now reported in adults.

Whooping cough is seldom more than a mild inconvenience in those over 10, who may experience prolonged upper respiratory symptoms (runny nose, fever, persistent unproductive cough), but rarely have more serious consequences. Nonetheless, the presence of the B. pertussis infection in adolescents and adults who may transmit the bacteria to infants has led healthcare providers to promote booster immunizations after childhood.  However, booster shots have been approved for adults in only a handful of countries (Canada, France, Germany and the United States), which means that there remains a tremendous reservoir of unprotected adults around the globe, even in developed countries. To compound matters further, there is newly emerging evidence that some strains of the bacteria that cause whooping cough have developed resistance to the newer (acellular) version of the vaccine

Fortunately, the CDC now recommends that anyone traveling outside of the United States receive the DTaP (which includes pertussis protection) vaccine prior to travel. Some resistance notwithstanding, compliance should minimize the risk of contracting the illness overseas and passing it on to susceptible infants who tend to suffer more devastating clinical consequences.

While Bastille Day is a decidedly French holiday, it is celebrated in many parts of the world.  According to Wikipedia, Belgium, Hungary, South Africa and the UK all have events scheduled.

Here in the United States, over 50 cities participate, and one can even see them listed on an interactive Bastille Day map.  My favorite, not to be too parochial, is the Eastern State Penitentiary Bastille Day Festival which took place last weekend.  A reenactment of the storming of the Bastille takes place with “dozens of French revolutionaries” playing their roles to the tee including dragging Marie Antoinette to the guillotine.  Of course, no one said it was historically accurate – for those of you a little short on your French history, the storming of the Bastille took place in 1789.  Louis XVI lost his head in January of 1793, but Marie kept it all together until October.

Eastern State Penitentiary and the Fairmount area of Philadelphia make a great backdrop for the celebration which ends with special French meals in the many local restaurants and bars.

Do you have any Bastille Day stories for us or unique, local ways it is celebrated in your neck of the woods?  We would love to hear about it, and, of course, stay safe and healthy while you are out “storming” – avoid too much cake and let the professionals handle the fireworks.

Photo by Ammar Abd Rabbo.

Last week  Healthy Travel Blog was recognized as one of the Best Health and Lifestyle Travel Blogs by Iglu Cruises.com.  One of the leading online travel agencies serving the UK and Canada, Iglu bestows its award on sites that help travelers maintain good health and lifestyle practices while on the road, whether for business or pleasure. Iglu’s staff noted that “Each and every one of our award winners are experts at collating and conveying the information you need to succeed, from insightful articles to innovative health tips and a great deal more.”

We think we’re in good company and encourage you to visit the sites of the other winners: Globorati, The NuNomad, ArtTrav, A Luxury Travel Blog, and Health Conscious Travel.

Please continue to check in for updates on news, trends, issues and solutions relating to healthy travel!

In today’s New York Times’ Globespotters post, Fresh, Sweet and Seasonal in Mumbai, Dan Packel tells us about the abundance of fresh fruit available in the APMC Fruit Market in Navi Mumbai.  It covers a huge, 22-acre area and sounds delicious.  Not to rain on Dan’s parade, but I did think we should remind travelers of dangers sometimes associated with food when traveling.

According to the CDC, “Traveler’s diarrhea (TD) is the most predictable travel-related illness.”  It hits 30% to 70% of travelers, depending on the destination.  We have covered this subject before, so we don’t need to rehash all of the same information (see Eating Safely: What can I do? and Stop Me If You’ve Heard This One: Where I Met Montezuma); I will stick to fruits and a weird English anomaly.

Simply put, it is better to eat fruit that can be peeled and that you have peeled yourself.  Obviously, wash your hands and the fruit prior to peeling.  This leads me to my English anomaly:  what does unpeeled mean?  Is this fruit that has been peeled, as in “undressed,” or is it yet-to-be peeled.  The CDC makes a very ambiguous statement in its guide on TD –  ”Other risky foods include raw or undercooked meat and seafood, and unpeeled raw fruits and vegetables.”  If it is risky, I assume they mean “peeled.”

Photo by gruntzooki

If you’re looking for places to visit where you can breathe easy and enjoy the local drinking water, green space and biodiversity, the European Union has started highlighting exceptionally “green” cities by handing out an annual Green Capitals award. The 2010 and 2011 winners are Stockholm, Sweden and Hamburg, Germany, respectively. The judges have also selected six finalists for the 2012 and 2013 awards: 

• Barcelona, Spain
• Malmo, Sweden
• Nantes, France
• Nuremburg, Germany
• Reykyavik, Iceland
• Vitoria-Gasteiz, Spain

Winners will be announced in October.

Cities are judged against twelve criteria and on their ability to demonstrate innovation, efficiency and compelling plans for the future:

• Local contribution to global climate change
• Local transportation policies
• Green urban areas
• Sustainable land use
• Nature and biodiversity
• Quality of local ambient air
• Noise pollution
• Waste production and management
• Water consumption
• Waste water treatment
• Municipal environmental management
• Program to promote best practices to sister cities

Now you can vote with your feet (and airplane ticket) and try ecotourism with an urban flair. There are plenty of other cities applying to be recognized as Green Capitals. Have you visited any of the winners or aspirants?