Gary Dickinson’s e-mail signature lets his worried friends know he’s learned his lesson.
“Yes,” he writes at the end of his communications, “I’m taking my malaria medication!”
His pals feel justified in checking up on him: Last year, a 105-degree fever, uncontrollable shivering and delirium landed the 60-year-old in the emergency room and culminated in a nine-day stay in the hospital.
“When I recovered from malaria initially, all of my friends were very concerned,” said Dickinson, minister of Olive Branch Ministries in Denver, which is developing an orphanage, medical clinic and school in Uganda.
“I take the threat very seriously now, even if somebody tells you that your odds of getting it are a million to one. You can be that one.”
While swine flu threats continue to rack up front-page headlines, Dickinson’s experience is but one example of the hundreds of other significant health risks that exist for worldwide travelers.
Food- and water-borne illnesses, such as hepatitis A, and diseases transmitted by mosquitoes, such as Japanese encephalitis, are on the rise, according to medical-travel experts.
Vaccines or preventive medicines can protect against many illnesses. But vacationers and even seasoned business travelers do not always get the necessary immunizations, routine booster shots or physical checkups before they leave.
“They’ve got their tickets and everything else ready for the trip, but immunizations should be part of their planning, as well,” said registered nurse Michelle Reesman, executive director of Passport Health Colorado. “The most important thing people can do to protect themselves is to see a travel health specialist at least a month before leaving.”
Having spent the past three years traveling and working in Africa, Dickinson said he adopted the locals’ casual attitude that malaria was just a part of life that had to be overcome, rather than a cause for alarm.
“I’ve got a missionary friend who has worked in Africa for 17 years, and she doesn’t take anti-malaria medications. And she’s only gotten malaria twice,” said Dickinson. “They are very conscious of the symptoms there and get medication out very quickly. There just isn’t this sense of panic.”
So when a last-minute trip to Uganda didn’t allow him enough time to start the required regimen of doses to prevent malaria, he left the United States without it.
Nor did he pay for the expensive doses he was supposed to take once daily while he was abroad or the doses he needed to take seven days after he returned — a precaution that would have cost him more than $100 to follow.
“The whole two weeks I was there, I just never thought I was vulnerable,” said Dickinson, who thought his nightly ritual of using mosquito repellant and sleeping under a net would be enough to ward off the nocturnal pests.
Within five days of returning home, however, Dickinson started experiencing what he and a doctor thought were extreme flu symptoms. A few days later, his fever had reached 105 degrees, and he was sweating and suffering from uncontrollable shivering.
When he finally was rushed to the emergency room, staff there contacted Dr. Jeff DesJardin, a specialist with Western Infectious Disease Consultants in Wheat Ridge. DesJardin diagnosed the illness as malaria, and Dickinson spent the next nine days at St. Anthony Central Hospital, delirious and so feverish his body had to be packed with ice.
“I scared the bejesus out of myself and all of my friends,” said Dickinson, who eventually recovered.
Don’t procrastinate
In some cases, immunizations take an average of two weeks before the body develops antibodies to prevent a disease. Others require numerous doses that must be taken up to six months apart to be effective.
If done correctly, Dickinson’s preventive regimen would have called for taking anti-malaria medications daily two days before he left, then daily while he was in Africa, and then for seven days after he returned to the States.
“I’m seeing a lot of people leaving the U.S. who aren’t fully protected,” Reesman said.
Problems often occur if stays are extended longer than vaccinations are effective or if travelers move from one country to another. Some countries require specific vaccinations, such as yellow fever, which can catch travelers by surprise.
“If you leave the United States for Costa Rica, you won’t need a yellow fever (shot), but if you leave Peru to go to Costa Rica, they won’t allow you on the plane unless you show them proof you’ve been vaccinated for yellow fever,” Reesman said.
Many HMOs, state and local health departments and independent medicine clinics provide travel immunizations.
The Kaiser Permanente International Travel Clinic is a telephone-based service operated by clinical pharmacy experts with special training in travel medicine. The clinic is overseen by an infectious- disease physician, and consultations are provided by phone.
Consultations are included as part of members’ base plan, said Amy D. Smith, a Kaiser spokeswoman. Patients do not pay an additional fee or co-pay to consult with the clinic’s travel experts. Basic vaccines such as hepatitis are typically covered under a member’s prevention benefit. But some less- routine vaccines and medications require a co-pay or pharmacy payment, depending on the member’s plan.
Most independent travel clinics operate on a fee-for- service base, in which patients pay out of pocket for travel-related advice and vaccinations, DesJardin said. While some insurance companies pay for these services, most don’t, DesJardin said.
Patients usually pay a physician’s fee, as well as fees for vaccinations. DesJardin said a typical physician’s fee is around $50, while vaccines range widely, based on type and how many are needed. For example, a hepatitis A vaccine could run about $60, while Japanese encephalitis, which is a two-dose vaccine, can cost up to $200 for both doses.
Travel clinics do more than administer shots.
The consultation is less regular physical exam and more educational conference, said DesJardin. Potential health risks are assessed based on what part of the world patients will be traveling to, the time of year and what activities they will be doing. Then recommendations are given.
The consultation determines if a patient has underlying chronic health conditions that would prevent them from taking certain vaccines.
“When you go to a travel clinic, you go over an itinerary, a patient’s vaccination history, and we do a full review of their medical history, known allergies and what medicines they are on,” DesJardin said. “We have to make sure that there will be no drug interactions or contraindications to any of the vaccines we recommend.”
Educate yourself
In cases where there is no vaccine for a commonly contracted illness, then prevention information is shared to help travelers stay well. For instance, there is no vaccine for the most commonly contracted illness abroad, the one known as travelers’ diarrhea. Clinic staffers spend time reminding travelers about food and water safety, and give them medications to self-treat themselves, DesJardin said.
There also are no treatments or vaccines for insect- contracted diseases such as dengue fever in Central and South America, Africa, India and Southeast Asia, and chikungunya fever in India. Patients are counseled on mosquito-bite prevention, such as wearing long sleeves, covering up neck and ankles, and using chemical repellants.
DesJardin often asks his patients to come in with a list of information they’ve garnered from the Centers for Disease Control and Prevention or other travel resources.
“I’m humble enough to have them quiz me to make sure I don’t miss anything,” DesJardin said. “Patients need to take some responsibility for being an educated traveler.”
Part of that self-education process is for travelers to have access to their own health records, said Pam Steele, an immunization program public health nurse with the Larimer County Department of Health and Environment.
“Sometimes practices close or move, so you don’t want to be depending on someone else to keep those records,” Steele said. “We often have people coming to our travel clinic who don’t have any records at all, and we have to start all over again.”
Travelers should check their health records to make sure they’re current on all their childhood series of vaccines, including tetanus, polio boosters and measles, mumps and rubella. Even though you may no longer be exposed to those diseases in America, you can still acquire them abroad, DesJardin said.
Routine childhood diseases such as measles, mumps and rubella are resurging overseas because more people are traveling internationally without adequate routine immunizations, Steele said. Pertussis disease, known as whooping cough, is also on the rise, and the vaccine is recommended for all adult travelers, she added.
“Because adults don’t mount lifelong immunity against pertussis even if they’ve had whooping cough, they need to get the booster,” Steele said.
Travelers also are advised to register with the U.S. State Department or the nearest U.S. embassy or consulate when traveling out of the country. Registering makes it easier for them to be contacted in case of an emergency, and it enables travelers to get updated information on disease outbreaks or security issues.
For example, students from the University of Denver traveling abroad are told to register with the Department of State so they can be found in case American citizens have to be evacuated in the event trouble arises.
“It could be bad weather, political unrest or a disease outbreak, but we tell our study- abroad students to use common sense, do their homework and be aware of anything that’s relevant in the country where they will be living,” said Carol Fairweather, the university’s study-abroad director.
After surviving malaria, Dickinson is aware of what he needs to do.
“I told Dr. Jeff (DesJardin) that I was heading back to Uganda in January,” Dickinson said. “So I will be in his office in December.”
Sheba R. Wheeler: 303-954-1283 or swheeler@denverpost.com
Know before you go
Use these tips to keep safe when traveling or vacationing abroad:
• Check with health insurance providers to make sure travelers are covered when overseas.
• Avoid foods and drinks that are not boiled, steamed or peelable. Vegetables like lettuce and tomatoes are easily contaminated and are hard to wash well.
• Don’t have drinks filled with ice, as the ice may have been made with contaminated water. Avoid popsicles and flavored ices. Use bottled water when brushing your teeth.
• If staying for extended periods of time, take along a water purifier.
• Avoid foods and drinks from street vendors. It’s difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors.
• Keep a spare pair of glasses and the prescription handy.
• Keep additional prescription medicines on hand if health care access is limited, making sure the meds are their original containers. Also, don’t check the meds away in luggage.
• In the event of an emergency, know what number to call in a host country.
• Check with a host-country consulate to make sure American prescriptions aren’t controlled substances in another country.
• A flu shot is also recommended, even when traveling someplace warm. The seasonal flu is transmitted yearly into the tropics and subtropics.
• Notify mental health counselors or therapists about travel plans if medications are needed for extended stays.
• Know a country’s rules and procedures when dealing with someone who is infected. Some countries require immediate quarantines or temperature screenings that could be at the traveler’s expense.
Sources: Center for International Programs at the University of Dayton;
Passport Health Colorado; University of Denver’s study-abroad program
Seven diseases put travelers at risk
Experts say travelers leaving the United States should take precautions to guard against these significant health risks:
Hepatitis is a disease that causes inflammation of the liver. Hepatitis A is transmitted under unsanitary conditions and is one of the most common vaccines given, say travel-medicine specialists. Hepatitis B is contracted through unprotected sex and sharing needles.
“Typically, hep A was more of a routine travelers vaccination, but because we are seeing so much more of it in the United States, it has been added to the list of recommended vaccines that should be given to children at age 1,” says Michelle Reesman, executive director of Passport Health Colorado.
“I’ve heard recommendations that if people eat out once a week here in the United States, then they should have the hepatitis A (vaccine) because it’s so easily transmitted by food handlers who don’t use good hygiene,” she says.
Typhoid fever is a common life-threatening illness prevalent in developing countries in Asia, Latin America and Africa. It is contracted by consuming food or drink handled by an infected person shedding salmonella typhi bacteria (found in human feces). It also is found in sewage contaminated with the bacteria, which can get into the water used for drinking or washing food.
“A large part of our client consultation includes talking to people about food and water safety when they travel,” Reesman said. “If the food isn’t boiled or steamed or if they can’t peel it, then don’t eat it. As far as water, just stick to bottled water and break the seal (yourself).”
Yellow fever is a virus transmitted to humans through bites from infected mosquitoes. It occurs in tropical regions of sub-Saharan Africa and in parts of South America. In the United States, the vaccine is given only at designated yellow fever vaccination centers. Travelers must have an International Certificate of Vaccination (issued after receiving the yellow fever vaccination) in order to enter and exit designated countries.
“Patients need to remember that yellow fever vaccines take 10 days to be effective,” Reesman says. “A lot of times we don’t see people until one or two days before they leave. They are going into a yellow fever endemic area and putting themselves at risk.”
Meningitis is an inflammation of the membranes that cover the brain and the spinal cord. It is caused by viral or bacterial infection. It is most prevalent along the “meningitis belt” that stretches from Senegal to Ethiopia in the Sahel region of African, says Jeff DesJardin, a doctor specializing in infectious diseases.
Rabies, endemic in India, is a viral disease that spreads to humans who are bitten by an infected animal. It occurs in wild animals, including raccoons, skunks, bats, monkeys and foxes, as well as domestic animals such as cattle, dogs or cats.
“There is a lot of human rabies in India, but that vaccine is something that people tend to overlook,” DesJardin says. “If you are going to be trekking through Nepal for two months and don’t have quick ways to get out of there, we can give you rabies as a preventative vaccine.
Japanese encephalitis is a virus transmitted by mosquitoes. It is most common in rural areas of Asian countries, including China and Thailand.
“I’m seeing a lot of travelers to Southeast Asia who are staying for extended trips but don’t know they need two doses of Japanese encephalitis vaccine given 28 days apart,” Reesman says.
Polio, even though it has been eliminated in the U.S., is still endemic in Pakistan, Nigeria, India and Afghanistan. It’s an infectious disease caused by a virus that lives in the throat and intestinal tract.
“We’ve eliminated polio here in the United States, but if you are traveling to those areas, you need to get an adult polio booster even if you’ve had a childhood series of vaccines,” says Pam Steele, a Larimer County public health nurse.
Source: Centers for Disease Control and Prevention
More information: Numerous online sources provide regional outbreak information and travel- well tips.
The federal Centers for Disease Control and Prevention:
Register with the U.S. Department of State: travelregistration
Get Worldwide Caution alerts at the Bureau of Consular Affairs: .
For a list of travel clinics in Colorado, visit the list provided by the Colorado Department of Public Health and Environment at zation/cliniclist.html or the travel health resource at travel /colorado.asp
