PlanetRx - Community - Mary Ellen Guroy, M.D.

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		Mary Ellen Guroy, M.D. Be a Healthy Traveler! Mary Ellen Guroy, M.D., is a diplomat of the American Board of Internal Medicine in Infectious Diseases and certified in travel
and tropical medicine. She is in private practice in Sausalito, Calif., in infectious diseases, serves as a consultant to the Marin County Department of Health and Human Services, and is an associate of the Northern California Travel Clinic.
Dr. Guroy was a live event chat guest on PlanetRx.com on November 16, 1999. This is an edited transcript of the chat.

PRx Host :	We're fortunate tonight to have Mary Ellen Guroy, M.D., to chat about the health issues we face when we travel overseas. Dr. Guroy is a tropical disease specialist and travel medicine consultant. She has a private practice in Sausalito, California. Welcome, Dr. Guroy!
Dr. Guroy :	Great to be here.
PRx Host :	To begin, staying healthy while you travel is becoming more complicated. What's going on?
Dr. Guroy :	Well, it's a couple of things. One, it's the global economy. A good number of the patients I see belong to families that are being relocated overseas for business. People are going to more exotic areas, such as Southeast Asia, for longer periods of time. It's not just a two-week vacation, it's a six-month stay to start up a software company, projects like that. And they're taking their families. We've got children, mothers, women who might become pregnant, who are being exposed to exotic diseases and Third World conditions. The second issue is global warming. I was talking earlier this evening about dengue in South and Central America. With global warming, we see mosquitoes 1,000 to 2,000 feet higher than we have before. Villagers who never saw dengue are now having outbreaks, and trekkers to those regions are experiencing episodes of dengue. So being aware of the changes in climate and what vector-borne diseases might encroach on those areas is important.
PRx Host :	What about vaccines? I'm thinking especially of yellow fever vaccines -- some health centers vacillate about their importance. What is your opinion? Are any vaccines optional?
Dr. Guroy :	Thanks for bringing that up. I think it's a good opportunity to remind people not to take vaccines for granted. Traditionally, a trekker or adventure traveler will take a list of vaccines written by his doctor to a vaccine clinic, who will simply consult the CDC guidelines without any further consultation. I was involved in a situation recently where an adventure traveler did just this, but opted against yellow fever vaccine prior to his trip to Venezuela. I don't really know why. It's possible that he thought it was too expensive, so he chose only the typhoid and hepatitis vaccines. It's also possible that when he looked at the guidelines from the CDC, it noted that Venezuela doesn't require this vaccine, so he didn't really think it was important. Unfortunately, he came back from Venezuela with yellow fever and died seven days later in our hospital in Marin [California]. When we looked back at the group of 10 who traveled with him, only four or five had gotten yellow fever vaccine, and they hadn't really been counseled about its importance. It's very difficult just from written recommendations to appreciate how important vaccines are. This is why you need to sit down with your doctor or healthcare practitioner and talk about your itinerary. The length of your trip is going to directly relate to the risks you'll experience. The longer you stay overseas, the more likely the chance that you'll travel to exotic areas and rural areas, even if you're working in Singapore most of the time. You need to anticipate, along with your doctor, what else you should think about.
PRx Host :	What about children? What precautions are important for them?
Dr. Guroy :	Let's stick with Singapore. Let's say a young family is relocating there for a year. There's a 1-year-old child who hasn't finished her measles vaccine series. Usually in the United States, we finish at 15 months. A situation like that calls for accelerated vaccine protection because you're moving to an area where there's more disease activity. This is just one example. It's very important if you're going to be taking children overseas to talk to your pediatrician and get vaccines accelerated and updated. There's something else that's real important, and that's the rabies vaccine. We take for granted in this country that we're never going to be exposed to rabies. Young children who travel outside of the U.S. are very friendly to animals, and they reach out and pet animals. Every dog, every cat, every animal that a child meets overseas should be considered rabid. You have to take that one step further and decide if you want to talk to your pediatrician about the children getting rabies vaccines.
PRx Host :	Are rabies vaccines at all dangerous? We never hear about them here.
Dr. Guroy :	No, not at all. We have a very effective human diploid rabies vaccine. When given properly, it's 100% effective. On the topic of children, I should also mention that any extended trip overseas -- for example, several months -- should be followed by a checkup by the pediatrician after you return. This is because children get into things. They get into the soil and the sand. They're more likely to pick up hookworm and other parasites. They're also much more susceptible to tuberculosis, which is ubiquitous in the Third World. Something as simple as a tuberculin test after you return can protect them from further illness.
PRx Host :	We're getting a lot of audience questions, so let me pose a couple of them here.
ellipso :	Question about travel fatigue: For trans-Atlantic/Pacific trips, is melatonin really free of side effects? Any other suggestions?
Dr. Guroy :	Just some general comments about jet lag. The general rule for jet lag and avoiding it, is that you try to get on the time schedule of your host country as soon as possible. One of the best things you can do to avoid jet lag is to stay well hydrated while you're flying, and avoid alcohol while you're flying. If you arrive at nighttime, it's often helpful to have some type of sleeping aid that's going to allow you to go to sleep right away, even though it was daytime when you left home. I tend to use mild sleeping pills such as Restoril, or even low-dose Halcion, for the first two or three nights. Melatonin is used by some people as an alternate sleeping aid. It's perfectly safe, but it's not FDA-approved as a prescription drug [would be]. You can buy it in any drugstore or health food store, however. Essentially, melatonin mimics a hormone secreted by the hypothalamus which induces sleepiness, and if you take three milligrams a day for two or three days when you want to sleep, this might help. Frankly, I haven't had much good feedback regarding its effectiveness, so I stick to sleeping pills. In the health care industry, I know some pharmacists and nurses who have to change shifts at their hospitals or places of employment. They use melatonin to try to adjust their schedules, and report that it's fairly effective.
nrhine :	My daughter had dengue fever in India -- she eventually recovered here at home in the U.S. Could she have any kind of permanent health damage from going through that?
Dr. Guroy :	Dengue is a very serious illness. It's known to the layperson as breakbone fever, because it makes you feel terrible. Fortunately, most people survive dengue. It has about a 5% mortality rate in healthy adults. It's serious for children, and for elderly, more frail adults, or for Third World people whose immune systems might be compromised. The problem your daughter faces is the possibility of a second episode if she travels overseas again. It's been observed that the second episode of dengue provokes an immune response known as dengue hemorrhagic fever. This is much more serious, carries a higher fatality rate, and should be avoided at all costs.
Jambalaya :	I was tested TB positive in college. I had lived in countries such as Turkey and other less developed countries, where I must have been exposed to it. Is there a vaccine for TB that I should have gotten or should recommend other people to take? I took a year of medication so I would not contract TB.
Dr. Guroy :	The current available TB vaccine is known as BCG. It's not really used much in this country, because it's only about 50% effective, and once you've had it, it renders useless the PPD test. We use the PPD skin test to detect exposure to tuberculosis, and if you've had the vaccine, it will be positive possibly for life. I think this is something that needs to be discussed with your physician if you're going to be traveling overseas for a prolonged period of time, especially to high-risk areas. I think the best approach would be PPD testing upon return, and if you're found to be reactive, you should take the medication that's prescribed for this. But there are so many ways to approach this. I can't stress enough how important it is to talk with and discuss these kinds of issues with your health care provider.
PRx Host :	This is such helpful information. Now to another area: water purification tablets. Is any one system better than another?
Dr. Guroy :	Yes, there are some that are better than others. The simplest way to avoid water-borne diseases in the Third World is to drink only bottled water. You can never really be sure sometimes if a bottle wasn't opened and filled with tap water, so you have to use your judgment. The most popular and easy system for trekkers is iodine. Iodine is good for water-borne bacteria like salmonella, shigella, and E. coli, but it doesn't kill parasites. There are filtration systems. One company that makes an excellent one is Pur. These have very fine ultra-micron filters that filter out the larger parasites. Some filtration systems even have iodine resin, which at the same time kills the bacteria. I should say something about iodine. Pregnant women should not use iodine as their water purification system because it can affect the thyroid of the fetus. Somebody with thyroid disease certainly needs to discuss this with their doctor before leaving. Finally, boiling water for a good 30 minutes will usually take care of parasites. Bacteria are killed much earlier. This is why you'll see, when you're trekking, that you'll always have scalding hot food prepared by your guides, and there'll always be a big pot of boiling water at the campsites, so that you can make tea or coffee. You should also understand that ice made from infected water is not safe, so your gin and tonic will have to be at room temperature. Beer and bottled water, again, are safe.
PRx Host :	What about precautions against AIDS in countries where it is especially prolific, as in Africa? Are there any caveats beyond what we know in this country?
Dr. Guroy :	This is a big topic, but an important one. There have been accidents in automobiles where industrial-world travelers have been infected because someone else injured in the same vehicle was HIV-infected. I don't know how you avoid something that catastrophic, but there are other measures that you can take. Earlier this evening, I was speaking to a friend's son who was talking about yellow fever vaccine, and he wanted to avoid getting that overseas. I told him that was a good idea, because any injection that you get overseas, be it a vaccine, an antibiotic, is going to be given by a needle. You cannot verify how that needle's been handled. It's very common in the Third World to reuse needles because supplies are very short. I should also say something about sex and travel. Many of us in business don't think about sex when we travel, but many travelers do engage in sex, even anonymously, with [prostitutes] overseas. This is particularly prevalent in North Africa, Thailand, throughout Asia, and India. If you know that you're going to be having sexual relations overseas, carry your own condoms and practice safe sex. Condom breakage rates are 10 times greater if you buy them over the counter in a Third World country. Believe it or not, this has actually been studied. This is because the latex is of lower quality, the product is probably sitting on a shelf in sunlight all day, and there's probably not much turnaround in those countries to the local consumers. I can't stress strongly enough how important it is to use your own condoms to assure the quality of the condom. Since we're talking about HIV, it's really important that anyone who's infected with HIV who is going to travel overseas consult their physician first. There are certain vaccines that are necessary, and certain ones that are actually dangerous because they're made from live viruses. Recommendations for anyone with a compromised immune system or a health problem like peptic ulcer disease, steroid-dependent diseases such as asthma or auto-immune diseases need to be sorted out with your physician. These people have to take complicated medical regimens that might affect the medications they need to protect themselves overseas. This needs, again, to be reviewed with their physicians.
PRx Host :	Thank you for such thorough and thoughtful information. What about malaria? How great a problem is it, and what is the best way to be safe from it?
Dr. Guroy :	The single best thing that you can do to protect yourself from malaria is to be aware of it, and know what the prevalence is in your host country. Of course, this is a tropical disease, so sub-Saharan Africa straight through equatorial South America and Southeast Asia are all heavily infected with malaria. Malaria is probably 10 times more prevalent in Africa than Asia, and a more serious problem. Now that you know it's a problem, what do you do? Number one, practice strict mosquito precautions. These are mosquitoes that bite at nighttime into the early morning, so that if you're camping, you wear netting; if you go out in the evening, you wear long pants and socks with your sandals. Number two, specifically for the prevention of malaria, there are medications. These need to be chosen with the help of your physician. I say this because malaria is very different in different parts of the world. In Thailand, malaria is resistant to many, even most, of the available preventative medications that we have here in the U.S. When you travel to that country, your doctor may tell you not to take preventative medication, but to carry backup medication for treatment, and then consult a local physician if you become ill. I want to make two important points here. The first is that you'll notice that I stressed mosquito precautions before medication. The reason I did this is that there are other diseases carried by mosquitoes for which we have no vaccines, nor do we have medication to prevent them. We already talked about yellow fever, for which there is an excellent vaccine. However, in the same areas that you find yellow fever, you'll find dengue, and dengue-carrying mosquitoes bite all day long, night and day. If you don't protect yourself, I can't protect you. Your doctor can't protect you. There's also Japanese encephalitis virus, for which there is an excellent vaccine, and for people who are traveling to high-risk areas for prolonged periods -- especially people with families -- they should consider this vaccine even for children as young as 1 year old. That's the first point. The second point about traveling to malarious areas and other areas where there are exotic illnesses is that you should always carry with you the name of a reputable physician or healthcare facility in the destination country. At the end of the chat, you'll see listed some websites. I strongly recommend that you consult the International Association for Medical Assistance to Travelers (IAMAT). This is a worldwide directory that's updated continually which you can consult. So again, if you find yourself in Thailand taking no medication to prevent malaria and you get sick, you can take the backup medication your physician gave you, but you'll also have a name readily available.
PRx Host :	We have a number of audience questions -- let's turn to a few of those now.
MamaT :	Can simple mosquito repellant keep away mosquitos? Does it matter if you only get one bite, or do you have to be severely bitten?
Dr. Guroy :	That's a great question, and it's an important one. It takes only one bite to get malaria, and there are a lot of great and effective mosquito repellants available. If you go to any REI or Any Mountain (these are travel gear shops), they can show you what's out there. There's been a lot of press about Skin So Soft, which is a lotion that repels mosquitoes for about 15 minutes. This gained a lot of popularity for use in children because it was felt to be nontoxic. I don't think any parent wants to be put in the position of applying Skin So Soft every 15 minutes to their child. In general, what you're looking for is any product that provides 25%-30% DEET [diethyltoluamide] to the skin to repel mosquitoes. For pregnant women and children, there's a polymerized form of DEET called Ultrathon by 3M Corporation, which stays on the skin for 12 hours, isn't absorbed, and is an ideal mosquito repellant. This was used by the troops in Desert Storm, but I think the patent might have been sold by 3M to someone else after the war. But look for it, because I think some people have similar products in stock.
ellipso :	I'm not sure if my question went through: Does gin and tonic really protect against malaria? Does other alcohol do anything?
Dr. Guroy :	There probably isn't enough quinine in tonic to give you the blood levels you need to protect you from malaria, but this did gain favor in the early part of this century for European settlers who were settling sub-Saharan Africa. One of the other strategies they used was to buy and locate their farms above 4,000 to 5,000 feet, essentially above the mosquito line. If you remember Out of Africa, Isak Dinesen's farm was probably about 4,800 feet. But remember what I said about climate changing. That might not be a good strategy anymore because the mosquitoes are traveling and thriving at higher altitudes. And to finish the answer to your question, no, alcohol doesn't protect against mosquitoes, it just lets your defenses down.
PRx Host :	Very interesting! Now another audience question
nrhine :	I'd like to ask about Micronesia, a remote island I'm visiting there this winter -- what shots do I need before going there?
Dr. Guroy :	That's such a specific question. I guarantee you'll need something, but it's always a good idea to look up the most current reference from the CDC. In general, all travelers to the Third World should get typhoid vaccines, hepatitis A vaccine, an updated polio vaccine, and an updated tetanus (within 5-10 years). Then we look for recommendations more specific to your travel plans. In Micronesia, there's likely to be malaria, and dengue. This will depend how rural your exploits will be. You'll always need to follow strict water precautions as well. This goes for everywhere outside of the United States and Western Europe.
PRx Host :	What about emergency treatment when one is overseas? What is your advice in order to get the safest and best care in the healthcare system of another country?
Dr. Guroy :	Again, I would refer to IAMAT's website. Carry a few of their local physicians' names with you on your trip. Certainly, if you're traveling with children who are going to be getting continuing vaccines overseas, ask your physician to provide the vials and sterile disposable syringes and needles to take with you, as well as a prescription to cover those for Customs. That way, if you're in a situation that's remote, you could even give the vaccine, knowing that you've got a clean needle. This also goes for diabetics who require syringes daily and for people with life-threatening allergies to bees or to foods who might require an emergency epinephrine shot, often given as EpiPen. Buy your own, carry this with you. This is why it's a good idea to sit down with your physician to be reminded about your medical history. For example, if you have a history of asthma, there could be a situation where you might need emergency medicines that you don't need all the time but have needed in the past. It's best to bring these with you. And let me just say one more thing about the chronically ill. I mentioned before that medications that you take daily might interfere with the medicines you need to prevent illness overseas. There are a few examples. If you're hypertensive and take calcium channel blockers, that drug might actually prevent mefloquine or other quinine-like drugs from preventing malaria. Also, if you have peptic ulcer disease, you're probably taking medications that neutralize stomach acid. This makes you much more susceptible to cholera. As a rule, we don't recommend cholera vaccine because it's only 50% effective, and we stress water precautions to prevent cholera in the Third World. But if you're taking H2 blockers or chronic antacids, you might want to rethink this with your physician.
PRx Host :	If you run out of medication and must get some from a local pharmacy, can you trust it? Is there any way to tell if it is safe?
Dr. Guroy :	That's a little more difficult. but I suspect that if you consult a physician from the IAMAT directory, they'll help you find a reputable pharmacy. Anyone who takes chronic prescription medication should plan this in advance. Let me mention one more thing. I just read in a newsletter today from the Travel Medical Society something about birth control. We take for granted the availability of prescription medications in this country, and that emergency rooms are available 24 hours a day. There have been some reports of women who have been traveling for pleasure, even on short vacations, who have relied on the morning-after pill prescribed by their physician or the local ER to prevent pregnancy, but could not find this overseas. I hope you get the implication! Plan ahead.
ellipso :	I just took my 1-year-old to Italy -- should I have given him vaccines of any kind? Did I risk his health?
Dr. Guroy :	I suspect your child had most of his routine vaccines prior to departure. Italy isn't the Third World. The only thing I might recommend is a general medical check by the pediatrician upon return in situations like this. There are parasites in some of the southern beaches. I spoke about hookworm earlier. There is giardia in Italy, just like we have in the rural United States. So those things might be considered on a well-baby check by the pediatrician. But no, you did not risk your child's health. I'm curious, how long did you stay? If you were only there for a week or 10 days, I wouldn't worry about it.
AlexFoz :	Are there parasites in U.S. and First World waters, too, and we are just used to them?
Dr. Guroy :	That's an interesting question. We have very sophisticated water purification systems which consist of chlorination, sand filtration, and even sewer ponds. The chlorination takes care of coliform bacteria and good sand filtration takes care of parasites. But we do have a situation in this country in that cryptosporidium is not killed by chlorine, and is actually quite ubiquitous in our water. In Minnesota, three years back, there was an outbreak of cryptosporidiosis downstream from some turkey farms. There were 50,000 cases in healthy citizens. Then, of course, there's always giardia. We see giardia in rural corners of the country. A lot may be imported and then passed on under conditions of poor hygiene, or you may also see it in the mountains, as there are intermediate mammal hosts like the bear. So we'll always see some giardia here.
PRx Host :	What about diarrhea, the scourge of many travelers! Is there anything you recommend?
Dr. Guroy :	This is the number one cause of illness in overseas travelers. Up to 50% of travelers from the U.S. report some type of diarrheal illness. In long-term studies of children who've relocated overseas, up to 35% have problems with diarrhea. The single best thing you can do is to follow the water precautions we spoke about earlier. Some people take bismuth (Pepto Bismol) as a preventative strategy. This actually works quite well, but you have to chew two tablets four times a day for the entire time you're overseas. This may not be practical. I don't recommend preventative antibiotics, but it's a good idea to carry a single dose of Cipro, for example, or a similar antibiotic to take in the event that you develop true dysentery. The distinction I try to get across to my clients is that most diarrhea is coliform intolerance, or viral, and can be treated just with Imodium, which you can buy at the pharmacy, preferably here, before you leave. But if you have diarrhea that is not relieved with two doses of Imodium or you get high fever or blood in your stool, you should take the backup antibiotic, because then you may be talking about shigella, salmonella, or campylobacter.
PRx Host :	We are drawing to the end of our chat. You've given us so much to think about as well as healthy procedures to follow. Is there anything you want to add before we close?
Dr. Guroy :	I'd like to say a few things about safety. The biggest killer overseas in the pleasure traveler is the automobile. The biggest killer of Peace Corps volunteers overseas was the motorcycle without a helmet. Just simple investigation into a rental car for seat belts, availability of child seats, quality of tires and brakes, could save a life. This should be kept in mind. Also, on the subject of safety, think about civil unrest and issues like bioterrorism or even kidnapping. There are websites that will be posted at the end of this chat that can be consulted for up-to-date disturbances in your host country. A few examples come to mind. Kidnappings of wealthy American tourists for ransom are on the rise in Ecuador. Theft and con artist activities too elaborate to explain here are on the rise in Colombia. Brazil is a hot spot for child kidnapping. Hopefully, these things are rare, but you really need to think about them, especially if you're traveling with your family or young children.
PRx Host :	Thank you, Dr. Guroy! I know that many people will travel in better health because of this information. Again, thank you so much, and we hope you'll come back again.
Dr. Guroy :	I'd love to! This is a great service PlanetRx is providing for the community. I hope to look for more chats on your Starlight stage.
PRx Host :	We'll see you here again soon, and good-night!

Travelers' Health Websites

International Association for Medical Assistance to Travellers (IAMAT)
(subscription required)
CDC Travel Information
U.S. State Department-Bureau of Consular Affairs

More About Dr. Mary Ellen Guroy

Mary Ellen Guroy, M.D., is a diplomat of the American Board of Internal Medicine in Infectious Diseases and certified in travel and tropical medicine. She is in private practice in Sausalito, Calif., in infectious diseases, a consultant to the Marin County Department of Health and Human Services, and an associate of the Northern California Travel Clinic.

Dr. Guroy received her medical degree at Ohio State University College of Medicine and completed medical residency training at UCLA. In addition to her work as a consultant and with the Travel Clinic, Dr. Guroy is an assistant clinical professor in the department of medicine at the University of California-San Francisco. She is also a clinical instructor at the Sexually Transmitted Diseases Prevention Training Center in the San Francisco Department of Public Health.

Dr. Guroy has a special interest in counseling travelers with pre-existing health risks, such as AIDS, other immune deficiencies, physical disabilities and pregnancy. She also counsels individuals who must relocate overseas for work, including families with children.

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