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With a Travel Medicine Doctor

With all of the news reports and information about health risks when one ventures into the great unknown, thought it was a good time to consult with an expert on all things travel health related. Enter Dr. David Shlim, President of the International Society of Travel Medicine and and former director, for 15 years, of the Clinic Travel Medical Center in Kathmandu, Nepal -the busiest destination travel medical clinic in the world. Dr. Shlim created a research program into the diseases that affect travelers and is one of the most knowledgeable travel medicine doctors in the world.

Oh ya – in addition to all of his international experience, writing and research he was also recently the on tour doctor for The Rolling Stones throughout Canada, Japan, China and Australia.

  • What immunizations should everyone be considering when they are travelling?  To cities?  To more adventurous locales?

Dr. Shlim:  The distinction between cities and rural travel has never really made sense when one is in a country with a high degree of disease risks. The one time it can make a difference is with Japanese encephalitis. More adventurous locales usually mean destinations from which it is more difficult to get medical care or get evacuated to medical care.

The number one travel-related vaccine is hepatitis A vaccine.  No one should go to a developing country without taking it.  One shot is completely protective, and a second shot 1-5 years later boosts one for life.  The disease itself can make people sick for months, has no treatment, and is occasionally fatal.

Typhoid fever is less common than hepatitis A, but still associated with destinations that have poor hygiene.  The risk is highest throughout the Indian subcontinent. The injectable vaccine is safe, about 70-90% protective, and lasts two to three years.  The oral vaccine is also safe, but is a little complicated to take (four doses over an eight day period), and lasts for up to five years.

The risk of hepatitis B virus, which is entirely different than hepatitis A, has been over-promoted to travelers.  Hepatitis B is a sexually-transmitted, bloodborne infection that can only be acquired through unprotected sex, sharing needles, piercing, tattoos, or unsterile medical treatment.  Although it is theoretically possible for a traveler to acquire hepatitis B infection without engaging in these actions, it is phenomenally rare.  That said, most travelers under age 25 have all had hepatitis B vaccine as part of their routine childhood immunizations, for the most part, and some older travelers would have had it in middle school.  For long-term travelers, or those who may engage in casual sex, hepatitis B vaccine is still important.  The disease may not make you very sick when you first get it, but it can ultimately destroy your liver or cause liver cancer.

Yellow fever vaccine is the only internationally regulated vaccine at present. It may be required to enter some countries, or it may be recommended to protect travelers to countries that don’t require it. Throughout the world, clinics need to have a special license to give yellow fever vaccine and issue the official certificate. Yellow fever vaccine carries some rare but potentially serious risks, and these need to be discussed with your travel medicine practitioner before receiving the vaccine.

Polio has disappeared from the Western Hemisphere, and from most of the world, but is unfortunately making a comeback in Pakistan and India, and in growing areas of Africa.  Travelers to areas where there may be polio transmission should receive one polio booster as an adult (over age 18) if they have completed their usual childhood series.

Measles has been in the news a lot lately.  Persons born before 1957 are presumed to be immune to measles through natural infection.  People born after 1957 should receive two doses of MMR vaccine in their lives.

The risk of tetanus is no greater—and no less—while traveling in other countries. The tetanus bacteria live in soil, and are accidental contaminants of wounds. The reason for having an up-to-date tetanus shot before travel is to avoid having to seek out a tetanus booster from an iffy clinic in another country if you got injured.  Another reason for having a booster is the addition of pertussis (whooping cough) vaccine to the tetanus shot.  Pertussis is making a comeback in developed countries, and everyone should make sure they have had a TDAP (tetanus-diphtheria-acellular pertussis) booster within the last ten years.

Every traveler should leave home with a strategy to prevent rabies, including avoiding contact with mammals while traveling, and knowing where they would have to go to get post-exposure rabies preventative treatment.  For some travelers, taking three rabies shots before they travel can increase the margin of safety, and make it simpler to give a booster after a suspicious bite.  Alternatively, travelers can go without taking rabies shots, but they then may have to travel to another country to get the post-exposure rabies treatment that they need.  The three pre-exposure rabies shots may cost as much as $1000.00 in the U.S.

Japanese encephalitis virus is very similar to West Nile virus.  It is carried by mosquitoes, and is present throughout Asia.  However, the chance of a traveler acquiring Japanese encephalitis is exceedingly low, around 1 per million travelers.  Longer travel, rural itineraries, and certain seasons can increase a traveler’s risk, so the vaccine should be discussed prior to a trip to Asia.

Most adolescents and college students get meningococcal meningitis vaccine.  There are certain parts of Africa where the risk of this disease is seasonally increased.


  • With immunizations, some are required and some are recommended, where can a person turn for information as to which immunizations they need and-or should get?  What if due to other medical reasons (ie. allergies) I cannot get a particular vaccine-should I forget about going to that destination?


Dr. Shlim:  Travel medicine has become a specialty over the past twenty-five years, and most travelers should try to find a travel medicine clinic to get their immunizations and advice.  The International Society of Travel Medicine is a 3000 member organization spanning 84 countries that also offers a Certificate in Travel Health to prove competency in travel medicine.  A list of members and their clinics, and whether they are certified or not can be found on the ISTM website:

Travel medicine practitioners can discuss the risks and benefits of travel to certain areas with or without immunizations, particularly if a patient can’t take a certain vaccine.

  • Travel Medical Insurance?  There are so many products out there, plus some people have coverage through their health care plan:  Is this necessary?  How do you know if you are getting adequate coverage?

Travelers from all nations need to do some research as to what kind of insurance they may require.  It depends on the insurance they have in their home country and the type of health care regime in the country of destination.  Anyone travelling to the USA should absolutely obtain travel medical insurance as it is the most expensive medical care in the world and in many cases, health care providers will require a payment up front or proof of insurance prior to treatment. Most other developed countries have national medical care but you should do your research to determine if you will be charged as a foreigner,  can be reimbursed for expenses from your insurance back home or will have to pay up front etc. Medical care overseas is usually far less expensive than in the USA but given the relative low cost of travel insurance it may be a wise choice.

The kind of insurance that travelers should consider as part of or in addition to travel health insurance is evacuation insurance.  If you are hit by a car, or are in a bus crash, or just become so ill that you are in intensive care, you will need to travel to safe and definitive medical care.  An air ambulance is almost impossible for an individual to organize or afford—the cost can be $50,000 to $150,000 for a single trip, and has to be paid in advance.  Evacuation insurance, which costs around $200 for a one-month trip, will allow the insurance company to arrange everything and pay for all evacuation costs.  Although the chances of needing an evacuation are small, it could be the difference between life and death.  When making your travel health medical insurance ensure this is included.

( tip:  In addition to checking your regular health insurance coverage for trips abroad, also determine if any of your credit cards provide evacuation and travel health insurance.  Many do, as long as you pay for your trip on your card. Bring a copy of the coverage info and contact numbers with you)

  • What should I be carrying in an emergency first aid kit?  Should I be asking my doctor for some “just in case” prescriptions?

An important part of the pre-travel visit to a travel medicine specialist is figuring out what medications you should carry in order to treat yourself if you become sick in certain situations.  At a minimum, you should have an antibiotic, such as ciprofloxacin or azithromycin, to treat travelers diarrhea, and you should carry Imodium, in case you have to sit on a plane or a bus before your diarrhea is controllable. There are other drugs worth carrying as well.  Have this conversation with a travel medicine expert.

( tip:  Don’t presume you will be able to find common or familiar over the counter drugs at your destination.  If you regularly need allergy medication, pain killers, etc…bring them with you, in their original packaging so you have them when you need- See our list of suggested travel first aid kit items in Travel Hacks)

  • If I am going to be trapped on a plane, in an airport, on bus etc with a bunch of people, how do I avoid getting sick and picking something up from being in a flying petri dish?

Dr. Shlim:  The only self-protective action that has been shown to be effective in avoiding colds and other illnesses while traveling is washing your own hands frequently. The good news is that the risk of getting sick from being on an airplane or other mode of public transportation is far less than most people think.

  • Drinking the water:  There are so many mixed messages out there, for example, you are told not to drink the water in Mexico but when you get to your hotel they tell you that you can, and serve you tap water.  What are some guidelines?

Dr. Shlim: Providing clean and safe drinking water consistently is one of the definitions of being in a developed country.  That doesn’t mean that every drop of water in a developing country is contaminated, but it does mean that safe water can’t be guaranteed.  Since municipal water in many countries, such as Mexico, may be contaminated, some high-end hotels treat their own water, and it would be safe.  How can the traveler know whether this is true or not?  You can’t—you have to use some judgment about the company that runs the hotel.  Although water in developing countries is potentially contaminated, the highest risk of getting diarrhea is from food, from hygiene mistakes in the kitchens that prepare your breakfast, lunch, and dinner.  The majority of travelers can avoid drinking tap water—or treating it themselves—but still have a 30-50% of getting travelers’ diarrhea in some higher risk destinations.

  • Activities:  There are a lot of “adventure” type excursions people do on holidays that they never would otherwise, or things like going to the spa etceteras that seem harmless but might not be…what are some things you can do to ensure what you are doing is safe?

Dr. Shlim:  This is an important question, as it gives me the chance to urge travelers to avoid “magical thinking,” when they are on their overseas adventure.  Because one is so far out of one’s normal environment, one can begin to feel that you can get away with anything: sex, motorcycle riding, drugs, and not wearing life jackets or seat belts.  I would really urge travelers not to try riding a motorbike around for the first time in a foreign country (and often on the wrong side of the road).

( tip:  Look for providers that are recommended by reputable hotels and travel companies and don’t forget to pack your own good judgment when obtaining spa services and engaging in higher risk activities)

  • What are the things travelers worry about that actually aren’t a big deal?

Dr. Shlim: Travelers worry way too much about getting worms.

  • What should travelers be MORE worried about than they are?

Dr. Shlim:  I’ve found that most of the travelers who come to see me have not thought about the risk of rabies while traveling, and the need to have a strategy to deal with that if there is an exposure.

  • So I’m home and I am feeling under the weather, how do I know if this is one of the usual suspects of a bug going around or something that I should be concerned about?

Dr. ShlimIn the few days to weeks after travel, one should pay attention to fever.  Fever is the main presentation of most serious post-travel illnesses, and could be the start of anything from the flu to dengue fever, malaria, typhoid fever, African tick fever, and so on.  If you get a fever in a post-travel period, make sure you volunteer your travel history to your medical practitioner, who may not think to ask.  If you have been in certain malaria risk areas, there is one form of malaria that may come out even months after your trip, so giving your history of travel will be important.

If you have ongoing intestinal symptoms after your trip, you may want to investigate, as you may have picked up Giardia, or amoebas.  There is no need to screen your stool if you are feeling well after your trip.

  •  And just for fun, in your 15 years of running a travel clinic, what is the strangest case you came across?

The disease that captures my imagination the most—in a bad way—is a worm that can be acquired from eating undercooked freshwater fish in Thailand.  The gnathastoma worm is meant to inhabit the stomachs of felines in Thailand, but when ingested by a human, the worm gets lost and eats its way through the body, including the brain and the spinal cord in some instances.  I’ve never seen a case in a traveler, but did see a patient in a Bangkok Hospital once who was paralyzed from a worm in her spinal cord.

  • What is the best thing to do when you are ill or injured while traveling?

Dr. Shlim: Keep your head.  Figure out where you are and what your options are.  Ask local people for help, if you can. The world is incredibly connected by cell phones and internet these days—know your options.  Remember, you decided to go on this trip, and if something happens you may be a long way from medical care.  Make this decision consciously before you go.  In mountain climbing, this type of awareness is called commitment.

  •  Are there ways to get assistance with this while abroad; translation, arranging for care, transport, communication back home etc.

Dr. Shlim:  Carry the phone number and e-mail of the travel medicine practitioner that you saw before you left.  They often know how to get help in a variety of situations.  This is also the role that the evacuation company that you signed up with can play.  Call them, and they will direct you to the closest adequate medical care, and then possibly arrange to evacuate you from there.


  •  Remember you are your best defense against getting sick or hurt.  Make wise decisions and be prepared for unexpected events.  Have a game plan in the event your are hurt or ill abroad.  Thank you Dr. Shlim!
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