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

First some worldwide statistics from the report:

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

How did we arrive at this dangerous place?

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

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

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

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

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

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

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

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

Photo by Ammar Abd Rabbo.

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

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

Winners will be announced in October.

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

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

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

Last month we addressed dengue fever’s reappearance in the United States.  Since last summer 28 cases have been reported.  Though this disease is a little known entity in the United States, it is the most common vector-borne viral disease in the world, causing an estimated 50–100 million infections and 25,000 deaths each year.  Dengue is now the leading cause of acute febrile illness in U.S. travelers returning from the Caribbean, South America, and Asia.  However, those who have not travelled abroad or do not reside close to the Mexican border have historically not been at risk.

Dengue fever often exhibits only mild symptoms, so there is an excellent chance that hundreds of other infections have gone undetected.  The virus is transmitted primarily by the Ae. Aegypti mosquito, and results in fever, chills, headache, muscle aches, nausea with vomiting, eye pain, and occasionally a spotty red rash on the trunk or legs.  The disease may be suspected when there is a drop in the body’s platelet count- the small cells responsible for blood clotting, but can only be confirmed with the detection of antibodies in the blood. There is no treatment for dengue fever, and symptoms will usually resolve spontaneously within days.  However, in a small percentage of cases, the disease may progress to cause internal bleeding with organ failure and death. 

A vaccine for dengue fever is in development, and may ultimately join vaccines for hepatitis and yellow fever as recommended inoculations for U.S. citizens travelling to tropical areas.  In the meantime, visitors returning from areas where dengue is endemic should be suspicious of possible dengue infection if experiencing flu like symptoms, and seek medical attention if a spotty red rash develops.

Photo by Koala:Bear

Last summer we analyzed the World Health Organizations (WHO) comprehensive study of road hazards across the world.   The report showed that the differences in fatalities in the analyzed countries were a result of road safety laws and the resources necessary to support them.  Some countries don’t have the road and traffic patterns necessary to manage the large volume of travelers.  The New York Times shows that the road death statistics in India are increasing dramatically while other countries, such as China, are seeing their numbers decline.

Improvements can be made in the form of more strictly enforced safety laws, better roadways, and paths for pedestrians and bikers that will keep them from having to share the already congested roads with careless drivers in unsafe vehicles. 

Before you hit the road this summer, find out what to expect on the roads in your host country.

Photo by alex graves

The two main labor unions in Greece, representing three million workers, are striking in major cities and ports today. The strikes are in response to the opening day of the financial reforms debates in the Parliament.  These debates are expected to last at least a week, so it’s possible the turmoil outside will continue at least that long.

Unfortunately, this coincides with the beginning of the busiest travel months – July and August – and will negatively impact Greek tourism which generates 15 – 20% of the national income.

Tourists and visitors to Greece are being disrupted and displaced by the protest rallies in Athens and the demonstration at the country’s main port, Piraeus, where unionists are stopping passengers from boarding the ferries and blocking the departure of some ships.  In an effort to minimize the chaos, police are ordering people away from the port.

In addition to water transportation being made difficult, the strikes have resulted in disruptions to the airports, roads and railways.  International train service was suspended as were domestic flights. Most international flights are ok. The local trains and bus schedules have been suspended for most of the day with restricted services available to allow demonstrators to attend the rallies.

Public services have been shut down which means that the hospitals are running on emergency staffing.

Additionally, journalists are on strike so all today’s newscasts were cancelled and newspapers are not being printed. Ironically, those in Greece may have to get the local news from an international source. Where would you turn for information if you were in the midst of chaos on your vacation? We hope mPassport.com, but you let us know!

Photo by: apas

While most were unaware of it, June 14^th was “World Blood Donor Day”, celebrated internationally to encourage those eligible to donate blood at least once a year.  Indeed, although 95% of Americans either receive blood during their lifetime, or know someone who has, only about 8% of Americans currently donate blood.  The requirements are fairly simple: be 16 or older, weigh at least 110 pounds, and enjoy good health.  Apart from doing the right thing, donating blood includes free screening for infectious diseases such as HIV and hepatitis.

The need for “good” blood around the world is critical.  The World Health Organization (WHO) makes a strong statement on blood transfusion safety and places the responsibility for enforcing it on the health administrators around the globe to “galvanize entire communities towards regular and non-remunerated blood donations.”  Just yesterday, one of our clients in China inquired about the reliability of blood in that country.  In fact, some of the blood collected in China may still be contaminated with the HIV virus.  Over the past twenty years, hundreds of cases with dozens of deaths have been traced to blood collected from those in China willing to sell their blood.  Following a government ban on imported blood products in the mid 1980s, literally thousands of blood and plasma collection stations popped up in China offering remuneration for donors. 

These unregulated centers used an unusual method of collecting blood and then reinfusing donors with pooled red blood cells after the plasma had been removed.  The technique was practiced in order to speed recovery following donation but is thought to have infected hundreds of thousands of donors and those who received blood transfusions.  Although Chinese authorities have endeavored to ban this practice and close illegal blood donation stations, the problem has not gone away.  A report published in 2007 claimed that China’s blood supply is still not being properly monitored for HIV.  The demand for blood products is growing, and the supply is short which “creates an economic incentive for hospitals to rely on illegal, untested blood donations.”

China is not alone.  The World Health Organization estimates that 5 – 10% of all HIV infections in Africa occur as a result of unsafe blood transfusions.  In addition, countless thousands are infected with hepatitis and/or malaria due to the lack of proper screening.  The organization “Safe Blood for Africa” is attempting to correct the problem by encouraging voluntary blood donations from adequately screened applicants and discouraging facilities from using untested blood.

The United States, Canada, Japan, France and a host of other developed countries experienced similar problems with contaminated blood from for-profit centers in the late 1970s and early 1980s before adequate screening for HIV and hepatitis was available.  We can only hope that emerging countries learn quickly from the experience of others.  In the meantime, the international traveler must be aware that significant risks still exist from getting blood products in many parts of the world.

Key West, FL has reported 28 cases of dengue fever since July 2009 – prior to July 2009 dengue was absent from the continental U.S. since 1945 and from Florida since 1934. Why dengue has returned to Florida is still being investigated but some contributing factors might be an increase in mosquitoes capable of delivering the disease, an increase in international travel to areas where dengue fever is more common (Key West is, after all, a Caribbean destination — see below), and the popularity of south Florida as a vacation destination.

Travelers headed to Africa, the South Pacific, Central and South America, the Caribbean and Middle East are reminded to take precautions to guard against the mosquito while traveling.  According to the Centers for Disease Control (CDC), a high number of cases of dengue fever, are being reported from the following areas:
Africa
Cape Verde, Senegal, and the Indian Ocean islands of Mayotte and Reunion

South Pacific
Malaysia, Philippines, Singapore, Sri Lanka, Vietnam and the northern parts of Queensland, Australia

Central and South America and the Caribbean
Argentina, Brazil, Colombia, Costa Rica, Dominican Republic, El Salvador, French Guiana, Guadeloupe, Honduras, Peru and Puerto Rico

Middle East
Jeddah (Saudi Arabia)

Meanwhile,the polio outbreak in Tajikistan seems to be spreading to the borders it shares with Uzbekistan.   An additional 261 cases have been reported since our post in early May.  The CDC is reminding travelers headed to these areas to talk to their doctors regarding the necessary vaccinations for children and those previously vaccinated. 

When traveling into any area affected by an outbreak, be smart, protect yourself however you can, and practice good hygiene.

Good news for travelers throughout Asia.  There is a new vaccine against Japanese encephalitis that significantly reduces typical side effects.

We all know that mosquitoes transmit some very serious viruses to humans. In addition to malaria and dengue fever, another mosquito-driven disease is Japanese encephalitis virus (JEV).  As reported by the World Health Organization (WHO) JEV is endemic in parts of China, India, the Republic of Korea, Japan, the Russian Federation, islands in the Torres Strait of Australia, Nepal, Thailand, Viet Nam, Cambodia, the Lao People’s Democratic Republic, the Philippines, Taiwan, Indonesia, Malaysia, and Sri Lanka. Its breakouts are generally most prevalent during the summer and fall.

There is no treatment available for this disease which can lead to permanent damage to the nervous system or death. Though many vacationers or expats will not find themselves in high-risk areas during peak times, it is recommended by the Centers for Disease Control (CDC) that anyone travelling to an endemic area during a possible transmission season or those who are headed toward a potentially dangerous area should be vaccinated for JEV.

Historically, the vaccine was toxic to some people — especially those with a history of allergy to wasp/bee stings.  Many doctors were hesitant to give the traditional vaccine and if they did, they would advise recipients to stay in a country with decent medical facilities in case they were one of the rare cases to develop an allergic reaction within 10 days of receiving the vaccine.  Fortunately for those over 18 years of age, there is now a new vaccine that does not cause those side-effects and can be given as safely as any of our other vaccines.

In summary: If you are over 18 years old and travelling to one of the high risk areas mentioned above, ask your doctor for the new non-allergic Japanese encephalitis vaccine.

Author: Charlie Easmon, MBBS
Charlie Easmon, MBBS is a General Practitioner whose practice has a strong focus on Travel Medicine.  He is a Regional Physician Advisor for HTH Worldwide and the Medical Director for The Number One Health Group on Harley Street in London and ALC Global Health Insurance.  He is a member of the Royal College of Physicians, UK and has a Diploma in Tropical Medicine and Hygiene from the University of Liverpool.   Dr. Easmon is an Honorary Lecturer at the London School of Hygiene and Tropical Medicine. 

The problems caused in Tajikistan by the polio virus have been aggravated by a natural disaster. There have been unusual levels of rain this spring. However, nobody could have predicted that rainfall on the night of May 6^th would have brought so much grief to Khatlon Province in the south of the country and to Kulyab, the provincial centre.

The number of deaths from the flooding has already reached 24, with more than 50 people missing and more than 200 injured. In addition to this, more than 500 homes were partially or completely destroyed, more than a thousand animals killed, thousands of hectares of wheat, cotton and vegetable fields were washed away and there was extensive damage to roads, bridges, schools, hospitals and electricity cables.

More than 2000 people are currently living in tent camps. For this agricultural area, where most of the population survives through farming, this natural disaster is a real tragedy.

UNICEF staff members, who were on mission in Khatlon Province during those days to monitor the national immunization campaign against polio, have seen with their own eyes what happened in Kulyab.

“I have never seen rain like that before,” says Salokhiddin Shamsiddinov, Child Protection Programme Assistant for UNICEF Tajikistan a witness to the natural disaster.  “In order to get to the city from Davlatobod village to observe how the immunization was going on, we had to take a detour because of destroyed roads, but the roads in the place that we went to had also been washed out, and so we travelled along a river bed. We saw how rivers were roaring and taking down everything in their paths. It was particularly painful to see what had happened in Kulyab. Many houses were flooded and washed out.”

Given that UNICEF staff were already in the field, they were immediately mobilized to provide support for the emergency relief. First-aid items were sent by UNICEF to Kulyab, and staff supervised its distribution as a first step to the affected families.

Despite the emergency, the UNICEF team continued its work and supported local health care professionals in their campaign to complete the first round of the national immunization campaign.

“I was most struck by the high dedication and commitment of primary health care workers during the polio campaign in the most isolated areas, in very remote villages,”  says Nisso Kasymova, UNICEF’s HIV/AIDS Coordinator.  “During the monitoring we met nurses and their assistants who under heavy rain, in rubber galoshes over bare feet walked around all the houses in the areas isolated by mountains to ensure that the children received their vaccinations on time.  It’s good that Khatlon Province received enough vaccines at the beginning of May — enough for all three rounds — otherwise, after everything that happened, delivery of vaccines would have been difficult.”

Currently, the Government of Tajikistan, along with the international and business communities, is taking measures to help people and often loved ones as well, to regain a place to live and hope in the future after having lost all their property so suddenly. Plans have been laid out to re-house displaced persons in safe districts, to build new houses and to provide the victims with essential supplies.

There is also a UNICEF team in the disaster zone that is cooperating with representatives of other organizations to evaluate the damage caused, and to assess the initial needs of the population, especially the needs of the children.

Despite the disaster, the Ministry of Health of Tajikistan has not altered its plans to carry out second and third rounds of vaccination of children against polio in Khatlon Province. “The only change that will happen during second and third rounds, “ says Sabir Kurbanov, UNICEF Health Specialist, “is that more mobile health teams will carry out vaccinations in Khatlon area now.”

Author: Olga Grebennikova
Olga Grebennikova, a guest contributor to Healthy Travel Blog,  is currently working for UNICEF in Tajikistan to help the country offices with the polio immunization campaign.  After her work there is finished, she will return home to Kyrgyzstan where she is the Media Liaison Office for the UNICEF Country Office.