Introduction and Welcome
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Table of Contents
Introduction………………………………………………………………………..3
Day one Clinical Immunology
Women Travelers…………………………………………………………………..6
Women’s medical kit………………………………………………….14
Pharmacology of Travel Medicine…………………………………………….…19 Antivaccinationists………………………………………………………….…..…29
Vaccine Safety…………………………………………………………………...…31
Immunizing Health Care Personnel……………………………………………...52
Cruise ship Health……………………………………………………………….…58
Mefloquine and Madness……………………………………………………….…74
Day 2 Expedition Medicine
Skin Cancer………………………………………………………………………….79
Medical Entomology for Backpackers …………………………………….………81
Third World Dentistry (Belize and Haiti)
& Dental Emergencies in the Wilderness…………………………………….…95
Flu, Colds, ad Avian Flu………………………………………………………..….103
Cultureshock………………………………………………………………………..110
SCUBA medicine……………………………………………………………………113
Arctic Medicine Meeting……………………………………………………………120
Introduction and Welcome
Thank you for your interest in this years meeting. We have some new speakers and have divided the sessions into a clinical day and an expedition day.
Our Clinical medicine day focuses on Pharmacology and Nursing and common scenarios will be explored. Some of the topics we will be explored are very lengthy so we decided to focus on specific scenarios for general debate and use these as springboards for discussion. By this we hope that our attendees will be learn more practical issues and be able to research solutions using the reference information we have provided in this syllabus.
Jacinda Wagner is a Compounding Pharmacist with Shoppers Drug mart. She is experienced in formulating medications to allow precise doses to be delivered in new ways. She will speak on the actions of immunizations and medications used to prevent illnesses in travelers. Often many doctors and pharmacists are unfamiliar with these drugs and her talk will introduce these products. She will also host a workshop that will examine drug interactions and contraindications.
Shane Woods RN, ONH is a registered nurse wit a specialty in occupational health nursing at Red River College. Shane manages, interprets, and is responsible for health related course student’s immunization records according to WRHA guidelines and with respect to students practicing in facilities under the direction of the WRHA.
He will speak on the Immunization record required for Health Care Students at Red River College, which also includes the Mantoux test for Tuberculosis. He will also host a workshop on immunization.
Candace Corroll is an Office Manager at the Skylark Travel Medicine Clinic and frequently assists prospective travelers in obtaining information for their trips. Her talk on Women travelers will focus on short vignettes involving women travelers with diverse and unique problems. She will go over these scenarios with possible solutions. A comprehensive reference guide will be included but not emphasized during he talk. We decided to focus on the specific cases to springboard discussion and emphasize the process on how we arrived at the solutions and not the solutions themselves.
Dr Gary Podolsky is the Conference Coordinator and Director of his Travel clinic. He will cohost the workshops on the Adverse effects of Immunizations with Shane Woods and another on Anti-vaccinationists in Winnipeg. These will be a series of scenarios with emphasis on real issues and controversies that revolve around the safety and effectiveness of immunizations. We have included an extensive reference document to back up this evidence. We wish for all of our delegates to be able to use this information to help educate the general public about misconceptions about immunizations. Gary has also expressed a wish that if anyone has problems regarding vaccine issues they may contact him after the conference.
He will also later talk on “Cruise Medicine” He will explore issues of safety and health aboard cruise ships. His talk on “Dive Medicine” will be a brief overview on the injuries that occur in recreational SCUBA.
Dr Simon Trepel is Psychiatry resident who will present two lectures- “Mefloquine and Madness” and “Fears in Travelers”. He will examine specific travel related problems from the perspective of a clinical psychiatrist. This will include a critical appraisal of the literature on such issues such as mefloquine-induced psychosis, traveller’s culture shock and substance abuse among travelers. In researching psychiatry and travel we have found that although this subject has been spoken of lightly in the past there are many areas to explore in improving mental health in travellers. Simon will define these psychiatric issues for non-psychiatrists as well so that we all may communicate these important discoveries to our own patients.
Dr Richard Heyday is a Dermatologist practicing at the Winnipeg clinic and is an Associate Professor with the Faculty of Medicine, University of Manitoba. He has trained at the University of Manitoba for both his MD and BSc Med and has additionally trained in New York with specialization of a Diplomate of the American Board of Dermatology (DAB Derm) University Skin and Cancer 1980 and an FRCP at the University of Manitoba 1983
He will discuss Dermatological problems in Travelers and will include emphasis on skin cancers in travellers, tropical illnesses in travelers and fungal infections. He has lectured on this for our group in the past and will include updates on the new powerful immunolgic drugs that are now being used routinely to treat skin cancers. This aspect of medicine is still one of the most important and exciting topics for clinicians- to learn about a non-toxic effective treatment for some severe cancers. This topic gives hope to very ill people and has been enthusiastically received at a number of sessions by both clinicians and non-clinicians alike.
Dr Terry Galloway is an Entomologist at the University of the Medicine. He has lectured to us several times and has always both entertained and informed us with accounts of the life of Insects. This year his talk will focus on Mosquitoes and he will also discuss the role mosquitoes played in the development of Malaria in the Dominican Republic this past winter.
Dr Elsa Hui-Derksen is a practicing Dentist with the Cholakis Dental group. She will present “Dental Emergencies in the Wilderness” as well as help define important components of a dental emergency kit. Her colleague Dr Eric Parsons will also present his recent dental relief work in Haiti.
Dr Scott Clifford, Veterinarian was tentatively scheduled to speak on the Avian Flu, continuing his previous years lecture on Zoonoses. He had defined emerging zoonoses as more likely with the increased communication among previously isolated biovars that had increased speciation in the past. As these isolated plants, animals, bacteria and viruses were brought together new recognized human diseases emerge as zoonoses through chance jump to humans. Scott is unable to join us because of work commitments but we wish him the best. Dr Podolsky will talk on Avian Flu in relation to the common cold and other flus and will add recent updates from the Public Health Agency of Canada that were recently presented here in Winnipeg at the National Antiviral Meeting.
Our Volunteers
We have volunteers from both our local Nursing and Medical Schools that will be attending the conference. We believe that it is important to include them as part of our forum as they will have fresh perspectives on a variety of topics and have much to contribute.
Delegates to our previous meeting might notice that some of the speakers this year were previously in the audience. We are always looking for new topics and new presenters and plan to rotate topics. We have done kept some lectures the same because there wide popularity but we plan on changing these as well.
Special Thanks to Candace Corroll, Gail Oborne and Kyoung-Hee Lee for their help in organizing this conference.
Feedback
Please fill in the feedback questionnaires and remember to take your certificate of attendance. This meeting is eligible for up to eleven M2 medical credit hours for physician and 10.75 CEUs for pharmacists. Pharmacists may also receive special accreditation cards on request.
We have tried to improve our meeting based on past feedback. This year we are having more formal meal breaks with a formal dinner and lunch set aside for our delegates to decompress.
We will be providing our volunteers with question sheets so that anyone who wishes to ask a question. If in our question period we are unable to answer all questions we will have our faulty respond later.
We are in the process of arranging two additional conferences that will expand on some of our present ideas.
European Neurology Conference in Odessa, Ukraine April 20th,2004.. Dr Podolsky will be attending and intends to bring some donations of medications that he will personally deliver to registered medical organizations there. He has asked for any clinicians who have any medications or useful medical equipment to please contact him. He is unable to accept cash only medications.
Arctic Medicine conference Oct 6,7,8,and 9 will take place on Thanksgiving weekend in Churchill Manitoba. This will involve 16 hrs of CME in the evenings. We have negotiated a group rate for accommodations that will also include a Tundra Buggy (Polar Bear Safari), Cultural program and a tour of Churchill- the Polar bear capital of the world. Delegates do not have to participate in any of the extra conference activities in order to attend our scientific meeting as our meeting is held separately and are welcome to stay at other accommodations.
Our keynote lecturer is Dr James Wilkerson one of the founder of the sub discipline of Wilderness Medicine. Those who register before September first will also receive a signed copy of his book “Medicine for Mountaineers”.
For those who cannot travel to Churchill a satellite symposium “Winter Sports Medicine” will be held in Winnipeg on October 5th, which will focus on more Sports medicine topics.
For more information on both please see the page at the back of this manual.
Advanced Wilderness Life Support is a new course that uses the ACLS and ATLS format. Dr Podolsky has recently been accredited as an instructor and may teach the course in Winnipeg. If interested please se him or one of our volunteers to go over the course.
Our Tropical medicine Meeting in Havana, Cuba is currently scheduled for February 2006. We are awaiting finalization with the Cuban government. This is planned to be a 36-credit conference with emphasis on Tropical Medicine and topics relevant to Cuba. We will be selecting our lecturers from Winnipeg and also plan on working with local Cuban physicians where Canadian and International people will be able to observe how the Cuban medical system works. Our goal is that by more direct interaction we may be able to help our colleagues financially and also learn valuable insights from their Medical system. We are still working on our program. Please see our volunteers for any questions and to be put on our mailing address update.
Women Traveller Scenarios
Candace Corroll
When women are travelling they may experience unique gender specific problems due to their physical differences from men and due to social forces.
The purpose of this session is to highlight common problems women may face and offer various solutions.
Abby is a 22 year woman going to Korea to teach English as a Second Language. She is going alone, although she has some contact phone numbers of people from her organization. She has never travelled before. She is physically healthy and has received all her immunizations but wants to know if there is anything else she should do before she leaves.
Abby has had a recent physical. She is sexually active but has not had a PAP test done recently. It is strongly recommended that she do so before she leaves. She is also taking the birth control pill and wishes to stay on it even though she will not have a current sexual partner. She was concerned about getting traveller’s diarrhea or taking other medication (such as antibiotics) that would affect the effectiveness of the pill. Her doctor discussed the new Birth control Patch (Evra) which is put on the skin for 3 weeks of the month and is not affected by nausea or stomach upset which can happen with travellers diarrhea.
Because she was going to be away for so long she was given information on how to find a doctor in Korea: (The International Society of Travel Medicine lists available clinics in many countries), (International Association Medical Assistance to Travellers has a free list of Clinics that also agree to standardize their prices, voyage.gc.ca (gives a list of Canadian Embassies and Consuls that will not provide medical services but will give information).
Barbara is an 18-year-old mother of two twins age 8months. She is going to return to Ghana to visit her parents and show her children. Barbara wants to leave her 2 twins in Ghana for at least a year so she can finish her school. She wants them to receive all the immunizations they need including Yellow fever.
Barbara was informed of the various vaccinations related to travel to Ghana for her 3-week trip. Based on what she will be doing it was recommended that she receive Tetanus-diptheria, Polio, Typhoid, Hepatitis A and B; and Yellow fever along with mefloquine for malaria.
Her twins were healthy with 38-week gestation births now at 8 months of age with normal developmental milestones and no problems. They are under the care of a regular paediatrician. They are up to date on their regular childhood immunizations. It was recommended that they receive an early MMR vaccine (which does not actually count toward the recommended 12 month vaccination since circulating maternal antibodies may partially neutralize the MMR, yet this vaccine will cover them for their immediate trip.
Twinrix Junior was recommended and started. The hepatitis B component is specifically emphasized for children visiting Developing countries or long periods, as a great burden of Hepatitis B is acquired from innocent activities- such as roughhousing with other Hep B positive children in routine play, or living in a household with Hep B. The Hep A component is normally recommended for children over 12 months but in this instant these children would be living long term in Ghana and not be breast fed so the doctor recommended this to them off label. They were too young for the typhoid vaccine or the multivalent (menomune) meningitis vaccine.
Yellow fever is prohibited in children less than 9 months because of the risk of encephalitis yet these children would be at high risk of yellow fever in Ghana. Barbara was offered the choice of waiting for them to be a few months older and receiving it in Ghana versus receiving it just after their turning 9 months in Canada. She chose the latter.
Lastly a 3-month supply of mefloquine was prescribed for each twin with instructions to continue antimalarial treatment after the children are reassessed in Ghana. Barbara was repeatedly cautioned of the importance of continuing an effective malaria treatment and to ensure that her Mother also continues this medication. Because of the children’s likely weight gain over the next few months the doctor felt it would be harmful to recommend a static prescription without periodic reassessment. Barbara’s twins were an extremely complicated case and all decisions were well discussed in detail.
Cara is a 25-year old nurse who just returned from Hawaii. She went to a bar with her girlfriend and later woke up the next day alone in an empty house with her clothing missing. She realized that a man must have put something in her drink and has no memory of what had happened. This happened 2 weeks ago and she wants to be checked out. Despite what has happened to her she does not seem anxious or upset.
At this point the chain of evidence is so weak that forensic evidence is difficult or impossible to establish. The main focus should be on Cara’s health.
Counselling by a nurse or doctor skilled in Rape management should be initiated.
Blood tests for Syphilis, Hepatitis B, C and HIV were ordered. This case happened before routine use of post exposure antivirals was widespread. In this case it is probably too late to be of benefit (these medications have significant side effects as well)
A proper gynacological exam was done with swabs for gonorrhea and chlamydia sent. After these were taken antibiotics were given to empirically treat for these conditions.
Lastly Cara was examined for any other injuries. She was offered follow-up both for results as well as for further counselling.
The police in Hawaii were notified and a bartender admits to having seen a man put a pill into her drink but did nothing. No charges were laid.
Dian is a backcountry camper and is going with some girlfriends to camp in Northern Thailand for two weeks. She would like to put together a first aid kit, which will include items for feminine problems.
Dian is specifically asking for tests and medications to diagnose and treat bladder infections. A dipstick urinalysis was recommended with a prescription for Ciprofloxacin to treat any positive results. Two of Dian’s friends are nurses and can do this easily.
Dian’s group are also all taking doxycline for antimalaria prevention but they know that doxycycline is associated with increased incidence of yeast infections. Additional items for their “female” first aid kit include canestin inserts and Diflucan (Fluconazole) pills.
Ella age 26, is Dian’s friend and wants to go as well but just found out she is pregnant. Can she still go, and are all the medications recommended for Dian all right for Ella to take?
Ella is healthy and is not having any problems with her pregnancy. It has been established that her pregnancy will be in the 2nd trimester during her trip to Thailand. Unfortunately she will be travelling to a very drug resistant malaria area. This area of Thailand is resistant to both Chloroquine and Mefloquine. She may not take Doxycline because this will stain childrens’ teeth. The medication Malarone will work in that area but its safety in pregnancy has not yet been established. Malaria is often more severe in pregnant women. At present there is no good effective antimalarial for pregnant women going to this part of Thailand. Ella’s situation highlights that many drugs or immunizations are different for pregnant women .
The website is very detailed in describing both theoretical and proven risks from medications and is a good resource.
Fiona, Dian’s other friend just delivered her baby and wants to now take her 12-month old son with her. She wants advice for her and her baby.
She was advised of the same vaccines and antimalarials as the others. Doxycline is not recommended for breast-feeding mothers. Motherisk was again consulted for each medication or drug.
Fiona then decides that she will instead spend her vacation in Dominican Republic where she has heard there is a malaria drug that she may take.
Fiona is informed that the vaccines commonly recommended for the Dominican Republic- tetanus diptheria and Hepatitis A are safe for her but she still needs to take an anti-malarial such as chloroquine or mefloquine and these do cross over into breast milk. However, her son is not protected by her breast milk and must take his own medication adjusted for his weight. Anti malarial drugs are not pediatric sized so Fiona may want to take the prescription to a compounding pharmacist to adjust for the proper dose. Her son is up to date on all his childhood vaccines including the newer pneumonia, varicella, and meningitis shots so the only vaccine he needs is the pediatric Hepatitis A vaccine.
Lastly Fiona was counselled that even though her son is up to date on his basic childhood immunizations and has received both hepatitis A and appropriate malarial medication, travel is still difficult on the very young as their immune system are still immature. Fiona should be meticulous with hygiene and see a doctor promptly or any problems encountered by her son..
Geraldine is 83 and lives alone but enjoys going on trips by herself. She wants to go to Bhutan on a trek but her Daughter doesn’t think she should. They come in together and want to speak about what the actual risks are. Geraldine is taking medication to anticoagulate her blood, which has to be checked every day. Is there any compromise that can be reached so that Geraldine may still travel?
Geraldine represents a small but growing type of adventure traveller- seniors who are now travelling to remote areas. Many of these trips are well organized but clinicians may be called upon to give a risk assessment. Traditionally this has been with regards to infectious diseases but now may include a fitness to travel assessment. It may be beyond the doctor or nurse to be able to assess all risks but we should be able to help establish some facts and allow the patient to make an informed decision.
Geraldine has several medical problems, so it is recommended that she have a full medical exam by her family physician, making sure he knows what she will be doing. If she is going to a remote area she should have enough medications. The remoteness of her travel and failure to be able to be speedily evacuated must be understood. Portable Coagulocheks are now available for people on anticoagulants to be able to monitor themselves. ()
The proper risks are explained for Geraldine so that she can make an informed decision. On speaking with her and her daughter she appears competent and clear minded with no signs of Alzheimer’s or other dementia, and the final decision will rest with her. Her daughter is still anxious but attending with her mother has helped her to articulate her concerns. At her insistence Geraldine has agreed to make sure her insurance will also cover Helicopter evacuation and Overseas Funeral arrangements. This has also led Geraldine to modify some of the more risky parts of her trip.
Helena came in with her husband 3months ago and received several immunizations. At the time she did not believe that she was pregnant, but has now found out that she is 4 months pregnant. She and her husband are very worried that her immunizations may have hurt their baby.
Helena’s vaccine record was reviewed. On the form she had checked off that she was not pregnant and had written the date of her last normal period, which is important for clinics to ask and document.
She had received tetanus-diptheria, inactivated polio, Hepatitis A and Hepatitis B, all of which are fine in pregnancy; but she also received the live MMR vaccine.
The MMR vaccine would normally not be given, but this was recommended because she had never received it before and was going to an area of the world high in measles. It is well recognized that infection with measles, mumps, and rubella during pregnancy can cause birth defects. The MMR vaccine is attenuated but still not recommended for use in pregnant women. There are no documented fetal malformations caused by the MMR vaccine yet it is still not recommended for pregnant women. Women are advised not to conceive for 3 months after receiving the vaccine.
This patient had also seen a Genetics counsellor to reassure them. The Geneticist who advised them of the likelihood of a normal birth (compared with baseline). The inadvertent use of MMR is not a reason for a therapeutic abortion.
Iris is planning to go on a trip around the world with her partner Janice. They want to know what countries are friendly to Lesbian couples and if there is anything they need to know. At this point they do not know which countries they are going to yet.
Many countries have different laws and beliefs with regards to open displays of homosexuality, so that assumed rights may be very different abroad. Open displays of sexuality may lead to prejudice and violence in some countries. The International Lesbian and Gay Association has a data base of specific countries and their attitudes and can help travelers abroad.
Kellie, a patient seen 6 months ago calls long distance from Suriname worried that she has caught an STD and might also be pregnant. She does not have any people she can talk to and doesn’t trust the local doctor.
In this case we had Kellie check to see if she was pregnant as this is something that every doctor can easily diagnose all over the world. When it was established that she wasn’t we gave her the contact number for the Canadian Embassy. They found her a gynecologist in the Capital. At first she did not want to pay extra to see him. We spoke with the Agency that sent her (while maintaining her anonymity) and we were ale to establish her insurance would cover this and rely this back to her. We stressed that several types of STDs may cause severe problems (infertility and Pelvic Inflammatory Disease) and must be treated. She agreed and was treated.
If she was pregnant and wanted an abortion there is a serious exists concerns of unsafe back door abortion clinics. They still exist in many parts of the world. The Marie Stopes Foundation provides information about emergency contraception and abortion listed by country. (.uk/abortion1icpd.html)
A Brief Outline of information for Women Travelers:
Compiled by Candace Corroll and Dr Gary Podolsky
Emergency Contraception
Women travelling the world may become pregnant. Proper birth control methods, such as condoms or female condoms, should be arranged before you depart.
Many countries do offer emergency contraception i.e.) the morning after pill.
The consortium for emergency contraception website will give travelers up to date information about where they are going: http:/cec.htm
Emergency contraception website:
Emergency contraception hotline: 1-888-NOT-2-LATE
Women travelers, as with men, may acquire tropical infectious diseases and their treatments can significantly affect women. Often the complications and severity of tropical infections are worse for pregnant women.
Contraception and Travel
|Spermacides |-easy to carry, can bring from home |
| |-long-term use may cause mucosal injury that may increase risk of HIV transmission. |
|Cap |-needs to be fitted |
| |-can use up to 48hrs, but need practice in correct use |
| |-rubber may deteriorate in heat and humidity |
|Sponge |-protects for 24hrs and may be left in place for 6hrs after intercourse |
| |-one size, some types must be moistened with water, remove within 24-30 hrs to prevent |
| |Toxic Shock Syndrome |
| |-easy to use and carry |
|Diaphragm |-gives protection for 6hrs |
| |-needs fitting and use of extra spermacide with repeated intercourse |
| |-after use, leave in for 6hrs |
|Condoms |-use good grade |
| |-check for expiration date or poor quality |
|Female Condoms |-spermacide not required |
| |-one use only |
| |-may insert 8hrs prior |
| |-does not deteriorate in heat and humidity |
|Male Condoms |-possible allergy |
|Latex |-some oil based lubricants destroy them |
| |-“male controlled” |
| |-may breakdown in heat and humidity |
|Lambskin/natural condoms |-do not prevent viruses |
|Hormonal Methods |-may use if unable to take estrogen |
|Progesterone Pill |-take everyday at the same time |
| |-decrease menstrual cramps, less bleeding |
| |-can use when breastfeeding |
| |-useful for older women and smokers |
| |-may have irregular bleeding |
| |-does not prevent STD’s |
|Combined Pill |-increase regularity of cycles |
|(estrogen and progesterone) |-less blood loss, cramping |
| |-less pelvic inflammatory disease |
| |-can be used for emergency contraception |
| |(need special preparation and instructions) |
| |-should not take if at risk for blood clots |
| |-need to take every 24hrs |
| |-does not prevent STD’s |
| |-watch for drug interactions |
| |-intramuscular injection every 3months |
|Depo-Provera |Side Effects |
| |-weight gain |
| |-menstrual irregularities |
| |-acne |
| |-mood changes |
| |-decreased libido |
| |-good for women who can’t take estrogen |
| |-no memory for daily pill required |
|Norplant Implant |-capsule under skin giving progesterone |
| |-implants difficult to remove |
| |-weight loss, acne |
| |-not recommended if; blood clots, liver tumors, breast cancer |
| |-long-term protection 3-5yrs |
| |-irregular bleeding or no bleeding |
|IUD |-increased risk of infection at time of insertion |
|Estrogen Patch |Three patches replaced weekly on, then one week off |
| |Isn’t affected by diarrhea or antibiotics |
|Estrogen ring |Ring with reservoir of estrogen fits around cervix |
| |Isn’t affected by diarrhea or antibiotics |
Many other different methods of contraception exist. For more information, check Maria Stopes International website:
Pregnant Travelers
Travelling is discouraged if:
-congenital or acquired heart disease
-history of blood clots
-severe anemia
-chronic lung disease
-obstetric risk factors
If pregnant, all women should be assessed early in their pregnancy, prior to travelling.
PAP tests for all women are also recommended to screen for cervical cancer.
Immunizations During Pregnancy
|Vaccine |Live or Not |Safe or Not |
|Measles, Mumps, Rubella |Live |Not Safe |
|Polio |IPV (inactivated) |Safe |
|Varicella |Live |Do Not Take |
|Tetanus-diphtheria |Not Live |Safe |
|Influenza |Not Live |Recommended 2/3 trimester |
|Meningitis |Not Live |Safe but only if needed |
|Typhoid |Ty21a Live |Not recommended |
| |Typhim VI Not Live |Use if needed |
|Hepatitis A |Not Live |Safe |
|Hepatitis B |Not Live |Safe |
|Japanese Encephalitis |Not Live |Side effects, not recommended unless high|
| | |risk of infection |
|Tick Borne Encephalitis |Inactivated |Not recommended |
|Lyme Disease |Vaccine no longer available | |
|Rabies |Not Live |Not unless high risk |
|Immune Globulin |Serums for: |Only if high-risk |
| |Snake/spider bites | |
| |Diphtheria, Rabies, Hep B | |
| |Rabies, Tetanus, Varicella | |
|Cholera |Live |Not recommended in Canada |
|Medications Safe for Pregnant and Lactating Women |
|Medication |Pregnancy |Breastfeeding |
|Tylenol (acetaminophen) |Safe-low dose |Safe |
|Anti-inflammatory Drugs |Safe in 1&2 trimester |Safe |
|(Ibuprofen, Motrin) | | |
|Antibiotics |Safe |Safe |
|(Amoxicillin, Zithromax) | | |
|Cephalosporins |Safe |Safe |
|Clindamycin oral or vaginal |Avoid 1st trimester |Safe |
|Cloxacillin |Safe |Safe |
|Doxycycline |Can stain fetal teeth |Not Safe |
|Erythromycin |Safe |Safe |
|Nitrofurantoin |Safe-good for urinary tract infections |Safe |
|Septra |Safe |Safe |
|Anti-diarrhea Medication | | |
|Comotil |Not Safe |Not Safe |
|Immodium |Safe |Safe |
|Antacids |Safe |Safe |
|Bismuth(pepto-bismol) |Not Safe |Not Safe |
|H2 Blockers | | |
|Cimetidine (Tagamet) |Safe |Safe |
|Ramitidine (Zantac) |Safe |Safe |
|Gravol |Safe |Safe |
|Anti-nausea | | |
|Accupressure Bands | | |
|Non-pharmaceutical |Safe |Safe |
|Ginger |Safe |Safe |
|Meclizine |Safe |Safe |
|Vitamin B6 (Pyridoxine) |Safe |Safe |
|Milk of Magnesia |Small amounts safe |Safe |
|Psyllium |Safe |Safe |
| |
|Hemmorhoids- increase fibre and fluid in diet. |
|-Anusol HC suppository safe-minimal use |
| | | |
|Upper Respiratory Infections: | | |
|Antihistamines | | |
|Benadryl |Safe-use caution |Not Safe |
|Claritin |Safe-use caution |Unknown |
|Sudafed |Not safe in 1st trimester |Unknown |
|Saline Nasal Spray |Safe |Safe |
|Topical nasal decongestants |Safe |Safe |
|Nasal Steroids |Use if indicated |Safe |
|Inhaled Steroids |Safe |Safe |
|Inhaled Ventolin |Safe |Safe |
|Anti-Malarials | | |
|Mefloquine |Not safe in 1st trimester |Safe-does not protect infant |
|Chloroquine |Not safe in 1st trimester |Safe-does not protect infant |
|Malarone (Avovaquone/Proguanil) | | |
| |Unknown |Unknown |
|Doxycycline |Not Safe |Not Safe |
|Primaquine |Not Safe |Not Safe |
|Halofantrine |Not Safe |Not Safe |
|Proquanil |Safe-not effective as single |Unknown |
|Fansidar |Not Safe near term |Safe short term |
|Quinine |May cause severe Hypoglycemia |Unknown |
|Azithromyacin |Unknown |Unknown |
|Insect Repellents | | |
|DEET |Safe – sparingly |Safe |
|Anti-parasites | | |
|Albendazole |Avoid 1st trimester |Unsafe |
|Metronidazole |Avoid 1st trimester |Use caution 1dose therapy and delay B/F |
| | |12-24hrs |
|Anti-virals | | |
|Acyclovir |Safe if indicated |Safe |
|Altitude Medication | | |
|Acetazolamide (Diamox) |Not safe in 1st trimester unless |Not Safe |
| |indicated | |
|Dexamethasome (Decadron) |Safe |Not Safe |
|Calcuim Channel Blocker |Only used to treat severe Pulmonary |Safe |
|(Nifedipine XL) |Anemia | |
|Water Purification | | |
|Iodine |Not Safe |Not Safe |
Additional Website links for women:
Office of Population Research Emergency Contraception -website with information on emergency contraception searchable by country.
Marie Stopes International-provides information about emergency contraception, abortion, and sexual health by country http.uk/abortion.html
.The Centre for Reproductive Law and Policy provides list of countries where abortion is legal and what restrictions exist. http:abortion1icpd.html
WHO Gender and Health Technical Paper -article on gender and health. (use search engine as site frequently changes) http:who. int
Organization of Tetrology Information Services For further information on drugs in pregnancy, see:
The Canadian Dept of Foreign Affairs Publication “On Your Own” specifically developed for Women travellers is available free from voyage.gc.ca. and is a handt resource for women travelers
|Suggestions For A Medical Kit For Women Travelers |
| |
|Menstrual Supplies |
|-calendar |
|-supplies – pad, moist towelettes, plastic bags, PMS medication |
|(Ibuprofen, Mefanamic acid) |
|-medication for dysfunctional uterine bleeding |
|-premarin |
|-oral contraceptive pill |
|-Ibuprofen |
|Urinary Infections |
|-Ciprofloxicin 500mg PO BID x 3 days (also good for traveler’s diarrhea) |
|-Macrobid 100mg PO BID x 7 days, if pregnant, urinary dipsticks |
|Vaginitis |
|-Yeast infection (PH paper4.7) |
|-metrogel cream, clindamycin cream, or metronidazole pills |
|-Trichomonas (can be women diagnosed by woman herself) |
|-metronidazole pill |
|Contraception |
|-chart to keep track of pills |
|wrist watch timer to record when to take pills while crossing time zones |
|-male/female condoms |
|-spermacide |
|-pregnancy test |
|Emergency Contraception |
|-can discuss with doctor how to use the morning after pill |
|-available as Plan-B in Canada or use equivalent dose of birth control pills/ and gravol |
|Post HIV Prophylaxis |
|if at high risk for unprotected sex. This can be very expensive and people often get sick from the medication. Use updated |
|recommendations |
|Pre-Menopause/Menopause |
|-vaginal dryness (estrogen cream) |
|-hot flashes |
|-estrogen replacement |
|-vitamin E |
|-ClonidineOsteoporosis |
|-calcium |
|-vitamin D |
|-Fosamax |
|Pregnancy Supplies |
|-blood pressure cuff with stethoscope |
|-urine protein and glucose strips |
|-leukocyte esterase strips |
|-supplies for lactating mothers |
|-breast pumps/pads |
|-nipple cream |
|Personal Safety |
|-alarms |
|-pepper spray |
|-lessons in self-defense |
Appendix: Vaccines for Children Traveling
Children travelling with their parents may need their vaccinations adjusted either because of the decreased availability of pediatric follow up where they are going, or because of the increased risk of diseases in areas they will be visiting.
Changes in Schedule for Routine Immunization due to Travel
|Vaccine |Age Routinely Given |Accelerated Schedule |
|DTaP - Diphtheria, Tetanus, Pertussis |2,4,and 6 months |6wks, 10wks, and 14wks |
|Hepatitis B (note: Hep B is given much earlier in the U.S |Birth, 1, 6-12 months |0,1 month, 2 months, booster-12 months |
|than in Canada) |Grade 4 in Manitoba |(Hep B is given much earlier in U.S than |
| | |Canada. |
|MMR – Measles, Mumps, Rubella |12-15 months |6 months |
|Polio |2, 4, and 6 months |6wks, 9wks,and |
| | |12 wks |
Note: When vaccines are given younger than routinely recommended or when vaccine intervals are shortened, vaccinations may need to be repeated at a later date.
Special Notes on Immunizations for Children
Cholera Vaccine – Is not recommended. The risk of Cholera to travelers is very low. Breast-feeding protects children. In older children close attention to food and water will help to protect them.
Hepatitis A – is given to children over 1 yr old. (This is 2 years in the US literature) Breast-feeding protects small infants by way of passive immunoglobins from mothers’ milk. (Immunoglobulin is now de-emphasized for children as the vaccine or mothers milk gives better protection. The immunoglobulin now in use contains less antibodies against Hepatitis A since this is reflective of current blood donors not having anti-hep A antibodies compared with prior generations.)
Japanese Encephalitis Vaccine is given to children over 1yr old who are travelling to rural areas endemic with this infection during the peak transmission season. Japanese Encephalitis is recommended if persons are staying in areas near rice paddies or pig farms, where the risk of JEV mosquitoes is high.
Rabies – Children may be more susceptible to rabid animal attacks than adults. Parents may consider this vaccine if their child is staying in a high-risk area for rabies.
Typhoid – Breast fed infants are protected from this. For older children careful boiling or chlorinating water prevents this disease. The new injectable vaccine is given to children between ages 2-6. An oral typhoid vaccine is available for older children.
Yellow Fever – Vaccination against this mosquito borne infection is required for travel to some countries. It is never recommended to children under 4 months, and only in exceptional circumstances for children 6-9 months. Infants greater than9 months may be vaccinated if they require it.
Other Travel Concerns for Children
Diarrhea – No good vaccine exists yet but Pepto-bismol can also be given for children to prevent traveller’s diarrhea.
Pepto-Bismol Preventative-Treatment, to be started on the day of travel and up to 3 weeks. This will decrease traveler’s diarrhea by 50%.
|Children may take Pepto-Bismol providing they have no allergy to ASA |
|AGE |DOSE |
|7-12 yrs |2tbs (30ml) |
|9-12 yrs |1tbs (15ml) |
|6-9 yrs |2tsp (10ml) |
|3-6 yrs |1tsp (5ml) |
|0-3 yrs |½ tsp (2.5ml) |
Each dose may be taken every 4 times per day
Children and Bugs – Preventing insect bites is very important in preventing many diseases. The following are recommended:
1. Placing nets over baby carriages and cribs
2. Eliminating standing water around living quarters
3. Stay inside between dusk and dawn.
4. Dress children carefully in long sleeved clothing over neck, wrists, and ankles
5. Not allowing children to go barefoot
6. Cover skin with DEET 20-30% - This is higher than what many others recommend. DEET is safe to use on children when used correctly. Apply on exposed skin, but not on irritated skin and wash it off after use.
7. Use a flying insect spray in living and sleeping quarters
8. Sleep in an air-conditioned area when possible
Malaria Medication and Children
Children are very susceptible to malaria and over 2 million die of it each year.
Chloroquine is safe and well tolerated but has a bitter taste. Eating adult strength doses can harm children. Chloroquine should be kept in a safe place away from children.
Mefloquine (Larium) Is very safe in children. Neurological agitation from mefloquine is not seen in children as with some adults.
Malarone is a new medication and is more expensive. It is taken daily according to weight.
|WEIGHT |DOSE |
|10-20 kg |1 Pediatric strength tablet |
|21-30 kg |2 Pediatric strength tablet |
|31-40 kg |3 Pediatric strength tablet |
|40+ kg |1 Adult strength tablet |
Doxycycline is safe for 9+yrs. And is safe in lactating mothers, but not in pregnant mothers.
Adolescent Health Visits
Infant and childhood vaccinations have greatly decreased the incidence of many childhood infections. Teens and young adults still remain susceptible to vaccine preventable diseases like Hepatitis A and B, Measles, Mumps, and Rubella. In order to protect young adults and teens an adolescent health visit is recommended at age 11 or 12.
This is a good opportunity for parents and their family doctor to discuss the recommended vaccines and decide what immunizations their child needs. This visit can also affirm the adolescent’s comfort level with attending the doctor’s office in the future.
Immunizations Required For Adolescents
|Hepatitis B |-Should be considered if never received. At present this is at patients cost unless attending|
| |the grade 4 school schedule. Hepatitis B is so far the only vaccine against a sexually |
| |transmitted disease. |
|MMR-Measles, Mumps, Rubella |-A 2nd dose is recommended if not previously given. |
|Td-Tetanus-Diphtheria Booster |-the only regular vaccine that requires boosting throughout adulthood |
| |Note: aP Acellular pertussis was recently added to the Td |
|Varicella |-If no prior immunization or history of the disease. A simple blood test can check if the |
| |person has had a previous asymptomatic infection and subsequent immunity. |
|Hepatitis A |-This is an optional vaccine but may be recommended for people planning to work in health |
| |care, daycare, or will be doing international travel |
The Pharmacology of Travel Health Medicine
Jacinda Wagner BscH(biology), Bsc(Pharm)
Introduction
Medications to prevent travel related illnesses are becoming more commonly prescribed. This talk will discuss medications and vaccines and their methods of action. Important contraindications and interactions with other medications will be discussed.
I. Hepatitis A
- An infectious virus that causes inflammation of the liver
- Transmission occurs via contaminated food or water
- Individual presents with nausea, vomiting, diarrhea and fever
- Active disease may last up-to 12 weeks with some developing jaundice +/- proving fatal
- Vaccination is available: Havrix, Avaxim, Vaqta, and Twinrix
A. Havrix 1440 (18yrs +), Havrix 720 (2-18 yrs), Vaqta, Avaxim
1. Dose and schedule
- Initial dose at day 1 provides immunity up-to 12 months
- Booster dose between 6 & 18 months after initial dose may provide immunity up-to 10 yrs +
- Shake vial well prior to IM administration into deltoid (avoid gluteal region due to sub-optimal response as it deposits into fat tissue rather than muscle)
2. Precautions
- Consider delaying administration in those who present with acute febrile illness
- Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection
- Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity
3. Contraindications
- Because Havrix may contain trace amounts of neomycin, individuals with allergies to this substance
- Relative contraindication: consider delaying administration in those who present with acute febrile illness
4. Drug interactions
- Since these are inactivated vaccines, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response
Note: Havrix, Vaqta and Avaxim are considered interchangeable and equal
B. Twinrix (18 yrs +), Twinrix jr (2-18 yrs)
- When administered appropriately, provides immunity against hepatitis A and B
- since hepatitis D does not tend to occur in the absence of the hepatitis B virus, it is thought, in theory, twinrix should
- protect against hepatitis A, B, and D
1. Dose and schedule
-Traditionally a 3 dose schedule with the 2nd dose a minimum of 4 weeks after the initial dose and the 3rd dose 6 months after the initial dose.
- Dose 1 gives some protection, but needs a 2nd dose which gives up-to 12 months of immunity, and a third scheduled dose gives prolonged protection of 10-20 yrs + for hepatitis B and ~10-20 yrs for hepatitis A
2. Precautions
- Consider delaying administration in those who present with acute febrile illness
- Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection
- Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity
3. Contraindications
- Relative contraindication: consider delaying administration in those who present with acute febrile illness
4.Drug interactions
- since this is an inactivated vaccine, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response
II. Hepatitis B
- An infectious inflammation of the liver, which may progress into chronic liver disease or liver cancer
- Individual presents with nausea, vomiting diarrhea, fever +/- yellowing of the skin, abdominal pain and anorexia
- Transmission occurs via contaminated bodily fluids
A. Engerix B 1mL (adults) and 0.5 mL (jr £ 19 yrs) and Recombivax HB
1. Dose and schedule
- Canadian pediatric society recommends routine vaccination of all infants; this is just a recommendation not a guarantee & so Inquire!
- Traditionally patient receives 2nd dose 1 month after the first, and the 3rd dose 6 months after the first
- Doses should be separated by a minimum of 4 weeks
-Shake vial gently prior to administration
- An accelerated induction may be achieved by dosing at 0, 1 and 2 months with a 4th dose 12 months after the first for those who desire prolonged protection
- A rapid induction at 0, 7, and 21 days (adults only) is currently used for those previously non-vaccinated individuals being vaccinated within 1 month prior to intended travel (last minute planners!) The 1st 3 doses in this schedule provide immunity for up-to 12 months, while a 4th dose may provide prolonged immunity up-to 10-20 yrs +
- Intended for IM injection into deltoid region
- Avoid gluteal region due to sub optimal immune response when vaccine deposits into fatty tissue rather than muscle
- Infants and newborns should receive IM injection into their anterolateral region due to the small size of their deltoids.
- in special circumstances SC injection may be administered for those with severe bleeding disorders
2. Precautions
- ?????speculation that immune response to Hepatitis B vaccination may be reduced in those > 40 years of age????????
- Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection
- Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity
- A preservative (thimersol) free product is available and recommended for newborns and infants
3. Contraindications
- Hypersensitivity or allergies to yeast and /or other components of the vaccine
- Relative contraindication: consider delaying administration in those who present with acute febrile illness
4. Drug interactions
- since these are inactivated vaccines, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response
Note: Engerix B and Recombivax are considered equal and interchangeable
III. Traveler’s Diarrhea
- Advise your patients to take necessary precautions "cook it, peel it, boil it or forget it"
- Drink bottled water
- Avoid raw eggs, meat and fish
- Avoid milk or milk products (uncertain about pasteurization practices)
- Eat items off menus in restaurants
- Eat foods that physically hot
- Wash foods with iodinated water
- Wash your hands frequently
A. Pepto Bismol - Bismuth
1. Dose and schedule
Prevention - starting 1 to 2 days before traveling and continue up-to 2 weeks
0-3 yrs ½ tsp (2.5 mLs) QID*
3-6 yrs 1 tsp (5 mLs) QID*
6-9 yrs 2 tsp (10 mLs) QID*
9-12 yrs 1 tbsp (15 mLs) QID*
Adults 2 tablets QID*
* Regular strength liquid and tablets
Treatment - Pepto Bismol may be used for mild symptoms but antibiotics are recommended for short-term treatment
0-3 yrs ½ tsp (2.5 mLs) q 30-60 minutes Maximum 20mL/24 hours
3-6 yrs 1 tsp (5 mLs) q 30-60 minutes Maximum 40mL/24 hours
6-9 yrs 2 tsp (10 mLs) q 30-60 minutes Maximum 80mL/24 hours
9-12 yrs 1 tbsp (15 mLs) q 30-60 minutes Maximum 120mL/24 hours
Adults 2 tablet q 30-60 minutes maximum 8 tablets/24 hours
2. Precautions
- Salicylates should be used with caution in those less than 18-21 years of age due to the risk of Reye’s Syndrome especially in the presence of a viral infection (which may be silently present!)
- Due to its salicylate nature Pepto Bismol should be avoided during pregnancy, there are enough treatment alternatives available that its use need not be contemplated.
- Use with caution in those with a history of GI bleeds
- Black tongue is likely with prolonged use
3. Contraindications
- Avoid in active GI bleed
- Avoid in ASA allergy
- Avoid in 3rd trimester of pregnancy (preferred that its use be avoided all together during pregnancy)
- Avoid in hemophiliacs
4. Drug interactions
- Warfarin (due to increased effect of anti-coagulant)
- Acetazolamide (due to increased effect of cationic anhydrase inhibitor)
- Ciprofloxacin, tetracycline, doxycycline, levofloxacin (due to the formation of non-absorbable complexes)
- Prednisone (due to decreased effect of salicylate)
B. Septra - Sulfamethoxazole + trimethoprim
1. Prevention - prophylactic antibiotics are not recommended except occasionally in high-risk individuals (people with compromised immune function &/or disorders of the digestive tract)
Treatment- worldwide misuse and overuse has led to worldwide resistance
2. Precautions
- Worldwide resistance, not drug of choice anymore
- Use with caution in those with blood dyscrasia (avoid if possible)
- Photosensitivity
- Requires plenty of water with use therefore have to consider the availability of non-contaminated water
- G6PD deficiency (avoid if possible)
- Caution in hepatic insufficiency and alcoholism due to risk of liver toxicity and disulfiram reaction
3. Contraindications
- Sulfa allergies
- Avoid in 3rd trimester of pregnancy especially the last 2 weeks prior to anticipated delivery date due to risk of kernicterus
4. Drug interactions
- Warfarin may risk of increase effect of anticoagulant?
C. Ciprofloxacin
1. Dose and schedule
Treatment dose:
500 mg BID x 3 days
Or
1000 mg (one dose)
2. Precautions
- Not recommended in those 15 years of age or younger or during pregnancy -(potential damage in bone/joint formation)
3. Contraindication allergy to cipro
4. Drug interactions
- Warfarin (increased anticoagulant effect)
calcium, aluminum, magnesium, iron, and zinc may form insoluble, non-absorbable complexes and potentially rendering ciprofloxacin inactive)
D. Azithromycin (Zithromax)
1. Dose and schedule
Treatment dose:
Adults 500mg once daily x 3 days
Children 10mg/kg/24 hours x 3 days
Pregnant women 500mg once daily x 3day
2. Precautions
Since the major route of elimination for azithromycin is via the liver, precaution should be adhered to in the case of significant hepatic disease/disorder
3. Contraindications
Those having known hypersensitivity or allergic reaction to the erythromycin family or macrolide antibiotics
4. Drug Interactions
- Antacids, dairy and other products containing calcium, magnesium, aluminum, iron and zinc should not be administered simultaneously with this agent due to the risk of formation of non-absorbable complexes.
Note: treatment antibiotics should show optimal results and significantly decrease symptoms within the first 24-48 hours but if the individual is still sick after 2 to 3 days he/she should contact the nearest Canadian embassy and get their assistance in finding medical attention locally
E. Loperamide 2mg (Immodium)
1. Dose and schedule
- Treatment dose:
(adults) 2 tablets at onset then 1 tablet after each substantial loose bowel movement to a maximum of 8 tablets in a 24-hour period
(children) routine use not recommended but for acute diarrhea in 1st 24 hours (maintain hydration!!!!)
-2 to 5 yrs (10 to 20 kg) 1mg TID (3 mg daily dose)
-6 to 8 yrs (20 to 30 kg) 2 mg BID (4 mg daily dose)
-8 to 12 yrs (> 30 kg) 2 mg TID (6 mg daily dose)
2. Precautions
-Exceeding the maximum recommended dose of 16mg/24 hours could bring about rebound constipation
- Ensure proper hydration, replacing electrolytes if the problem persists beyond the first 24 hours, showing no signs of improvement despite treatment
- Use with caution in the case of hepatic insufficiency
3. Contraindications
- Avoid its use in those in whom constipation must be avoided
- Avoid in the case where blood, mucous and/or fever accompanies stool
- Avoid in psuedomembranous colitis
- Avoid in shigellosis
4. Drug interactions
- None mentionable
IV. Malaria
- A disease caused by a parasite and spread through the bite of an infected mosquito
- Initial symptoms are minor and flu-like and can go on to result in severe complications such as respiratory and kidney failure, liver problems, anemia and even prove fatal
- It is always better to prevent than treat when you consider the long-term consequences of malaria
A. Chloroquine
- The drug of choice in chloroquine sensitive areas
- Available in tablet form for adults and can be compounded into a weight based suspension and flavored to taste for children and infants
- Suitable in pregnancy and “for all ages” but over-doses are frequently fatal so verify the dose if uncertain
- Symptoms of overdose may include headache, drowsiness, visual disturbances, CV collapse, seizures, respiratory and cardiac arrest
- Acidification of the urine enhances its elimination
1. Dose and schedule (Prevention)
(adults) 500mg/week* (on the same day each week)
(children) 8.3mg/kg/week*
*Doses are expressed in terms of the chloroquine phosphate salt (250mg of the phosphate salt = 150mg base and either can be used in the compounding of tailored doses)
- Dosing should begin 1 week prior to intended departure to the malarious area and continue weekly while in the malarious area and for 4 consecutive weeks after departing from the malarious area.
2. Precautions
- Get the advise of a travel health expert based on each individuals travel itinerary and medical history to determine the most appropriate anti-malarial to use
- Appears to be a safe choice in pregnancy and while breast-feeding (keep in mind that although considered safe during breast-feeding, maternal administration does not protect the suckling infant)
- Take with food
- Bitter to taste
- May cause discoloration of urine
- May cause reversible yellowish corneal deposit in prolonged use (i.e. long term trip)
- Avoid taking antacids at the same dosing time as chloroquine
- Use with caution in the case of alcoholism
- May? Exacerbate symptoms of psoriasis
- May cause photo-sensitivity
3. Contraindications
- Allergies to chloroquine, hydroxy-chloroquine or primaquine
- Avoid in dialysis (hemo and peritoneal)
4. Drug interactions
- Methotrexate, as it may reduce the efficacy of methotrexate temporarily
- Cyclosporin, as it may increase the blood concentrations of cyclosporin requiring temporary dosage reduction during such co-administration
- Chlorpromazine, as it may increase the blood concentration of chlorpromazine thus requiring close monitoring for signs of increased neuroleptic effects
B. Hydroxy-chloroquine (Plaquenil)
- Traditionally used for arthritis but may be indicated as an anti-malarial
1. Dose and schedule (prevention)
- Prevention
(adults) 400mg/week#
(pediatric/children) 6.5mg/kg/week#
- Starting 2 weeks prior to travel, continuing while in malarious area and for 8 consecutive weeks after leaving malarious area
# Doses are expressed in terms of the hydroxy-chloroquine sulfate salt (200mg sulfate salt = 155 mg base)
2. Precautions
- Since related to chloroquine, it is extrapolated that hydroxy-chloroquine is safe for use during pregnancy although its actual safety is unknown
- Its appear to be safe for use while breast-feeding due to lack of evidence suggesting otherwise but benefit must always outweigh possible risk in terms of both pregnancy and breast-feeding when it comes to the use of chemicals and drugs
- Bitter to taste
- May cause reversible yellowish corneal deposit in prolonged use (i.e. long term trip)
- Avoid taking antacids at the same dosing time as hydroxy-chloroquine
- Use with caution in the case of alcoholism
- May? Exacerbate symptoms of psoriasis
- May cause photo-sensitivity
- Take with food
3. Contraindication
- Pre-existing retinopathy of the eye
4. Drug interactions
- Concomitant use with digoxin therapy may result in elevated serum digoxin levels thus necessitating the close monitoring of patients receiving both; watch for signs of nausea, vomiting, anorexia, visual disturbance (unfortunately arrhythmias may be the first recognized sign)
C. Mefloquine (Larium)
1. Dose and schedule (prevention)
- Adults and pediatric patients > 45kg
- 1 tablet at least 1 week prior to travel to malarious area
- 1 tablet once weekly (on same day of the week) while in malarias area
- 1 tablet once weekly for 4 weeks after leaving malarious area
- > 30kg to 45kg
- ¾ of a 250mg tablet = 187.5mg
- > 20kg to 30kg
- ½ of a 250mg tablet = 125mg
- 5kg to 20kg
- ¼ of a 250mg tablet = 62.5mg
2. Precautions
- May want to limit or avoid activity that requires mental alertness or fine motor control
- Use with caution in those with cardiac conduction disorders, mild anxiety disorders or seizure disorders or tendencies
- May use during pregnancy and breast-feeding but does not protect the infant (some suggest that its use be postponed until after 16 weeks of pregnancy due to lack of studies revolving around teratogenicity)
3. Contraindications
- Concomitant administration of Mefloquine with quinine, quinidine, chloroquine or anti-epileptics may increase the risk of convulsions and minimize seizure control, respectively
- In patients with unstable psychiatric disturbances or overt, uncontrolled anxiety alternative suggestions should be considered
4. Drug interactions
- None mentionable (see precautions and contraindications)
D. Doxycycline (Vibramycin)
1. Dose and schedule (prevention)
(adults) 100mg daily
(children 9yrs +) 2mg/kg daily (maximum daily 100mg)
- Starting 2 days prior to intended travel, while in malarias area and continue for 4 consecutive weeks after leaving malarious area
2. Precautions
- Not recommended in pregnancy, especially beyond 14 weeks gestation week the fetus’ teeth are scheduled to begin calcification process
- Classified as a code D in pregnancy by Briggs: Drugs in Pregnancy and Lactation
- Little to no evidence of harm to a breast-fed infant
- Overall recommend avoidance during pregnancy
- Photo-sensitivity
- Avoid use in children < 9 yrs due to increased risk of permanent tooth discoloration
- Women prone to yeast infection while on antibiotic treatment should make typical lifestyle/dietary modifications while on antibiotic treatment (i.e. yogurt acidophilus/lactobacillus)
3. Contraindications
- Individuals with hepatic or renal insufficiency
- Allergy to tetracyclines
4. Drug interactions
- Concomitant use with digoxin therapy may result in elevated serum digoxin levels thus necessitating the close monitoring of patients receiving both; watch for signs of nausea, vomiting, anorexia, visual disturbance (unfortunately arrhythmias may be the first recognized sign)
- Antacids, dairy and other products containing calcium, magnesium, aluminum, iron and zinc should not be administered simultaneously with this agent due to the risk of formation of non-absorbable complexes.
- ~Birth control, women who rely on the oral contraceptive may and should practice an alternate means of protection while using antibiotics in general
E. Atovaquone and proquanil (Malarone)
1. Dose and schedule
- Adults 1 tablet daily starting 2 days before intended travel, continue daily while on trip and for an additional 7 days upon leaving malarious area
2. Precautions
- Use with caution in those with a history of uncontrolled psychiatric disorder(s) or epilepsy
-Little to no evidence surrounding its use in pregnancy or lactation (clinician and travel health expert should determine its need based on the potential risk vs. benefit in each individual case
3. Contraindications
- Still fairly new medicine, none mentionable
4. Drug interactions
- Avoid administration with other anti-malarial medications
V. Altitude Illness prevention Medicine
A. Acetazolamide (Diamox)
- Aids the acclimation process when used in conjunction with safe acclimation practices
1. Dose and schedule
(adults) 125 mg (1/2 of a 250mg tablet) twice daily starting 1 day prior to climbing and continuing for ~ 3days
2. Precautions
- Best to avoid during pregnancy and breast-feeding (risk and tolerance is unknown)
- Common side effects (> 10%) include diarrhea, generalized malaise, increase volume (dehydration?), muscle weakness and nausea
3. Contraindications
- Avoid in those with known sulfonamide allergies (may be beneficial to look into nature of such allergies given that acetazolamide is one of the only options here)
4. Drug interactions
- Salicylates tend to increase the effect of the carbonic anhydrase inhibitor
B. Dexamethasone (Decadron)
1. Dose and schedule
(Adult) 4mg every 6 (~12) hours
- Possibly given in the case of allergy to acetazolamide
- Mainly reserved for rescue efforts to dampen the symptom when altitude gets the best of a climber, thus buying time in the rescue attempt
-OR in those well trained individuals who cannot take acetazolamide but must ascend quickly
- Be very careful of this drugs ability to quickly wear off leaving the individual with the risk of rebound altitude sickness symptoms
C. Viagra (Sildenafil) and Cialis (tadalafil)
- ?may improve blood flow when pulmonary edema is a threat?
Summary
Many of the immunizations and medications mentioned today may be novel for pharmacists and doctors but are becoming more frequently prescribed with newer products being developed. Understanding their mode of action will help avoid ineffective doses, conflicts with other medications and contraindications with specific diseases.
References:
•Grabenstein JD ImmunoFacts: Vaccines and Immunologic Drugs St.Louis, MO: Wolters Kluwer Health, Inc.; 2005
•CPS 2004
•
•Dr. Gary Podolsky M.D.(personal communications)
Pharmacology Scenarios
Jacinda Wagner
Sarah and John and their 6-year-old son Arnold are going to the Dominican Republic. Their doctor has prescribed 500mg of Chloroquine per week for each adult and 165mg for their 20kg son. On checking at the pharmacy none of those doses exist. What should they do?
Chloroquine (Aralen) has traditionally been prescribed as 300mg base or as 500mg chloroquine phosphate salt. In this case we are referring to the salt, which is the most common designation although the old notation may persist. In Canada, Chloroquine comes as a 250mg salt dose, so each adult will require 2 pills per week starting one week before exposure, and continued every week of their trip and for 4 weeks post trip. Arnold will need 8.3mg/kg salt once weekly.
A 250mg tablet may be scored into quarters of 62.5 mg but for lower doses having a compounding pharmacist prepare exact doses is preferable. Chloroquine also has a very bitter taste.
Edmund is going mountain climbing and has been prescribed Acetazolamide (diamox) for the prevention of altitude illness but his pharmacist has noted a previous allergy to sulpha drugs. What should be done?
First it would be best to find out what the previous allergy was and to what drug. Distinguishing a mild rash from a full-blown severe anaphylactic or Stevens Johnson Syndrome due to a sulphonamide drug is essential.
Acetazolamide contains a sulfaryl group, which is distinct from a sulphonamide group. In the history of only a mild rash the Acetazolamide may be given however caution must be used when severe reactions had occurred in the past however unlikely.
Given enough time a referral to an allergist could be arranged but this is unlikely to be practical. If Edmund urgently needs Acetazolamide a trial dose may be tried at home prior to departing on his trip.
Mrs Smith is leaving to go to Guatemala in 2 weeks and has a history of Psoriasis and is on metaprolol, a beta-blocker, digitalis and adalat. Are antimalarials safe for her?
Chloroquine should not be prescribed for those with psoriasis.
Mefloquine should not be used in those with heart conduction (it is not the beta blocker that is a contraindication but the underlying heart conduction defect), nor for those with underlying anxiety or depression.
Doxycycline or Malarone would be good choices. Guatemala malaria strains are chloroquine sensitive all of the above medications are suitable choices provided the individual has no contraindications or medication interactions with the medications.
Mary wants to know the differences between the typhoid oral vaccine (Vivotif-ty21a, Berna) and injectable typhoid (typhim vi, Aventis; Typherix, Glaxo).
Both brands of the injectable typhoid vaccines are inactivated and give protection for 3 years. They are much less side effects from modern typhoid injectable vaccines than from the injectable typhoid vaccines of the 70s that required 3 weekly injections and were painful. Injectable vaccine may be safely given to children, HIV infected individuals and to pregnant women.
The ty21 vaccine (vivotif) is a live attenuated oral vaccine taken in 4 dosed at 0,2,4,and 6 days and should not be taken by anyone whom a live vaccine could be unhealthy (such as pregnant women, AIDS patients). Some questions about the vaccine may be found at abt_faq.cfm
Can Alcohol be taken with the oral dose?
Alcohol should not be taken for 1 hour after the vaccine is given as this may dissolve the capsule in the stomach not in the intestine where it is absorbed effectively.
Can the capsule be opened up instead of swallowed whole?
No the capsule must be taken whole so it is absorbed correctly in small intestine..
What happens if I miss a dose of Vivotif?
If 3 doses are taken properly a delay of up to 72hrs is acceptable.
If 2 doses are taken properly a delay of 24-48 hrs for the 3rd dose is ok but the 4th dose must be taken 2 days later.
If only one dose was taken, the course should be discontinued and the 4 capsule series must be restarted.
Vivotif is the one exception to the general rule about immunizations that normally it is acceptable to allow extra time may pass between vaccination doses without penalty and without one having to restart the series.
Are Antibiotics all right to take with Vivotif?
No, they kill off the attenuated typhoid
Are antimalarials all right to use at the concurrently with the oral typhoid?
Both chloroquine and mefloquine may be used with no interaction with oral typhoid.
Doxycycline is an antibiotic and will kill off the attenuated typhoid oral vaccine.
Malarone should not be used until 10 days after vivotif is given for a theoretical interaction
A client asks about the use of antibiotics to stop travelers’ diarrhea. Do they still recommend this?
Current evidence supports that antibiotics do help with Traveller’s diarrhea
Antibiotics are no longer recommended to be taken prophylactically (that is before getting sick) as this increases bacterial resistance and increases side effects.
Pepto-bismol taken at 2 pills four times daily will decrease the risk of traveller’s diarrhea by 50% and may be used for up to 3 weeks.
Antibiotics are now recommended to be taken at the onset of symptoms.
Septra was previously widely used but now has worldwide resistance and is no longer effective.
Instead a broad-spectrum fluoroquinolone such as Ciprofloxacin will be helpful at 500mg po bid for up to 3 days. This will work against enteric bacteria that cause travellers diarrhea. It will of course not kill viruses and parasites.
Recently Captylobacter bacteria in Cambodia have resistance to Ciprofloxacin..
Pregnant women and children under 15 may use Azithromycin instead of Ciprofloxacin.
A new antibiotic Rifaximin (Xifaxan) has been developed but is not yet available in Canada. It may perhaps replace Ciprofloxacin, as it may be more effective and safer for pregnant women.
Eve has called the pharmacy asking for Ledum Palustre or Malaria 0fficinalis to prevent malaria on the advice of a homeopathic website. She can buy these products through the site but wants to know if the pharmacy is cheaper.
A recent review of homeopathic medication for the prevention and treatment of malaria did not find these preparations to be helpful (British Medical Journal http:bmj.cgi/content/full/321/7271/1288/a).
At present the CDC, Health Canada and WHO have not authorized any homeopathic product for use in the prevention of malaria. One new natural product of interest is the Chinese shrub Artisinea that is a very good antimalarial. It is beginning to be marketed in North America and is use in other parts of the world.
Examining the Anti-Vaccination Movement
Gary Podolsky MD
There are many people who do not believe in Immunization in Manitoba.
One may chose several reasons to reject a treatment such as immunization either for themselves or their children. In Manitoba it is legal for parents to opt their children out of the Public Vaccination program prior to entering school. Professional health colleges in Manitoba do require specific vaccines for entry, which are a reflection of the WRHA, National Advisory Committee on Immunization, Heath Canada, and CDC guidelines.
We live in a society that permits a plurality of views regarding religion, politics and other freedoms. It is important to preserve peoples right to make informed decisions regarding their health. But it is also important that they receive the correct information and are not over influenced from either the pharmacology industry or special interest groups with evidence that is not scientifically valid.
Anti-vaccinationists lobbyists rarely define themselves as “Anti-vaccinationists” as this has a distinct negative image. Instead titles such as “Concerned Parents for Immunizations” and the “Eagle Foundation” are used to connect themselves as a positive group seeking to disassemble a corrupt medical establishment. They present themselves as a group seeking balance but do not provide information that is in anyway provaccine so describing them as antivaccinationists is still true.
Public Health Groups have encountered this problem and tend to respond in one of two ways passively or aggressively.
Passive Approach
A passive approach is often taken, giving the critics of vaccines equal time in forums with the intention to not escalate confrontations (adding fuel to the fire). This approach is deeply flawed when it confers approval of unsubstantiated alternative health care philosophies and does not actual address gross inaccuracies in the attacks on vaccines.
At a recent public health exhibition on immunization in 2002 a forum was held, open to the public. The event was well publicized and speakers included Paediatricians, Victims of polio, and other Physicians from public health that spoke on a variety of issues all promoting vaccinations. Members of Winnipeg’s Anti-immunization group arrived near the end and began distributing their own literature (theirs was free while parents would have to pay approximately $25 for the Health Canada Publication directed at parents) One prominent Chiropractor then made the claim that immunization with H Influenza clearly causes diabetes. He was allowed to continue making several erroneous attacks all unchallenged while all of the Public Health doctors stood by and allowed the parents in the audience to accept this. I spoke to one of the Health officers and she steadily maintained that everyone was entitled to their opinion even in the face of my protestations that Public Health had paid and organized the event to educate the public. A poll was taken at the end and less than half of the parents present claimed they would vaccinate their children based on what was said that day.
An active approach to antivaccinationism has been perceived by some as to brutal, a very characteristic arrogance of a medical elite dictating what people should have while this elite authority ignores mounting unsafety of immunizations. This perception is often true of medicine. Although an education campaign may be won in the short term (forcing meningitis vaccines on High School students) long term distrust of Public health may persist.
Over belief in medicine can also approach an irrational fanaticism similar to that of vaccine critics with both sides ignoring each other’s evidence. By dismissing critics of immunization too quickly and ignoring that there are limitations to immunizations proponents of immunization programs may lose their arguments as well.
It is necessary to promote immunization in a positive way that is open to examination and critiscm especially since cost is an important consideration.
Several medical interventions including drugs and vaccines were previously thought to be very safe but later were withdrawn. If we depend too much on the integrity on any specific intervention we may be inevitably be let down such as in the recent case of Vioxx.
As Health Professionals and Consumers it is important to maintain a healthy level of critical thinking and be prepared to adjust our practices according to the best evidence available.
At present the best evidence is that most vaccines are a good idea. In the remainder of this talk I will emphasize key points about vaccinations I wish to communicate to other Health care Professionals and People in Manitoba.
For the remainder of this article I would like to avoid labelling any individuals as Anti-vaccinationists as this term is a broad classification that covers many heterogeneous individuals with a variety of beliefs regarding vaccines. Antivaccinationism as a philosophy or set of beliefs may be better dealt with than attacking a set of individuals with those beliefs.
People who have been misinformed or have an incomplete understanding of the science of immunization are good candidates to spend extra time explaining immunization with. By correcting misunderstanding these people may come to accept immunization on their own terms without being bullied or cajoled.
Debating Antivaccinationism
Antivaccinationism Activists who pursue an agenda against public health and the widespread use of immunizations are less likely to be reasoned with. Time should not be spent on debates where the rules and conduct are similar to brawls in the street. Debates with defined rules and equal time to both sides have been held between both groups with the provaccination group usually coming out ahead. In venues controlled by critics of immunization such as at Alternative Health Fairs debates are usually of poorer quality since a debater may be more easily shouted down or given ridiculous evidence they may not be able to refute or contest.
Clinicians focusing on educating the public and individual patients should focus on well-established facts on the benefits of immunization.
The limitations that vaccines have should be openly admitted and discussed. Side effects are infrequent and often only trivial but transparency in the surveillance and reporting of any perceived side effects must be maintained.
Immunization Questions continue after the vaccine is administered
Our clinic tends to insist on a face-to-face review of perceived vaccine side effects. This will reassure patients and has the added benefit of accurately diagnosing patients immediately.
One patient received Twinrix from us and had severe dizziness over the next several days. She had seen a medical doctor in follow up who did not examine her or give her a diagnosis or any type of treatment. In frustration she had seen her homeopathic physician who then told her she had multiple sclerosis caused by the vaccine and wanted to begin immediate homeopathic treatment. She began these but finally returned to us where I examined her with a very mundane Otitis media. She was prescribed antibiotics and I made sure she had a follow-up with me to ensure she had a full recovery.
Key Concepts in Promoting Immunizations
Immunization has saved Millions of Lives
Routine vaccines are safe
The eradication of diseases prevented by vaccines outweighs unconfirmed adverse reactions
Vaccine scares are common
Parental Concerns should be taken seriously
Health Professionals have a duty to provide accurate information to enable parents to make a truly informed decision regarding their Child’s vaccinations.
The following pages go into great detail on many issues in current vaccinology.
Why Vaccines Work in Protecting Us: A Message To Parents and Clinicians
Compiled by Gary Podolsky MD
This article is intended to help both clinicians and parents learn the most up to date information on vaccines. Parents have to make important and sometimes difficult decisions for their children, and often the most difficult decisions are in regards to healthcare. There are several concerns in our community concerning vaccine safety without merit. The purpose of this talk is to correct misinformation. We all want to make the right choices regarding what is right for our children and protect the general public health as a community. A recent article in the British Medical Journal explained how all Healthcare workers and Teachers in Britain are always given new information on immunization practices, regardless of their actual role in immunizing children. This constant reinforcement of the need for immunizations helps them to be able to inform their patients to make informed decisions about their health.
We designed this booklet to meet the needs for information on behalf of Canadian parents, health care professionals, school nurses, childcare providers and others in order to:
1. Provide information about immunizations and vaccine-preventable diseases, in a similar format to information presented on car seats, bike helmets, and age appropriate toys.
2. Balance the benefits and risks of immunizations to assist you in making an informed decision.
3.Clarify inaccuracies or misinformation about vaccinations and vaccine-preventable diseases.
This booklet is arranged so that each section may be read independently. We have used a question and answer format. We hope that you will spread our messages about the importance of immunization with your patients. Information on immunization is rapidly changing so extensive links are included.
Immunization Saves Lives
Immunization is one of the most successful medical discoveries in human history and has saved millions of lives in the 20th century. Many serious childhood diseases are preventable by using vaccines routinely recommended for children.
Since the start of these vaccinations, rates of disease such as polio, measles, mumps, rubella, diphtheria, pertussis (whooping cough) and meningitis from Haemophilus influenza B, have declined by 95-100%. Before immunizations hundreds of thousands of children were affected each year with thousands dying each year (U.S. figures).
In under-immunized countries there are still 600,000 children dying each year from pertussis alone. Without routine vaccinations diseases we are now protected from will return. They will sicken and kill many infants and children while many survivors of severe illness will go on to have chronic health problems. Many countries are having problems because they stopped vaccinating against diseases that were felt to be under control. (The rebound incidence of diphtheria in the former U.SS.R. is a good example of this). It is only after a specific disease is no longer found in people and exists nowhere else (eg. soil, water or animals) that a vaccine can be safely discontinued. Smallpox vaccination lead to smallpox’s official eradication and vaccinations were discontinued once this was certain.
Immunizations Prevent the Spread of Disease
Diseases spread through communities by infecting un-immunized people and the small percentage of people for whom immunizations do not work. For some highly contagious diseases like measles, even a small number of susceptibles can lead to outbreaks.
In 1989-1991 a measles outbreak occurred in the U.S. due to the failure to vaccinate preschool children on time. This epidemic was responsible for 55,000 cases of measles. At least 120 deaths occurred in children under age 5 months who had not been vaccinated.
In 1998, all of the measles cases in the US were cases that originated from other countries. With widespread globalization and travel to other countries, dangerous infectious diseases are only a plane ride away. By being well vaccinated as a population, we also increase our ‘herd immunity’ such that if an infectious agent does enter our population it will be blocked immediately from spread to others.
Immunizations are Safe
Immunizations are extremely safe and getting safer and more effective due to ongoing research. Immunizations are given to keep healthy people well. They are held to the highest safety standards. The number of vaccinations available keeps expanding as more and more diseases are being studied.
Immunizations Save Money
Every dollar spent on vaccinations saves seven dollars in medical costs and 25 dollars in overall costs (i.e. missed work). Complications from hepatitis B related liver diseases exceed 500 million dollars U.S. (U.S. figures). This total cost includes direct (medical costs) and indirect (lost work) but doesn’t include human suffering.
Immunizations are Strong Protection
Immunization is the single most important way parents can protect their children against serious disease. Children who are not immunized are at a far greater chance of becoming infected with severe disease.
Immunizations work naturally by using the body’s immune system and make it stronger and more effective at fighting disease. There are no other effective alternative ways to prevent many of these diseases. Breastfeeding is helpful in preventing some diseases among babies but is not effective against preventing all serious diseases.
Other Important Facts:
Infants are often affected more severely than older children by the same diseases. Their immune systems are weaker and cannot fight off bacteria or viruses as well.
Even if a disease is not currently reported in a region the bacteria or viruses may still be present. Disease outbreaks are prevented by routine vaccinations.
Most vaccines are provided free through Manitoba Health.
Many are covered in other jurisdictions but not Manitoba. In Manitoba, Hepatitis B is covered for grade 4 children only. Varicella (chicken pox), meningitis and pneumococcal pneumonia are now covered by Manitoba Health for children born in 2004. Immunizations such as Hepatitis A are not covered in Manitoba.
How the Immune System Works
The immune system is the body’s defense system against disease. Medical research has developed vaccines to help the immune system fight disease. When you get an infection the body produces antibodies. Antibodies will attack antigens (invading bacteria or viruses) and help fight illness. Antibodies will stay in the body after the original disease is gone to protect you from getting that disease again. This memory of the immune system is called immunity.
Mother’s milk confers immunity temporarily as antibodies in the mother’s milk are passed on to protect the infant. These antibodies wane with time leaving no memory or lasting immunity. Therefore infants need to be vaccinated in order to develop their own immunity. In making a vaccine against a bacteria or virus, the infectious agent is weakened so that the vaccine does not cause illness. The body is tricked into responding to the antigens of a vaccine so that the specific immunity it develops will be effective against real bacteria or viruses.
Vaccines are available in different types. Live vaccines are made from weakened (attenuated) viruses or bacteria. Live vaccines are extremely effective and produce lifelong immunity after only 1 or 2 doses.
Inactivated vaccines are dead viruses and require multiple doses to buildup a good immune response. Some inactivated vaccines require boosters throughout life (like tetanus-diphtheria which is repeated every 10 years).
Questions and Answers
Question: Do vaccines really work?
Answer: Yes. Everywhere where vaccination occurs, diseases have declined in incidence.
Question: Why do some children still get measles after vaccination?
Answer: We know that one dose of measles does not protect 100% of people immunized and that 5-10% will still be susceptible to a measles infection. That is why a second shot is later given. There are always small amounts of people who may not respond well to vaccines and are not immune. If they get ill they usually are still protected by the vaccine from developing full-blown disease.
Question: Isn’t catching a natural infection such as wild measles, better than an artificial immunization from a vaccine in giving immunity?
Answer: No. In neither case are infections or vaccines natural. A ‘natural infection’ with an agent like measles, will also carry the risk of disease. The vaccine is intended to stimulate the immune system without getting the disease. Vaccines are made to optimize immune function. Some diseases such as tetanus do not even induce immunity after an infection, while others may (Hepatitis A infection survivors will have lifelong immunity). It is also unnatural to have a child’s spine manipulated, adjusted, or jostled, which will not affect the immune system.
Question: Doesn’t immunity wear off after time?
Answer: Yes. Different vaccines give different immune responses after the proper schedule is carried out. Some like tetanus and diptheria, need to be boosted every 10 years for adults while others like measles, will require no further boosters.
Question: Can vaccines cause seizures?
Answer: Indirectly yes. Vaccines can cause a fever that may then cause convulsions in some children (3% of otherwise healthy children) but these seizures are not a sign of brain injury. Several large studies have looked at febrile (fever associated) seizures and found that there is no evidence of brain damage from any vaccine. If a child has a fever it is recommended that the child take an antifever medication such as children’s Tylenol.
Question: Can vaccines cause cancer?
Answer No. There is no evidence of this. There is strong evidence that the Hepatitis B vaccine will prevent cancer. The BCG vaccine is actually used to treat bladder cancer.
Question: Are the preservatives in vaccines (Formaldehyde, Aluminum, Mercury, Thimersol) toxic?
Answer: The amount of chemicals used as preservatives in vaccines is very minute and non-toxic, even for infants. These preservatives are reviewed by Health Canada and felt to be safe. Some vaccines do contain antibiotics or egg products, which should not be used if a history of allergies exists. Regarding eggs, if a child is able to eat an egg without difficulty then the vaccine may be given. Manufacturers of vaccines plan to substitute thimersol in their products not because of any health concerns, but to avoid further controversy. There is still no good evidence that thimersol in vaccines causes problems.
Question: Does any vaccine contain brain tissue, which transmit Mad Cow Disease?
Answer: No.
Question: Why do Chiropractors, Homeopaths, and Naturopaths, advise against immunization?
Answer: The Policy of the Faculty of Homeopathy at the London Royal Homeopathic Hospital is: “Where there is no medical contraindication, immunization should be carried out in the normal manner, using conventionally tested and approved vaccines”. The Manitoba Chiropractors Association has also formally stated that they approve of vaccinations. Despite these statements from official organizations, many alternative “practitioners” strongly oppose vaccination.
Anti-vaccinationists have been around for a long time, and may use false claims for any number of reasons but they do this without any support from their governing bodies and are hence are themselves “denatured”. Many early vaccines had well documented severe adverse effects but modern vaccines should not be confused with these. Anyone may state an opinion, but using a professional title to advocate a view that cannot be scientifically supported, is wrong.
Question: Do vaccines alter or weaken the immune systems own natural ability to fight off disease?
Answer: No, a vaccine only evokes an immune response specific to a specific group of antigens. For example, the vaccine for polio will have no effect on the body’s ability to handle hepatitis B since each infectious agent is recognized differently. This is why it is important to be vaccinated against all the diseases available.
Question: Does breastfeeding replace the need for vaccination?
Answer: Although breast fed babies receive antibodies in mothers milk that protect them in their early years, they are not protected from all diseases. Vaccines give specific and long lasting protection.
Question: Does giving more than one vaccine on the same day ‘overload’ the immune system? Would it not be better to give only one vaccine at a time?
Answer: No. Receiving more than 1 vaccine at a time does not harm a child’s body. Vaccines only use a tiny part of the body’s immune system. Many childhood vaccinations are given at the same time for convenience because this ensures that the child doe not miss important dates and also means fewer needles.
As a person eats and breathes, their immune system is constantly exposed to many infectious agents. Vaccines represent a small fraction of the antigens a person is regularly exposed to.
Question: Is the method of injection of vaccines harmful?
Answer: No. Injecting vaccines is a safe method and has been used for decades.
Vaccines are never injected into the bloodstream. Most are injected either into the muscle or into the fat just beneath the skin. Each needle and syringe is disposed of after use as they are only used once.
Question: Can someone get a disease that they had been vaccinated against?
Answer: Yes, modern vaccines are extremely effective but are still not perfect. If a vaccine is 90% effective then 10% of people will not develop sufficient antibodies to prevent disease. If an infection rolls into town the susceptible individuals (all of the un-vaccinated and 10% of those vaccinated) are likely to become infected. Those 10% may still have partial immunity in that they will experience a milder form of disease.
If a community is well vaccinated, diseases will be harder to catch since person- to person contact is blocked. This ‘herd immunity’ protects those susceptible individuals.
Many vaccines also require more than 1 dose to be effective. Some antibodies (such as tetanus) will wane with time and require future booster shots.
Question: I have heard that the real reason that these vaccine-preventable diseases began to disappear was because of better hygiene and sanitation and not because of vaccines. Is this true?
Answer: No. Many infectious diseases did become better controlled with better public health improvements but they remained serious threats due to periodic outbreaks in susceptible populations. It wasn’t until vaccines were introduced that the actual rates of incidence went down dramatically.
But fighting diseases involves many issues. Vaccines have definitely been assisted by other factors such as:
1. Better nutrition
2. Less crowded living conditions with better sanitation
3. More effective treatments such as antibiotics
But in spite of these improvements, vaccine-preventable diseases still occur due to lack of vaccination.
A good example of the effect of a vaccine after its introduction occurred with the Hib vaccine. In 1984 when it was first introduced in Washington State there were 80 cases of Haemophilus per year. Rates steadily decreased in the next 2-7 years to essentially 0 cases by 1998. Sanitation did not change much during this time. The Hib vaccine was the only new variable.
Similarly in 1963 there were 500,000 measles cases (with 500 deaths that year) in the U.S. In 1998 there were 100 cases reported with no deaths.
Question: Isn’t it still better to become immune from natural sources rather than through a vaccine?
Answer: No. Vaccine preventable diseases can still be lethal, or cause permanent damage (brain damage from measles or pertussis, liver cancer (from hepatitis B), or paralysis (from polio). Some vaccines such as tetanus are even better at creating immunity than the natural infection.
Vaccines prevent disease without risking an adverse effect from an infection. A good example is chicken pox. Chicken pox in an adult can be a very serious illness whereas most children only become mild to moderately ill. Previously before immunizations were available, parents were encouraged to have their children deliberately exposed to other children with chickenpox (“chicken pox parties”), so that their child would receive lifelong immunity. This was a rational approach at that time, since the risk to that child later in life as an adult could be life threatening if they missed their being infected as a child. We no longer advocate chicken pox parties because the varicella vaccine uses a live attenuated virus to prevent chicken pox illness in children without the associated risks of disease.
Vaccinating Children-To Wait or Not
Parents frequently wonder why vaccines are given to children so early in life. They may ask to wait until their child is about to enter school before getting immunized.
Question: Is it all right to wait until school starts to get immunized?
Answer: No, waiting too long may put your daughter or son at an unnecessary risk of contracting serious disease. Maternal antibodies fade during the first year of life. This also occurs when children are more frequently exposed to other children and adults. Many of the vaccine –preventable diseases are more severe in very young children.
For example, the peak vulnerability of children for Haemophilus disease is at ages 6-7 months, therefore for the vaccine to be most effective it should be given before this time.
In a measles epidemic in the U.S. (1990) 40% the of cases were in children less than 4 years old. Most of these could have received their measle vaccinations at 15 months but did not. Now children get their measle vaccinations as early as 12 months of age (and 6 months during outbreaks).
Question: Can my child catch up if they missed or are behind on vaccines?
Answer: Yes, but it is best to stay close to the recommended schedule. An interruption in the schedule does not mean having to restart the series. Until the vaccine series is finished, the child will not have maximum protection against the disease. If the child’s immunization schedule is behind parents should speak with their family doctor, immunization nurse or public heath clinic.
If a child is going to live overseas regular vaccinations may be given earlier to adjust for the increased risk of some diseases in certain countries. If planning an oversees trip consult a Travel Medicine Clinic for appropriate advice.
Question: Are immunizations safe even If my child has a minor illness?
Answer: Yes, immunizations may be given even if your child has a mild illness such as a mild fever, cold, diarrhea, or is taking antibiotics. The vaccine will still be effective since your immune system is always working and the vaccines do not overload it or prevent it from working against other illnesses.
Vaccines will not make other illnesses worse. Receiving immunizations on time is a way of cutting down on unnecessary doctor’s visits.
Question: But are there some instances when vaccines should not be given?
Answer: Yes, there are some medical reasons for not giving or for delaying vaccines. These instances are uncommon but should be followed. Generally a person should not receive a vaccine if they have significant allergy to one of its components. Components like neomycin or gelatin are added to some vaccines, and should be avoided in individuals sensitive to them.
Another example is the yellow fever vaccine, which is prepared with egg products and should not be taken by individuals allergic to eggs. If a person can eat one egg without vomiting or being sick then they may have this vaccine. The yellow fever vaccine is given only to international travelers going to South and Central America or Africa and is NOT routinely given to children.
Children with medical conditions, whose treatments or medications could reduce the effectiveness of the vaccines, may delay receiving vaccinations until they have finished their treatment. Examples include: receiving recent blood products (immunoglobulin or blood transfusion) and high dose corticosteroids both of which may impair the immune systems ability to respond to the vaccine. These children may not respond as well to some vaccines but they are also more susceptible to infections.
Very sick individuals (cancer patients, HIV positive people and those with other illnesses affecting immunity) should still receive vaccinations. Some people with impaired immune systems or immunosuppression treatments may not respond as well to vaccines, and may require additional booster doses. Families should speak with their family physician or specialist to determine how to proceed with vaccination or delay.
In most cases vaccines may be given if the child is breastfed, has an ear infection, is taking antibiotics, has mild diarrhea, or has a milk allergy. Check with a health case provider who administers vaccinations if you have specific questions.
There is no need to delay vaccinations for: minor cough, colds or diarrhea; high fever 40°C after a previous vaccine dose; prolonged tiredness after a previous vaccine dose; local skin reactions after vaccine; history of convulsions with or without fever; active allergy; allergy to eggs; being on current antibiotics; being born prematurely; those with family history of Sudden Infant death Syndrome (SIDS); infants breastfeeding (both mother or child can get vaccine); or a child’s mother is pregnant.
Vaccine Preventable Diseases
According to the World Health Organization (W.H.O), immunization programs save 3 million lives per year.
The following are diseases that we can prevent through vaccination.
Research is so that immunizations for other infectious diseases will be added to this list.
Diptheria, Tetanus, and Pertussis
Diptheria is easily spread through coughing or sneezing and can cause paralysis, breathing and heart problems, and death. Recent outbreaks have occurred in the former U.S.S.R, which had temporarily abandoned diphtheria vaccinations, which has made a large segment of their population vulnerable. Prior to vaccination in the 1920’s, there were 12,000 cases per year with 1,000 deaths per year in Canada. Diptheria still kills 1 in 10 of those infected.
Tetanus (lock jaw) occurs when a tetanus germ enters a cut or wound and can cause muscle spasms, breathing and heart problems, and death. The tetanus bacteria are found in soil and are everywhere. A booster is recommended every 10 years. Before vaccination, about 5000 cases per year occurred in the U.S. Even with modern treatment 10-20% of these infected will die.
Pertussis (whooping cough) is spread through coughing or sneezing and can cause long spells of coughing actually making it difficult to eat, drink or even breathe. Pertussis can cause lung problems, seizures, brain damage and death, especially in infants less than 1 year old. Before vaccination 5 out of 1000 children died of pertussis before age 5. Hygiene improvements as well as vaccination have decreased this statistic. Pertussis still kills 3 children per year in Canada.
Question: What is the difference between “whole – cell DTP and the new acellular DTaP?”
Answer: The new vaccines (available since 1997) are known as acellular or non-cellular. They contain only the antigens necessary to give immunity and not the “whole cell”. The older “whole cell” Pertussis vaccine contained the whole killed Pertussis bacteria, which lead to a higher rate of local reactions like redness, swelling, and pain at the injection site, and a fever also.
Health authorities now recommend that all Pertussis vaccines be acellular as this higher generation of vaccine has much less local effects.
Question: So what are the effects of the DTaP vaccine?
Answer: Most children receiving the DtaP will have no adverse reactions or experience only minor discomfort. The most common reactions are soreness, swelling, and redness at the injection site usually after the 4th and 5th DtaP. They last 1-2 days. Serious adverse reactions are rarely reported with the acellular Pertussis.
Question: How effective is DTaP and is it worth receiving?
Answer: A full series of 4 DTaP by 18 years of age is recommended to get full immunity. A full series protects 80 out of 100 children from getting severe Pertussis, 95 out of 100 from Diphtheria, and 100% are protected from tetanus. In the 20% of those vaccinated who do develop Pertussis they will have a milder form of the illness.
Small children and infants who catch Pertussis are often critically ill. Insufficient immunization in a community contributes to a higher rate of Pertussis there.
Most people vaccinated with DTaP are protected for many years. Adults are recommended to have TD (Tetanus-Diphtheria) shots every 10 years to boost themselves.
Because it is so contagious the possibility of a child getting severe Pertussis when exposed is far greater than the possibility of experiencing a severe adverse reaction from the vaccine.
Haemophilis Influenza Type B (Hib)
Hib bacteria can cause meningitis (inflammation of the brain) infections of the joints, skin and blood, brain damage and death. It is most serious in infants less than 1 year. Since vaccinations for this disease began, incidence of this disease has dramatically declined. Before 1985, about 1500 cases of meningitis from Hib occurred per year. Vaccination has dramatically decreased the incidence of severe Hib infection.
Hepatitis A-
Hepatitis A is a virus that causes infection of the liver. It can be passed from mother to child during birth, through blood or body fluids, and poor hygiene in food and water. Infected people can transmit it to others in the same household through casual contact. Symptoms include diarrhea, jaundice, hepatitis and death. Adults and elderly people are more severely affected. After exposure the average incubation time is 15-50 days (average 28 days). Illness does not usually last longer than 8 weeks although about 10-20% of those affected could have symptoms for 6 months.
Question: If Hepatitis A is most commonly transmitted by contact with the stool of infected people, why should we get vaccinated if we keep clean?
Answer: Cleanliness such as hand washing after using the washroom or changing diapers is essential for hygiene but still not 100% effective.
People who are infected with hepatitis A often transmit the virus for 1-2 weeks before they feel sick. Children will less often show signs of infections in Canada and U.S. mostly due to improvements in hygiene. New cases are acquired through people visiting other countries and bringing the infection home. Routine Hepatitis A vaccination of children is currently not strongly recommended. Parents planning trips to underdeveloped countries may consider Hepatitis A for themselves and their children. Cruise ship holidays would be included as well.
Hepatitis B- is a different viral infection of the liver. It is transmitted through blood and bodily fluids and intimate contact. It is more common, easier to catch and kills more people than AIDS annually. Infection may cause liver damage, liver cancer and death. It is the second most common cause of human cancer. The incubation period of Hepatitis B can be 45-60 days (average 120 days). Initially the preictal phase consists of malaise, anorexia, nausea, abdominal pain, fever, headache, arthritis, and dark urine. This usually lasts 3-10 days. Next the jaundice or ictal phase occurs and lasts 1-3 weeks. Jaundice, light or gray stools, liver tenderness or enlargement characterize it. Next convalescence occurs for weeks or months with persistent malaise and fatigue. Most people with Hepatitis B infections recover with immunity and clearance of the virus from the body but some do not. Fulminate hepatitis occurs in 1-2%. This liver failure can be severe with mortality ranging from 63-93%. Another 10% of cases go on to develop chronic hepatitis B infection. These people may not be symptomatic but they can infect others. They are also prone to fulminant hepatitis, liver failure cirrhosis, and especially liver cancer.
Question: Why are we vaccinating children against Hepatitis B since most of the people getting Hepatitis B are adults?
Answer: National recommendations for both Canada and the U.SA. recommend routine vaccinations of all children against Hepatitis B because it is impossible to predict who will be exposed to Hepatitis B in the future. Hepatitis B is acquired through blood routes (IV drugs, unprotected sex, non-sterile medical procedures, unscreened blood, and any body fluid-non intact skin or mucous membrane contact) all of which are unlikely for children but 30% of Hepatitis B cases are unknown in how they got the disease.
Most of these cases are believed to have occurred from being bitten or scratched, from sharing a utensil, or having some type of close contact with a playmate or family member. The earlier in life a child acquires Hepatitis B the more likely they are of becoming a chronic carrier. In the U.S. Hep B is given to infants while in Manitoba it is given at grade 4 (which is more for administrative purposes rather than a decreased increased risk between U.S. and Manitoba).
In the U.S Hep B infects 200,000 people per year, with many being adolescents or young adults. As yet there is no specific treatment for acute Hepatitis B. The virus may cause liver damage, liver cancer, and death.
In the U.S. 1.25 million people are infected. The Hepatitis B virus is more common than, easier to transmit, and kills more people than the HIV virus causing AIDS, yet is vaccine preventable.
People at high risk for Hepatitis B, are recommended to be vaccinated.
Recommending vaccination to high-risk individuals has not been effective in decreasing the incidence of Hepatitis B, since many people at risk for infection do not fit into the stereotype of a high-risk person (promiscuous or drug users), universal vaccination is now recommended or children.
Question: Does Hepatitis B vaccination cause Multiple Sclerosis (MS) or Sudden Infant Death Syndrome (SIDS) or Autism?
Answer: No. Multiple Sclerosis is an autoimmune disease where antibodies attack the bodies own myelin in the nerves causing many types of neurological problems that may stay stable or get worse throughout life. The cause of MS is still unknown but medical experts believe that certain patients are genetically at risk for the disease and that some environmental factors can trigger the disease.
There is no evidence that vaccination with Hepatitis B can cause MS or be one of the triggers. One French study analysed over 60 million people hepatitis B immunizations given between 1989-1997 and found that people vaccinated against Hepatitis B were less likely to have neurological disease than unvaccinated people.
A recent study in the New England Journal of Medicine also confirms this. The Multiple Sclerosis Society supports the wide and general use of this vaccine. There is some evidence that people vaccinated against Hepatitis B may be less likely to get MS.
Sudden Infant Death Syndrome (SIDS) is the name for increased mortality in apparently healthy infants. Investigators are continuing to find all of the possible causes for this syndrome including the observation that sleeping on the stomach may increase this.
In the U.S., infants receive Hepatitis B immunizations starting as early as the first day of life (since 1991). There has been a steady decrease in the number of newborn deaths as the number of Hepatitis B vaccines administered has increased.
The American Institute of Medicine has reported: “All controlled studies that have compared immunized versus non-immunized children have found no association or decreased risk of SIDS among vaccinated children.” To learn more about SIDS please check with your pediatrician or obstetrician or check the references at the back of this booklet.
Autism – There is no evidence to suggest that Autism is related to Hepatitis B vaccines. See the section on Measles, Mumps, and Rubella for more information on Autism.
Question: Isn’t the preservative in Hepatitis B (Thimersol) related to mercury and could my child get mercury poisoning from the Hepatitis B vaccine?
Answer: There is Thimersol in some Hepatitis B vaccines. Some manufacturers are now using other preservatives instead. It is still felt that the amounts of Thimersol in each dose of Hepatitis B vaccine are insignificant to cause problems.
The Hepatitis B vaccine has been scrutinized carefully before being approved in Canada, the U.S, and abroad and is felt to be safe for use.
Polio
One hundred years ago, Polio infection was one of the major crippling diseases. The last epidemic in Canada involved 2,000 cases of paralytic Polio (1959). Polio infection can cause fever and may lead to meningitis and lifelong paralysis. Persons infected with poliovirus shed the virus in the stool and spread it to others. With ongoing immunizations the World Health Organization’s (W.H.O.) goal date of eradication is 2005. Sometime thereafter if no new polio cases are reported worldwide, immunization will discontinue, possibly by 2007.
Question: Isn’t the Poliovirus supposed to be extinct?
Answer: No, not yet. The World Health Organization originally had set out to destroy it by 2000 but recent outbreaks of confirmed Polio cases in Africa and India, have confirmed it is still active. This failure was partly due to a failure to fully vaccinate children in developing countries.
Polio vaccination is still recommended for international travelers going to those countries. Polio vaccination must continue until confirmation of no known cases of the wild type has occurred. It is only spread among people so as soon as the last person is infected or immunized then it will be extinct.
It is still recommended to continue with routine childhood Polio vaccinations because if a susceptible person were to bring a Polio infection back to North America it could precipitate an outbreak among those who are not immune to polio. Efforts are being made overseas to vaccinate countries that have not had up to date Polio vaccinations with the new goal date of eradication being 2005. It is likely that vaccination will continue for some time after that and then stopped, as was the case with Small Pox eradication.
The Polio vaccine used in North America is the IPV or Inactivated Polio Virus, which has no significant side effects. The OPV or Oral Polio Vaccine is no longer used since this was known to have side effects including vaccine induced Polio (1 in 2.5 million chance) It was still recommended at that time despite its very rare side effects, it still saved lives and helped make polio disappear from North America). There is no good reason to use the OPV in Canada now, with the safer profile of the IPV.
Influenza
Influenza- (which is a different disease from the similarly named Haemophilis Influenza type B mentioned above) is a highly contagious viral disease with epidemics regularly occurring. Infection causes sudden onset of fever, chills, muscle aches, cough, headache, and may lead to pneumonia. Sneezing, coughing, or direct contact spreads it with the infected person. Children and adults with long-term illnesses such as asthma and diabetes are more prone to serious flu complications such as pneumonia, dehydration, meningitis, and even death. Influenza infection is a major cause of death in the elderly.
The virus has 3 subtypes A, B, and C. Type A causes moderate to severe disease, affects only humans and affects all age groups. Type B causes mild disease and affects only humans, mostly children. Type C affects animals and rarely humans and is not associated with epidemics. The influenza virus also mutates frequently. Antigenic shifts and drifts are major and minor changes in the antigens (or parts of the virus recognized by the body’s immune system).
These changes allow the virus to persist in the population and give rise to epidemics of the flu. Epidemics occur when the incidence of influenza cases increase and mortality rises. Pandemics occur with high incidence in all age groups and increased mortality. An influenza pandemic could affect up to 200 million people with an estimated 400,000 deaths. Sporadic outbreaks occur when clusters of cases occur in families, schools or small communities.
The virus is acquired from respiratory droplets. It replicates in the trachea and bronchi causing local destruction and is shed for 5-10 days. Maximal communicatability occurs 1-2 days before onset and 4-5 days after. Symptoms appear after an incubation of 1-2 days. Abrupt onset of fever, muscle aches, non-productive coughs, and headaches occur. Severity is less if the person has encountered a similar antigened virus before. Only 50% of people have the above classical symptoms of influenza. Symptoms last 2-3 days and rarely more than 5. Aspirin should not be taken by children with flu, because of the association with Reye’s syndrome, an often-fatal affliction.
Complications that occur with the flu include pneumonia (either a bacterial super infection on top of the influenza or an influenza pneumonia which is rarer). Reye’s syndrome is a rare complication in children with the development of coma and some types of brain swelling. Other complications include myocarditis (heart inflammation), and worsening of chronic bronchitis. Death occurs in 0.5-1 cases per 1000 cases, usually in those ages greater than 65 years.
Diagnosing influenza can be difficult and is largely based on clinical appearance along with the influenza prevalence in the community. Influenza peaks between December and March in temperate climates but can vary. It is year long in the tropics and outbreaks are common aboard cruise ships.
Vaccination against influenza- is done with an inactivated virus of circulating strains of type A and B influenza. Egg protein is present. The vaccine is effective in protecting 70% of healthy adults but only 30-40% of the elderly. It is not highly effective in preventing illness but is effective in preventing complications and death particularly in the elderly. The vaccine is most effective if given 2-4 months prior to flu exposure and is usually available in September. The vaccine may be given annually. Children from 6 months to 9 years receiving it for the first time should receive 2 doses 1 month apart. (Ideally the second dose should be before the end of November).
Flu shots are recommended for all people over 50 (those over 65 are covered by Manitoba Health), children >6 months with chronic disease, long term care residents, health care workers, students, travelers, pregnant women, and persons 6 months to 18 years taking chronic aspirin therapy (so that they do not develop Reye’s Syndrome). Any person who wishes to decrease the likelihood of becoming ill from influenza should receive the flu shot although Manitoba Health does not cover all the above groups. With a possible pandemic this recommendation may change.
Manitoban Groups Eligible for Free Influenza and Pneumococcal Vaccine (As of September 2005)
|Groups eligible for free vaccine |Pneumococcal |Influenza Vaccine|
|under the Manitoba Health program |Vaccine | |
|People aged 65 years and older |X |X |
|Residents of long-term care or Chronic care facilities |X |X |
|Adults and children (> 2 years old) with chronic health conditions, such as |X |X |
|lung disease, heart and kidney disease, diabetes, aspleenia, splenic |(excluding |(including asthma) |
|dysfunction, immunosuppression ( due to disease or therapy) |asthma) | |
|Children and adolescents being treated for long periods with acetylsalicylic | |X |
|acid | | |
|Health care workers and other personnel who have significant contact with | |X |
|high-risk individuals | | |
|People at high risk of complications traveling to destinations where influenza | |X |
|is likely to be circulating | | |
|Household contacts (including children) of: | |X |
|Persons who are immunocompromised or 65 years or older | | |
|Children aged 2-23 months and household contacts of children under 23 months | |X |
Adverse effects of the Flu Vaccine
Local reactions occur at the site of vaccination with soreness and redness lasting 1-2 days in 15-20% of people. Non-specific fever and aches last 1-2 days in ................
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