International Association For Medical Assistance to Travellers

Travel Health Advice for Brazil's 2014 World Cup

We here at IAMAT love soccer. Strike up a conversation with Nadia, our member services co-ordinator and she'll tell you all about the ins and outs of the European soccer league.

Next June and July, the world will be descending on 12 cities in Brazil to watch the FIFA Soccer World Cup. If you're one of the few lucky ones to get a ticket or even if you're planning to travel there soon, here's what you need to know to plan a healthy trip.

Getting ready
To start, give yourself at least six weeks before you leave to prepare.

Make sure that your routine immunizations are up-to-date. Infections like measles spread easily during mass gathering events like sports tournaments. Many adults don't keep up with their immunizations and an upcoming trip is a good reminder to make sure you're covered.
Image courtesy of Susan Chaaban
In terms of travel vaccinations, Hepatitis A and Typhoid Fever are recommended. These two illnesses are caused by improper hand hygiene and food handling. Hepatitis A is a viral infection while Typhoid Fever is caused by bacteria. Ask your healthcare provider what type of vaccine is best for you for protection against these illnesses. Note that while the Typhoid Fever vaccines may not offer 100% protection, being immunized will reduce the severity of the illness.

Yellow Fever vaccination is also recommended for many parts of Brazil, but is not required to enter the country. If you're going to see a game in Belo Horizonte, Brasilia, Cuiaba, or Manaus, these cities are within the Yellow Fever endemic area. The cities of Rio de Janeiro, São Paulo, Fortaleza, Recife, Salvador, Porto Alegre, Natal, and Curitiba are risk free. Yellow Fever vaccination is also highly recommended if you're going to Iguaçu Falls.

You'll also want to look out for Dengue Fever. Risk of this viral illness, transmitted by daytime biting mosquitoes, is present throughout Brazil. There is no vaccination so make sure that you take meticulous anti-mosquito bite measures like applying a DEET-containing repellent to exposed skin, wear long light-weight and loose-fitting clothing as much as possible, and ensure that door and window screens are in good working condition.

If you're planning a trip to the Amazon Basin, consider your risk of Malaria. Many regions in Brazil have multi-drug resistant malaria. See our World Malaria Risk Chart for affected areas and How to Protect Yourself Against Malaria for anti-malaria medication guidelines and other protection measures. There is no malaria risk at Iguaçu Falls.

Planning to swim in fresh water? Many parts of Brazil still have Schistosomiasis, a parasitic infection transmitted by snails living in fresh water such as lakes, rivers, streams and ponds. Swimming in the ocean or chlorinated pools is safe.

If you're planning to get insurance, don't forget to consult our Guide to Travel Health Insurance, a primer on what to look for when you're buying insurance.

10 things to keep in mind during your trip
You want to bring back great memories, not ones of being holed up in your hotel room or in a hospital emergency room.

  • 1. The fan cheering can get very loud and echo in a stadium. Make sure to bring along a good pair of ear plugs that allow you to hear the game and the voices around you, but protect your hearing.
  • 2. Practice good hand hygiene to protect yourself and prevent the spread of illnesses to others. Wash your hands thoroughly and frequently with soap and water or an alcohol-based sanitizer.
  • 3. Use the mantra Boil It, Cook It, Peel It or Forget It! Drink boiled or secured bottled water. Eat well cooked foods while they're hot and eat fruit and vegetables that you can peel yourself. Be judicious when it comes to street food vendors. Only eat well cooked foods and make sure the vendors practice good food handling practices. Avoid foods that have been out for long periods of time.
  • 4. Stay well hydrated and use sun protection measures like wearing a hat, UV-ray protecting sunglasses, and sunscreen.
  • 5. Avoid animal and insect bites. Use meticulous anti-mosquito measures during the day and at night to protect against Dengue Fever and Malaria. Take along a repellent containing DEET, wear light-weight long sleeves and pants, and use a mosquito bed net if you're going to malaria areas in Brazil.
  • 6. Know your alcohol intake limit and avoid using illicit drugs – the penalties in Brazil can be very harsh.
  • 7. Always practice safe sex to protect yourself and partners against sexually transmitted infections and diseases (STIs and STDs).
  • 8. Wear seat belts in vehicles and a helmet when riding a moped, motorcycle, or bicycle. Traffic-related accidents are very common in Brazil.
  • 9. Pack a travel medicine kit.
  • 10. Get lots of sleep to stay healthy and enjoy the festivities!
Need medical help?
If you need medical attention, contact an IAMAT English-speaking doctor in Rio de Janeiro, São Paulo, Porto Alegre, and Buzios. Our doctors are committed to helping travellers and charge a set fee to IAMAT members.

When you're back...
If you have persistent diarrhea, fever or flu-like symptoms, make sure to visit your healthcare provider. Post-trip follow-up is usually overlooked by many travellers, but it could prevent future health complications and even save your life.

Your chance to participate in a malaria study

Are you planning to travel to a malaria endemic country? Researchers at the Ottawa Hospital Research Institute want to hear from you!

Below is a description of the study:

La version française suit le texte anglais
Malaria StudyImage courtesy of Craig Parylo
The Ottawa Malaria Decision Aid Project
The Ottawa Hospital Research Institute, in collaboration with Health Canada, is conducting a study to evaluate the best way to prepare travelers for the decision about which malaria pills to take. If this research is of interest to you, you may be eligible to participate in this study.

Eligibility Criteria
* You have contacted a travel clinic
* You are an adult aged 18 years or older
* You will travel for 1 year or less
* You will travel to a malaria endemic country

Please be aware that your eligibility can only be determined by the investigators of this study. Even if you are eligible, your participation in this research study is completely voluntary. There will be no consequences to you whatsoever if you choose not to participate, and your regular medical care will not be affected by that choice.

If you are interested and are eligible, your participation will involve filling out 3 questionnaires; one before your travel appointment, one after your appointment and another upon return from your trip.

To see if you are eligible or to obtain more information about the study, please visit the study website:

Version française

Projet d'aide à la prise de décision du paludisme d'Ottawa
L'Institut de recherche de l'Hôpital d'Ottawa, en collaboration avec Santé Canada, mène une étude pour évaluer la meilleure façon de préparer les voyageurs qui ont à prendre une décision sur quelles pilules prendre contre le paludisme. Si cette recherche vous intéresse, vous êtes peut-être admissible à y participer.

Critères d'admissibilité
* Vous avez communiqué avec une clinique de voyage
* Vous êtes un adulte âgé de 18 ans ou plus
* Votre voyage durera d'un an ou moins
* Vous voyagez dans un pays à risque de paludisme

Notez bien que votre admissibilité doit être déterminée par les investigateurs de l'étude. Même si vous êtes admissible, votre participation dans cette recherche demeure complètement volontaire. Il n'y aura aucune conséquence si vous choisissez de ne pas y participer et votre décision n'influera nullement sur votre traitement médical.

Si vous souhaitez y prendre part et que vous êtes jugé admissible, votre participation comportera 3 questionnaires à remplir; un avant votre rendez-vous à la clinique de voyage, un après le rendez-vous et un dernier au retour de votre voyage.

Pour voir si vous êtes admissible ou pour plus d'information, veuillez visitez le site internet :

Thank you / Merci,

Chardé Morgan, MScPH
Clinical Research Assistant / Assistante de recherche clinique
Division of Infectious Diseases / Division des maladies infectieuses
Ottawa Hospital Research Institute / L'Institut de recherche de l'Hôpital d'Ottawa
Tel: (613) 737-8899 ext. 72424
Fax: (613) 737-8164

NEW! Guide to Travel Health Insurance

Did you know that our new Guide to Travel Health Insurance is out?

Hot off the presses, this guide seeks to answer one of the most frequently asked questions we get from travellers: "Where can I find travel health insurance and what should I look for?"

IAMAT members told us that they are looking for guidance on how to navigate the world of travel health insurance.
IAMAT Guide to Travel Health Insurance

Photo courtesy of Soumyendu Bag, Kolkata, India. Two girls venerating Lord Krishna and Radha.

We did the research for you and wrote a comprehensive primer to help you find the best coverage for your needs. Travel insurance insiders Bruce Cappon of First Rate Insurance and Damian Tysdal of Travel Insurance Review also share their tips on how to buy wisely.

We do not name any companies in the guide. Instead, we offer assistance on where to find travel health insurance and what to look for to ensure you make an informed decision before buying. There are many articles with travel insurance tips out there, but we haven't come across a definitive primer written by an impartial observer. We hope that this guide will give you a better understanding of how travel health insurance works and how to find the right coverage for you.

Don't miss out on this member exclusive!

Go to Member Services using your member number and postal code to download your guide today.

Not yet a member? Sign up here.

Don't forget to tell us what you think. Your feedback is important to us.

Wishing you a healthy and joyful holiday season!

Meet the doctors who will help you

Meet Vinay Vaidya from Nepal and Ali Raza from Pakistan. If you get sick away from home, you can count on them to help you.

Vinay and Ali are both doctors who trained at Hainan Medical University for three months with the 2013 IAMAT-HAINAN Travel Medicine Scholarship. This was made possible thanks to the generous support from our members.

Dr. Ali Raza
Ali's goal is to one day practice travel medicine back home in Pakistan, specifically in the Khagan Valley, a beautiful mountainous area that attracts many tourists. He became interested in travel medicine during a trip to Lanzhou, located in the semi-arid region of northwestern China. After coming down with a rash and dry skin, he realized how climate and geography affected his health.
IAMAT travel medicine scholars

Dr. Ali Raza, left, and Dr. Vinay Vaidya, right, at the Hainan Provincial Center for Disease Control and Prevention.

Says Ali, "I had been living in Haikou for a long time which is a humid tropical city. So I was uncomfortable when I first arrived in Lanzhou, my skin started to chap and I had an unbearable itch. Being a doctor, I knew that it was an allergy to the dry climate, but I did not have a solution to treat it. I felt ashamed that I could not cure myself. This sparked my interest in travel medicine knowledge; I want to be able to diagnose and treat travellers who may encounter the same problems I had."

Interested in community medicine, Ali sees the similarities with travel medicine which incorporates different disciplines including epidemiology, immunology, and geography. As a recent grad, Ali graduated with top marks from Hainan Medical University and was recommended for the scholarship by his professors. As part of the training, he got the opportunity to learn about the health challenges facing travellers, including the effects of poor sanitation, how to diagnose and treat infectious diseases, as well as visiting local travel health centres, emergency departments, and the Hainan Provincial Center for Disease Control and Prevention.

Dr. Vinay Vaidya
Vinay's interest in travel medicine stems from where he lives. Nepal's economy is highly dependent on tourism and he sees the challenges that travellers face in his country. A place renowned for its trekking and mountaineering, Nepal lacks the medical resources in remote areas to deal with travellers who need emergency care.

Says Vinay, "These places can cause trekkers to experience AMS (Acute Mountain Sickness) and failing to descend may lead to further complications like cerebral edema and pulmonary edema. Treacherous mountain trails make it impossible for immediate attention so they have to be flown back to the capital for treatment." Vinay, who trained as a dermatologist, also sees travellers who get extreme frostbite and he's often confronted with making decisions to save or amputate limbs.

He also sees the need to help people who travel to the Terai Region, flatlands located in the south and Nepal's source of agricultural production. Travellers going to this area are at risk of getting malaria and kala-azar (visceral leishmaniasis). "Travellers need to be counselled against these infectious diseases. Travellers' Diarrhea is another problem that almost all of them experience, so we need to tell them about safety measures," he adds.

Thanks to members like you, the IAMAT-HAINAN scholarship gave Vinay the opportunity to hone his skills in travel medicine. If you are sick in Nepal and end up at IAMAT's affiliated clinic, Nepal International Clinic, in Kathmandu, be sure to ask for him!

Get Your Guide to Healthy Travel

Are you confused about all the travel health advice out there and don't know if the information is credible? You're not alone.

You may come across inconsistent advice or don't know if you can trust the source. Travel health advice can vary from country to country and even between different public health and travel medicine professional organizations. According to travel medicine practitioners Alan Magill and David Shlim,"Some of the reasons why guidelines differ include availability of products in different countries, a different cultural perception or risk, lack of evidence (or differing interpretations of the same evidence), and sometimes just honest difference in opinion among experts."

Another issue we encounter in our work is the lack of monitoring or under reporting of health risks. In some instances, we are aware of health risks that are not officially reported but evidence provided by our doctors or public health partners on the ground show that there is risk for travellers and local citizens.

More and more, we're also seeing how climate change is influencing the spread of mosquitoes carrying Dengue and ticks responsible for Lyme Disease, for example, in more northern climates and at higher altitudes. Migration and international travel both also play a major role in the spread of infectious diseases.

As a traveller there's a lot of information to take in and potential risks to consider. If you're going on a last-minute trip, for example, there's no way you have time to make sense of it all. To make it easier for you, we've compiled all our materials in our eLibrary for quick access. You can also access information through our destination country index or via our health risk index for quick tips or more detailed information, depending on your needs.

One of our most popular quick guides is the IAMAT Guide to Healthy Travel. This handy passport-sized booklet tells you how to prevent and treat common travel related ailments. It's a single source of advice for traditional travellers and adventure travellers, including all the contents you'll need to assemble your travel medicine kit and a pre-trip planning countdown timeline. The guide, written by Dr. Elaine C. Jong and Family Nurse Practitioner Anne Terry, is now available in print or as a PDF download.

Why is the guide $15, you may ask? It's a fundraising project for our non-profit organization where all the proceeds go towards our travel medicine scholarships. This unique program is the only one of its kind supporting doctors and nurses from low income areas – typically popular tourism destinations – to study and train in travel medicine abroad.

Alan McGill and David Shlim are quoted in CDC Health Information for International Travel, The Yellow Book (2014); p23.
IAMAT Guide to Healthy Travel
Cover photo by Amitava Chandra.

Travelling with Food Allergies

How do you stay healthy during your trip if you have food allergies?

Our guest blogger, Robert Haru Fisher,* explains what he brings along on his travels to prevent an adverse reaction and tells us about his experiences along the way.

I've had allergies to certain foods all my life, and yet I have visited over 100 countries in my more than 50 years as a travel writer, mostly for the Fodor and Frommer guidebooks. At first, my only weapons were my wits, which taught me to speak English slowly if I did not know the native language and always to speak to whomever prepared the food. Fewer people outside English-speaking countries spoke English back then. (In the Mideast, the second language was often French or German, for instance.

Now, however, you can arm yourself with better weapons. I always carry three items with me whenever I plan to eat out, even in the USA or other English-speaking countries. They are (1) printed
travelling with allergies
Photo by Lin Kwan courtesy of stock.xchng.
Allergy Warning cards explaining what I am allergic to, in English and the appropriate foreign language; (2) an Epi-Pen with at least two vials of epinephrine; and (3) an IAMAT Directory, listing the local hospitals that are members of IAMAT.

If I am in a North American city or foreign destination where IAMAT has no listings, I research the place and write down a note with the name of the nearest hospital to the restaurant I intend to visit, and put that note in my shirt pocket, where I also place the Allergy Warning cards. (Your hotel front desk may be the easiest place to learn about hospitals where English is spoken, or where the foreign community goes.)

Sometimes, you may want to phone ahead to the restaurant and warn them about your allergy, but I usually just advise the waiter immediately on sitting down, then handing him or her my Allergy Warning card in both English and the appropriate foreign language, and ask the waitstaff to show the cards to the chef and report back to me if what I order was safe to eat. If the answer came back, "No, what you ordered is not safe," then I would ask the chef to recommend something that was OK to eat.

My cards read: "Allergy Warning! I can be killed by eating PEANUTS, PEANUT OIL, GREEN PEAS. Please be sure the food I order does not contain any of those products. Thank you! Robert Haru Fisher."(This is not hyperbole, as my throat can swell up and stop my breathing if I don't get help immediately.)

I print my own cards in English on my computer. For correct foreign-language cards, contact Select Wisely, where I have been able to buy laminated cards in most languages. Some years back, when the company did not have the appropriate language, I would go on the Web and search, in one case finding a woman in Prague who translated short items into Czech just for pleasure, not charging anything.

I have had dozens of wait staff tell me, when I hand them the card, that they appreciate such printed advice, it being very helpful to them. (And I have sat next to, on more than one occasion, someone who will tell a waiter, verbally, that he or she was allergic to five or six different things, expecting the waiter to remember the items. I once counted a fellow diner mentioning nine different allergies!)

My allergies have grown more severe as I grew older, and I have been incorrectly advised food was safe several times, resulting in brief hospitalizations, most of them in the USA, where occasionally a few people don't understand allergies, one fellow in Key West telling me, for instance, that "allergies are all in your head." My scariest experience was eating from a buffet in Kunming (China), then boarding a bus for Stone Mountain, about an hour's ride away. By the time I arrived, I could barely talk or breathe, but I found a First Aid station there, and after preliminary treatment which included using my own Epi-Pen, I was transported by ambulance back to Kunming to the Red Cross Hospital.

My best experience illustrating the usefulness of IAMAT membership was in Beijing, where a chef lied to me and my interpreter about the safety of our food, even after reading my Chinese-language (Mandarin) warning card. Back in my hotel room after a short nap, I felt my tongue and throat swelling, grabbed my IAMAT directory, took it to the front desk, and, unable to speak, pointed to the name and address of what I took to be the nearest member hospital, the Peking Union Medical College Hospital (Foreigners' Clinic). The hotel manager sent a bellhop with me to get a cab and accompany me to the hospital where he waited until he saw that I was in good hands. I was there two days, sharing a room with an Australian prisoner handcuffed to his bed (drug smuggling) in a "special" section of the hospital. I have been a believer in IAMAT for the past 40 years, but never more so than that time!

We'd like to hear your thoughts... Tell us and other travellers what you do to prevent food allergies abroad.

* Robert Haru Fisher is also Vice-President of IAMAT's Board of Directors.

Why IAMAT Doctors Abroad Are Different

We are very pleased to include more doctors providing trusted medical care abroad to serve you better. IAMAT members now have new or additional coverage in the following cities:

  • Antigua, Guatemala
  • Athens, Greece
  • Berlin, Germany
  • Cuernavaca, Mexico
  • Danang, Vietnam
  • Derrygonnelly, N. Ireland
  • Edmonton and Ottawa, Canada
  • Iquitos, Peru
  • Kandy, Sri Lanka
  • Kathmandu, Nepal
  • Kriel, South Africa
  • Ludhiana, India
  • Millsboro (DE) and Aptos (CA), USA
  • Moscow, Russia

Photo by Kurhan courtesy of
Here are just a few reasons why our affiliated doctors and mental health practitioners are different:
- They speak English fluently. You won't have to go through a medical translator to communicate your health concerns.

- They are vetted by our organization and clinics are inspected to ensure they meet international health standards.

- They volunteer to be part of our network because they are committed to helping travellers; they do not pay a membership fee to join, allowing us to maintain strict ethical standards.

Here's what long time travellers Gene and Jean B, of Edmonton told us, "We have travelled quite a lot and have used your valuable information several times. We have also made use of the Doctors' handbook to locate English speaking doctors. We have used IAMAT several times over the years in Greece, Malaysia, Morocco, Vietnam, and Hong Kong. It is very reassuring to have IAMAT's list of doctors with us when we travel as we are usually away for a long time". See other travellers recommending our work.

Next time you travel, consider accessing the services of an IAMAT doctor that you can trust. Our role is to help relieve some of your stress and to provide moral support from afar so you don't have to worry about the care you receive abroad.

Wishing you a great summer from all of us at IAMAT!

Health Risks Associated with Ecotourism

Booked your eco-adventure trip, check.
Packed all your gear, check.

But wait a minute, what about health considerations? Many of us don't consider the health risks associated with ecotourism, including how we impact the health of the animals and communities we encounter abroad. Our guest blogger, Michael Muehlenbein, explains what you need to consider when planning your ecotourism vacation.

What is ecotourism?
Nature-based tourism accounts for a growing proportion of international tourism activity. Ecotourism is specifically a sustainable version of nature-based tourism that attempts to educate visitors while minimizing modification or degradation of natural resources and broadly benefiting the social and natural environments by involving the participation of local communities. Certainly most activities traditionally considered to be ecotourism-related, like the proverbial zip-line experience through a forest fragment, do not technically fit the definition of ecotourism. That said, true ecotourism experiences run by local individuals, with money going back into local communities, can protect natural and cultural heritages and facilitate conservation of biodiversity.

Health risks associated with ecotourism are both similar and different to other travel experiences. Unfortunately, when travellers book a trip, many don't consider the health risks of their destination. Preventive health strategies like paying attention to food and water safety (avoiding salads, shellfish, and tap water, for example), understanding the sources and causes of infection, taking preventive medication if needed, and physician advice, are often ignored.

Tourists are also stressed due to sleep dysregulation, unfamiliar diets and climate, and exposure to novel pathogens. Consequently, illness during travel is very common, particularly gastrointestinal and respiratory infections. This is certainly the case for those visiting exotic destinations to view wildlife.

Risks to travellers
Actual health risks of travel depend on a variety of factors. These include where you are going, time of year, how long you are staying, your planned activities, and your pre-existing health conditions, among other things.

Ecotourism activities place travellers at risk due to participation in risky activities at extreme or remote environments. This might include high altitude sickness while mountain climbing, decompression sickness while scuba diving, as well as motor vehicle accidents in regions with poor infrastructure.

Infectious disease threats to ecotourists include the usual intestinal pathogens acquired through fecal-oral transmission, usually involving contaminated food and water. You must be mindful of your basic hygiene and what you are consuming. Vector-borne diseases like malaria, Dengue, Chikungunya, Japanese encephalitis, Yellow fever, African tick bite fever, and others can be common. You should therefore be mindful of protecting yourself against biting insects, which may involve avoiding outdoors at dawn and dusk, checking yourself for ticks, using insecticides and proper clothing, and sleeping under a net.

You should be also mindful of how your activities put you into direct and indirect contact with wildlife. Caving is associated with transmission of Histoplasmosis from bat guano. Exposure to water contaminated with animal urine is associated with Leptospirosis. Direct animal contact is associated with rabies. Over half of all human infections are zoonotic (nonhuman animal) in origin. Enjoy animals from a distance, and of course be sure to consult your travel health practitioner to make sure you are travelling with the correct preventive medication. You should also be prepared for a potential lack of in-country healthcare where you are travelling. Emergency evacuation insurance might be advisable.

Travellers putting wildlife and destination communities at risk
On the flip side, humans are also responsible for the transmission of pathogens to nonhuman animals (known as anthropozoonoses) especially in the context of ecotourism as travellers experience direct encounters with wildlife. This is particularly the case for primates that are genetically closely related to humans and are therefore particularly susceptible to many human pathogens.

The relative contribution of tourists to the spread of pathogens to wildlife is unknown, but the number of tourists visiting wildlife sanctuaries worldwide is increasing substantially. Pneumovirus and influenza are examples of pathogens transmitted from human to nonhuman primate populations that have been either suspected or confirmed to date. These outbreaks have affected nearly all major long-term chimpanzee and gorilla study populations, like Bwindi, Mahale, Gombe, Kibale and others.

It is critical that tourists, while visiting wildlife sanctuaries, maintain a respectful distance from wild animals. Arguably, this can be difficult to do. My own work in Malaysia and Japan has involved interviewing over 2000 tourists to date. In general, we are a species with intensive affinity for close interactions with wild animals. Of 650 people surveyed at the Sepilok Orangutan Rehabilitation Centre in Sabah, Malaysia in 2009, 98% believed that humans can give diseases to wild animals, yet 35% of them would still try to touch a monkey or ape if they had the opportunity. Of 686 people surveyed at the Takasakiyama Monkey Park in Kyushu, Japan in 2012, 61% of participants expressed desire to feed monkeys at the park, and 23% would own one as a pet. Of course there are regulations in place at many sanctuaries to prevent such contact, although these regulations can be difficult to enforce sometimes. People know there are disease risks associated with animal contact, yet their affinity for animals can cloud their better judgment, particularly when vacationing. We must be mindful of our actions on other animals, particularly when it comes to endangered species.

Travellers also put at risk the destination community members they are visiting. This might involve habitat degradation, the introduction of invasive species, pollution, overcrowding, and even the facilitation of sex trade. In a recent survey that I conducted with colleagues from the Destination Communities Support Interest Group of the International Society of Travel Medicine, we found that most travellers get advice on preventing the spread of pathogens (mainly sexually transmitted infections) to host inhabitants in destination communities, but little information is given on how to minimize traveller impact on destination communities and habitats.

Be prepared
I believe the best advice for any type of travel is to be prepared. This goes double for international travel, and triple for travel involving risky activities. Travel health practitioners can provide great resources, and there seem to be ubiquitous health regulations and advertisements both at home (including online) and abroad. However, it is ultimately up to you, as the traveller, to be a responsible one. Prepare yourself based on where you are going, what you plan to do, and other risk factors. I recommend you evaluate your vaccination status, as this not only protects you, but also the wildlife and destination communities you plan on visiting. I also recommend following local health regulations while travelling. This might involve doing things you might not want to, like wearing a facemask while trekking for mountain gorillas. Ultimately, you must think about the risks imposed upon you as well as the risks you place upon others. Use common sense and be respectful of the environment.

Michael Muehlenbein, PhD MsPH MPhil, is an Associate Professor of Anthropology and International Studies at Indiana University, Bloomington, USA. His research focuses on health and disease in relation to primate-based tourism, particularly in Asia. He is the chair of the ecotourism subcommittee of the Destination Communities Support Interest Group of the International Society of Travel Medicine. More information about his research can be found at See also his crowdfunding project to research the risks of infectious disease transmission from tourists to monkeys in South Africa on Microryza.

Malaria in Returning Travellers

Do you know if your travel destination country has malaria? If so, would you take medication to prevent a malaria infection?

As we pause to take stock of anti-malaria efforts on World Malaria Day, much progress has been made to prevent and control malaria since 2000, mainly a 25% reduction of mortality rates worldwide. Much remains to be done to successfully eradicate infections including direct community involvement, improved housing, access to healthcare, eliminating corruption, and addressing climate change.

From a travel perspective, regional and international mobility, counterfeit malaria medications, growing mosquito resistance to some antimalarial medications – particularly in border areas of Vietnam, Myanmar, Cambodia, and Laos – and the presence of malaria in new or previously eradicated areas like Greece, continue to be a concern.

Over the years, travel medicine practitioners have been sounding the alarm about the increase of malaria cases in returning travellers. The most recent study looking at imported malaria cases was published last week in PLOS ONE. The University of Calgary's Faculty of Medicine found that only 23.8% of travellers from Calgary returning with malaria sought prevention advice and of those, only 60% took preventive medication.

Here at IAMAT, we come across many travellers that take advantage of last-minute travel vacation deals and don't have the time to research if malaria is a risk at their destination or can't book a doctor or travel health clinic appointment prior to their departure to get their antimalarial prescription. Some travellers also tell us that the cost of antimalarial medication and travel health consultations can be prohibitive and they weigh the risks of not taking it. We are also seeing more travellers visiting friends and family in malaria endemic areas who believe they are immune to malaria because they lived in the region or had it as a child. Once in a while we also encounter travellers who prefer to take natural remedies which are not scientifically proven to prevent malaria.

Malaria is preventable. The infection is caused by the Plasmodium parasite transmitted by the night time biting (dusk to dawn) female Anopheles mosquito. Her bite does not itch or cause a welt, nor does she hum to warn you of her presence. There are five Plasmodium parasites that infect humans: P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. P. vivax is the most widely distributed around the world while P. falciparum is the most dangerous and can cause serious health complications, including death.

As a quick guide, follow the ABCD malaria prevention method:
  • Awareness of risk of malaria: Know where it occurs, the impact of seasonal changes and altitude, the health risks, and the symptoms.
  • Bite prevention: Know the mosquito's behaviour and when it bites, what protective clothing to wear, repellents to use, and how to properly use a bed net.
  • Chemoprophylaxis: Know which antimalarial medication is best for you and follow advice exactly as prescribed. Note that there is no vaccination against malaria.
  • Prompt Diagnosis and treatment: Know when to seek medical attention if you exhibit flu-like symptoms upon your return or suspect you may have been bitten by a mosquito in a malaria area.
For a complete list of malaria countries, see our World Malaria Risk Chart. For detailed prevention advice, including protection measures and medication dosages, side-effects, and contraindications, see our How To Protect Yourself Against Malaria guide. You can also access all our malaria information on our online Travel Health Risks database.

For more information about other organizations working to prevent and control malaria, see The Independent's World Malaria Day insert.

Roll Back Malaria World Malaria Day 2009

Are you ready for Germageddon?

Do you understand how your immune system works to protect you from disease? Do you know how vaccines work?

These questions are answered in the graphic novel Germageddon: The War of Vaccines Vs. The Human Immune System. Created, written, and illustrated by Natalia Burachynsky, a Medical Illustrator and Visualization specialist, the comic book explains immunity and the power of vaccines. We recently asked Natalia, an avid traveller who has visited New Zealand, Thailand, Laos, Indonesia, Malaysia, Greece, Portugal and many other European countries to tell us why she developed Germageddon for her Master's of Science in Biomedical Communications at the University of Toronto.

What is Germageddon?
Germageddon is an educational graphic novel that is unbiased, engaging, and humorous. It was created to inform and educate people on the science and benefits of immunization and to explain how the human immune system works.

Germageddon takes place on a busy train. Gordo the Germ, runs into an old acquaintance. Gordo, is moving on, times are tough, the humans he infects are becoming immune to him. He strikes up a conversation with his friend who is unaware of the dangers that strong immune systems present to the Germ world, and proceeds to explain what 'vaccines' are and how they work. With the help of other germ examples, fellow pathogens, and metaphors, the Germ characters help unravel the mystery and clear up the confusion about immunization and vaccines.

Image courtesy of Natalia Burachynsky.
Why did you create Germageddon?
There is general consensus within the mainstream medical community that vaccines improve immunity to disease, save lives, and that their benefits far outweigh the risks. Despite this, many people continue to believe anti-vaccination advocates who question vaccine safety and efficacy. In Canada and the US, for example, adults are not getting their routine vaccinations updated, putting themselves and others around them at risk.

To help people make informed decisions about their health and vaccination, I believe that they must have access to reliable information. There is an urgent need to teach people on the importance of vaccination to counter the misconceptions propagated by very persuasive anti-vaccine lobbyists.

A lack of knowledge in general science and a low science literacy rates are two obstacles contributing to this anti-vaccination trend. If you're not familiar with human biological functions, it can be difficult to make good health choices. Using visually rich, engaging, and entertaining educational tools that address the safety, science and importance of vaccinations, Germageddon helps readers understand complex scientific concepts related to immunity and vaccines.

Why a graphic novel?
Germageddon is 'Graphic Medicine', a new area of educational visualization. This science-themed comic addresses complex ideas using visual metaphors and entertaining storylines making an important public health topic highly accessible to individuals with various levels of literacy and reaching across diverse cultural and socio-economic backgrounds.

Germageddon achieves this without the use of scientifically challenging language, using well-conceived visuals and thought-provoking Socratic dialogue. This form of dialogue is a useful and popular format for expressing arguments and discussions as well as illustrating scenarios and character details of the individuals involved in the discussion. Socratic dialogue works wonderfully as an educational tool because it effectively addresses concerns and questions that an individual may have about a subject. Socratic dialogue is also useful in clearing up a misconceptions and misinformation while removing the necessity for a reader to ask or seek the answer themselves, often resulting in a 'safe' learning environment.

There is a lack of accurate visuals, illustrations and animations targeted at educating people on the science and safety of vaccination. Germageddon gives individuals a sound knowledge of microbiology concepts. My graphic novel can also be used to foster science literacy, helping individuals understand scientific terminology, concepts, and evidence so that they can communicate scientific ideas and draw their own conclusions. Current studies embrace the concept of using comics as an innovative and entertaining way of communicating science.

My hope for Germageddon is that it will foster scientific curiosity and literacy, and that it will convince readers to keep up-to-date with their vaccinations. Higher immunization rates can also lower the burden of economic costs associated with hospitalization, decreased productivity, and work absenteeism during a person's lifetime.

To see Natalia's work and to download your copy of Germageddon: The War of Vaccines Vs. The Human Immune System go to:

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