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.

Photo: istockphoto.com.

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 www.biologicalanthropology.org.

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.

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: www.burachynsky.com.

Guest post by Dr. Erik McLaughlin

Preparing your travel first aid kit is a vital part of your pre-trip planning and packing. When I think about getting ready for a trip it usually involves packing. This means all my clothes laid out on the bed, some Bob Marley music in the background and deciding what I will need. What I need has to be balanced with space and weight. This is true with your first aid kit.

The 'Perfect' kit The 'perfect' travel first aid kit is the kit that is carried with you and ready for any potential problem. If you talk to too many travel doctors, you will end up with a first aid kit that weighs between 30 and 50 kilograms and will likely require its own suitcase. This is not something that you will easily carry and consequently it will be left in your hotel room. The travel kit will not do you or your companions any good there! A small, portable kit with the essentials should be carried with you at all times and a slightly larger kit left in the suitcases or hotel room can be used to "re-supply" your smaller, portable kit. When designing a travel first aid kit, I look at several factors. First, what are the pre-existing medical needs of the travellers? Second, how long are they going to be travelling for? Third, where are they going? Last, what are they going to be doing? Let's take a look at these needs, one by one.

Photo: iStockphoto.

Pre-Existing Medical Conditions
Travellers with chronic medical conditions such as high blood pressure, diabetes, thyroid disorders or other problems that need regular mediation fall into this category. I also like to place people with known histories of allergic reactions here.. It is vital to remember to carry enough of your home medications with you on your trip. This saves the need to spend your "fun time" having to find a local pharmacy and sort out a new prescription and sometimes even worry if you are getting counterfeit medications! I always advise to carry enough medication for your trip plus ½ again as much. So for a 2 week trip, you should carry 3 weeks of medicine. This gives you some freedom if you find that perfect beach and want to extend your trip or have a delay with travel and want to be stress-free. Your home medications should be carried in two separate locations. Some should be in your carry-on bag and some should be in your luggage. This allows you freedom if your luggage is lost or your bag falls into a river. Lastly, carrying a copy of your prescription is a good idea. If things go bad and you find yourself out of medication, this copy will help the doctor in your host country write the prescription so that you can get the refill from a local pharmacy.

How long is the trip?
Carrying two band-aids for a month long hiking trip is not wise. Make sure you have enough first aid supplies for the duration of your trip. This may seem like common sense but only having two tablets of pain reliever will not do much good if you are gone for 3 weeks.

Where are you going?
Travellers headed to different parts of the world have different health related needs. Mosquito repellent is probably not needed on a trip to the Arctic Circle. Consequently, high-altitude medicine will just be extra weight on a trip to the beach. This concept is especially important when looking at the local diseases the travellers may face. I am especially talking about malaria and other insect carried illnesses.

If you are going to the tropics, make sure you have considered insect bite precautions and anti-malaria medications. If you are going to a high altitude area like Machu Picchu you should consider medicine for altitude sickness. I also place my insect bite prevention supplies in with the first aid kit as this is a vital part of staying healthy while travelling.

This is also a good time to look at your access to healthcare. Are you going to be in a remote Amazon village or backpacking through the mountains, far from medical care? Are you going to be in the downtown region of a capital city? The more remote you are planning to be means you will need to be more self-sufficient and possibly go longer without being able to re-supply your kit.

What are you going to do?
The activities planned on the trip are key in helping build an appropriate travel first aid kit. A hiking trip in the mountains has different needs than lying on the beach or shopping in a capital city. A trip that will be heavy on walking, whether it is shopping or hiking should carry a bit more supplies designed to care for your feet. This should include blister care and treatment supplies. A trip with a lot of time in the sun should go a bit heavier on the sun screen.

The basics
Regardless of where you are going or what you are doing, there are a few basics that should be found in every first aid kit.

Your personal medications	(carry prescription copies)
Pain control/Fever reducer	(acetaminophen, ibuprofen, paracetamol, etc.)
Allergy Medication	(Benadryl, antihistamines, etc.)
Assortment of Band-Aids	(for small cuts and scrapes)
Mole Skin or Blister Care	(for blisters on the feet)
Gauze	(various sizes to clean and dress wounds)
Electrolyte solution or powder	(to rehydrate with traveller's diarrhea)
Antibiotic ointment	(for small cuts and scrapes)
Sunscreen	(no matter where you go)

Often times this small amount of first aid gear can fit within a small container and should be carried with you in your coat pocket or daypack. As you use items from this small kit, replace them from your larger kit kept in your hotel room.

More remote areas
For travellers headed to more remote areas or looking to be a bit more self-sufficient there are some extras you should place into your kit. Some of the basics include:

SAM splint	(for sprains or stabilization of injured limbs)
Anti-malarials	(talk with your travel doctor about which type)
Broad Spectrum Antibiotics	(again, discuss this with your doctor)
Blood clotting agents	(Celox, Quik-Clot that can be bought in most outdoor stores)
Sling/Bandana	(for injured arms or as a dust mask, etc.)

Putting it all together
Probably the only mistake a traveller can make with their first aid kit is not having one. There are many commercially available kits to be purchased or you can assemble one from scratch. A bit of pre-planning can go a long way towards dealing with an unexpected injury or illness while on your adventure.

Travel safe!

Erik McLaughlin MD, MPH is a specialist in Travel, Expedition and Remote Medicine. He has completed a MPH in International Health and Diploma in Clinical Tropical Medicine and Travel Health. He is a Board Certified Doctor in the US and a Specialist level doctor in Australia. See his website at AdventureDoc.net

It's that time of the year when we take stock of the past year and look forward to new projects and goals for 2013.

This year, we're looking forward to providing more travel health products to help you plan a healthy trip. We're making changes to our website which will feature an online library of updated articles compiled from our Travel Health Blog. We'll also be adding a section where you can ask us your travel health related questions. Our Travel Health Planner will be smarter and existing mobile features will also be improved.

We're very pleased to provide the Guide to Healthy Travel in hard copy. It's currently only available in PDF, but will be available in print in March and will also be sold in select travel health clinics across Canada and the USA. There's so much health information out there that we designed this compact little guide to make it easier for travellers to get trusted advice in one place. This handy passport-sized booklet is packed with tips on how to prevent and treat common travel related illnesses. It also lists all the items you need to pack in your travel medicine kit and information on prescription and over-the-counter medications that you may need during your trip.

Look out too, for comprehensive advice on travel health insurance. We are very excited about this project and based on our member survey from last year, 55% of you are looking for more information on how to navigate the field of travel medical insurance.

We could not do this without the generous support from our members, donors, and supporters who give their money, time, and in-kind contributions to achieve our goal of making international travel healthier. A huge thanks and appreciation go to In-Flight Insider, Travelscope, Vaccines411.ca. We invite you to support their services!

In-Flight insider is a website that provides travelers with the latest luxury trends, and essential insider tips on travel preparation, health and safety, style, products, services, and the best discoveries – all designed to upgrade their flying and travel experience.

Travelscope, hosted by Joseph Rosendo, takes viewers on cultural adventures around the globe. Travelscope demonstrates the truth in Mark Twain's quote, "Travel is fatal to prejudice, bigotry and narrow-mindedness." Emmy-winning and hugely popular, you can join Joseph on his world-wide adventures on your local PBS station.

Vaccines411.ca is an online vaccination clinic locator which also includes reliable immunization resources for Canadians to easily find the vaccination resources they need.

Guest post by Faith Franz of The Mesothelioma Center.

With the holidays rapidly approaching, many families are planning vacations to visit loved ones or enjoy a favorite destination. Preparing for vacation is often a fun and exciting process. Unfortunately, for those with a chronic lung condition, it can be a major source of stress. Patients with lung cancer, COPD, emphysema, mesothelioma or any other illness of the lungs or respiratory tract often need to make special travel accommodations. From traveling with oxygen tanks to transporting medications, they have several special requirements they must address.

Photo credit: Shutterstock.

Making these arrangements can be time consuming, but with foresight, patience and diligence, patients with chronic lung conditions can ensure a smooth and easy travel experience. The following tips can help streamline the process.

General Tips

• Get your doctor's approval. Be sure to check with your doctor before making any travel arrangements. Most patients are cleared to leave town for vacation – but it's necessary to get your doctor's approval!
• Start planning several weeks in advance. This helps you avoid stressful last-minute situations. It also allows you enough time to contact your pharmacy to refill prescriptions or obtain any necessary medical documents from your physician.
• Make detailed packing lists. Include medical equipment, daily prescriptions, emergency medications and a list of contacts for your medical care providers. Double check your bag after packing to make sure you have all of your essentials!
• Find comfort aids. Traveling will likely require you to remain in a seated position for an extended period of time. If it is difficult for you to find a comfortable seated position, you may wish to secure pillows, braces, supports or similar items before you leave.
• Keep medications easily accessible. If you are checking luggage with an airline, bus company or train company, be sure to pack any medications you will need during travel in a carry-on bag. This includes pain medications and inhalers. If you need to take these medications with food or liquid, be sure to keep those accessible as well.
• If you are driving, consider a travel partner to share the responsibilities. If you experience a severe coughing fit, a sudden onset of fatigue or any other similar condition, it is helpful to have another driver to take the wheel. If you are driving and experience a sudden onset of symptoms that could potentially endanger yourself or your passengers, do not hesitate to pull over.

For Patients Flying with Oxygen

• Contact potential airlines before you book your tickets. Some – but not all – airlines allow patients to travel with portable oxygen concentrators. Airlines who do not allow you to carry on your own oxygen must provide an alternate source for you to use, but they may charge you for the service. Find out your airline's policy before you arrive at the airport. The European Lung Foundation has a database of oxygen use policies for European airlines. If you're looking for oxygen equipment at your destination, Oxytravel coordinates oxygen needs worldwide.
• Ask your doctor if you can temporarily disconnect from the oxygen during airport screening. If you need to stay connected at all times, be prepared to inform a screening officer at the airport. Allot extra time during check-in for alternate passenger screening procedures. If you are planning on alternate screening methods, be prepared for a pat-down procedure.
• Decide how you plan to transport your tank. If you can disconnect from your oxygen tank, you may check it as luggage. Some airlines offer the option of bringing the tank as a carry-on. Choose your transportation method ahead of time to avoid surprise baggage fees or delays.

For Patients Flying with a Nebulizer

• Pack the equipment in a plastic bag. You will be required to remove your nebulizer from its carrying case during screening. You may, however, bring a plastic bag to place it in for sanitary purposes.
• Pack nebulizer fluids in accordance with Transportation Security Administration or the Canadian Air Transport Security Authority guidelines.

Faith Franz has spent nearly two years researching and writing for The Mesothelioma Center. As an advocate for alternative medicine, she encourages patients to explore all of the treatment options that could potentially save their life. To keep current on the most up-to-date mesothelioma cancer information please visit the Mesothelioma News Center.

Earlier this year, we asked you about your travel destinations and travel health needs so that we can serve you better. Below are some of the result highlights from the 2012 IAMAT Survey based on 1517 responses.

Congratulations to survey respondents, Letty Ann Macdonald of Barboursville, Dave Smith of Sacramento, and Judy Stralka of Mill Valley, who won gift certificates from Mountain Equipment Co-op, Magellan's, and TravelSmith!

Top Travel Destinations

In the last three years members travelled to the following geographical regions...

Top 5 travel health concerns of IAMAT members

1. Immunization needs and requirements
2. Infectious diseases
3. Food and water safety abroad
4. Access to doctors who speak your language
5. How to travel well with chronic illnesses

55% would like to get more advice on how to navigate travel medical insurance

IAMAT DOCTORS

In the last 3 years, members needed to consult an IAMAT doctor for...

1. Acute conditions like fractures, burns, allergies...
2. Gastrointestinal illnesses
3. Prescription refills

Places where members visited an IAMAT doctor in the last 3 years

Overall satisfaction with medical care provided by IAMAT doctors 85%

MEMBERSHIP

Top reasons why travellers join IAMAT:

Our travel health advice and access to reputable doctors abroad

You've been an IAMAT member since...

You heard about us primarily through

• Word of mouth
• Internet search
• Healthcare professional

Our President, Assunta Uffer-Marcolongo, just came back from Beijing where she presented travel health education workshops and from a meeting of the South African Society of Travel Medicine in Johannesburg. Her round-the-world trip got us thinking about jet lag. As travellers, we've all experienced it. Some of us have our own tried and true coping mechanisms, while the rest of us can't shake off jet lag for days or weeks. The key to preventing jet lag is to understand how light and travel direction – east or west – affects your internal clock.

There are many over-the-counter drugs and diets purporting to prevent jet lag, and unfortunately there are few controlled scientific studies done on jet lag and travellers. For this article, we found the advice of Dr. Stephen Bezruchka, senior lecturer at the University of Washington, School of Public Health, helpful. When several time zones are crossed rapidly your sleep-wake pattern gets out of sync with your circadian rhythm (a 24 hour internal cycle) which is primarily regulated by daylight. Air travel does not give your body enough time to cope with the disruption and adjust to the new daylight / darkness cycle of your destination, temporarily affecting your health.

Image courtesy of Stock.XCHNG.

The most common symptoms of jet lag include:

• fatigue, insomnia
• poor concentration, disorientation
• irritability, depression, exacerbation of psychiatric disorders
• headaches, muscle aches, fluctuating body temperature
• indigestion, irregular bowels

The more severe implications of jet lag include increased vulnerability to infections, judgement and performance errors as well as reduced physical and mental functionality. Chronic jet lag can affect the central nervous system and cognitive behaviour.

Travel stress too, can intensify jet lag symptoms. Dr. Bezruchka points out that persons who suffer from chronic stress or those who cannot afford first class travel may be more affected by jet lag than travellers who have access to airport lounges, concierge services, and wellness and relaxation perks (such as massages or nap suites) during transit and at their destination.

What we know so far...

• Almost all travellers are affected by jet lag and most are affected by eastward travel.
• Symptoms intensify the more time zones are crossed. They usually start after a two-hour time difference and persist for one week or more. Typically, it takes one day to recover from one time zone change.
• Frequent travellers experience less jet lag symptoms over time.
• Older persons and those with pre-existing sleep disorders are at higher risk of being affected by jet lag.
• Exercise, healthy meals, and hydration can help reduce jet lag symptoms.
• Travel stress can intensify jet lag.

What about prevention?
Although jet lag can't be avoided when travelling across different time zones, you can minimize its impact by taking a multi-pronged approach which can make it more bearable.

Adjust your sleeping schedule
You've probably heard that one way to prevent jet lag is adjusting your sleep schedule prior to departure. If you're travelling from west to east, you'll want to go to sleep one hour earlier each night at least three days prior to departure to mimic the time at your destination as close as possible. The same method is used if you're travelling from east to west, you'll want to stay up one hour past your bedtime pushing your awake time by at least three hours by the time you leave. This method, however, may not be realistic for many travellers.

Exposure to light
Another anti jet lag measure is maximizing exposure to bright light (preferably natural light) during the right time of day. If you travel east, you'll want to get as much light as possible at sunrise continuing early in the morning to get in sync with the local time. The opposite is true when travelling west; you'll want to delay getting bright light exposure until late afternoon and early evening. Doing this for a minimum of five hours a day for a period of three to four days will help readjust your circadian rhythm. The idea is to limit exposure to light when not appropriate by shielding windows, staying indoors, and wearing sunglasses or visors and maximizing access when needed. The table below explains how to adjust your behaviour.

Travel Direction	External Clock	Circadian Clock	Light Exposure	Behaviour
West to East	Turn watch forward	Turn back circadian clock	Bright light during early morning	Early bedtime, early awakening
East to West	Turn watch backwards	Advance circadian clock	Bright light during the afternoon	Later bedtime, later awakening

Adapted from S. Bezruchka, in Jong E.C., Sanford C.A. (eds.), The Travel and Tropical Medicine Manual - 4th Edition, Philadelphia, Saunders/Elsevier, 2008, p.136.

Melatonin
Melatonin is a hormone produced by our pineal gland when we sleep and helps regulate our circadian rhythms with the help of exposure to light. Supplements are usually taken 1 day prior to your departure and continue 3 days after arrival or taken at bedtime when you arrive at your destination and continue up to a week after. Talk to your healthcare provider before taking melatonin, and if it's safe for you (it's not recommended for persons with cardiovascular or blood clotting conditions) get a prescription. Over-the-counter melatonin may not provide the adequate dosage, reducing its effectiveness. Also, the use of melatonin is unregulated in many countries, including in the USA. Note that the effectiveness of melatonin varies among individuals and there are currently no studies analyzing the long-term safety of taking melatonin, including during pregnancy.

Sleep Inducing Medication
Common sleep inducing medications belonging to non-benzodiazepine class (ie. zolpidem, zaleplon, zopiclone, and eszopiclone) offer short-term relief from insomnia, but do not readjust circadian rhythms. Check with your doctor if these types of medications are right for you and if they should be taken in conjunction with melatonin. Side effects may include memory loss, excitability, and depression. Do not drink alcohol or take anti-histamines when taking these types of drugs. Due to the psychoactive properties of both non-benzodiazepine and benzodiazepine drugs, some countries have banned their importation. Check the INCB (International Narcotics Control Board) website to see if your destination country is on the list. Note that the list is still incomplete and you may want to contact your nearest consulate for more information.

Quick tips to better manage jet lag
In flight:

• Set your watch or mobile to the time at your destination. This will train your brain to adjust to local time quicker.
• Wear an eye shield and use noise cancelling earplugs when you need to sleep on the plane to mimic the time at your destination. For example, if you're going from Toronto to Rome and your flight leaves at 9pm, you'll want to sleep in the plane as much as possible since it is 3am at your destination. You may want to pass on the inflight meal since it further disrupts your routine.
• Stay well hydrated. Refrain from drinking alcohol even though it may be sleep inducing. Alcohol consumption disrupts your sleep patterns.
• Do small exercises to keep your blood flowing (ie. ankle circles, knee lifts, neck rolls, walk up and down the aisles)

At your destination:

• Adopt daily cues to the local time. To adapt more quickly, try to stay awake as much as possible until local bedtime.
• Avoid renting a vehicle at the airport and take public transportation, a taxi, or the airport shuttle to your accommodation. Driving tired and being disoriented in a new city with different road rules increases your chances of getting into an accident, or worse injured.
• Take time to acclimatize to your new time zone and environment. Avoid important meetings or starting your adventure travel trip soon after arrival.
• Eat healthy foods. Try not to experiment with new foods or spicy foods for the first few days since they can disrupt your gastro-intestinal system.
• If you're only staying in the new time zone for one or two days, stick to your home schedule as much as possible.

We'd like to hear from you! Share your jet lag prevention tips in the comments section below.

Thanks to the generous donations from our members, more students passionate about travel medicine can now apply for an IAMAT scholarship. We've just expanded our International Travel Medicine Education Program to Hainan Medical University in Haikou, China where two more students will now be able to train in travel medicine. This new partnership complements our existing travel medicine scholarship training site at the Kaiser Permanente Honolulu Clinic in Hawaii.

IAMAT President, Assunta Uffer-Marcolongo, second on right, meets with Hainan Medical University staff and Vice President Zeng Yu, second on left. Photo courtesy of Hainan Medical University.

The IAMAT Scholarship Fund is the only one of its kind supporting doctors and nurses from low income areas – and typically popular tourism destinations - to study and train in travel medicine abroad. This unique program provides scholars with the knowledge and practice to become certified practitioners in travel medicine. Upon graduation, scholars return to their home country to lend their expertise in travel medicine clinical best practices, elevate local health care standards, teach their colleagues, and expand the network of IAMAT affiliated clinics around the world to benefit international travellers, including fellow citizens travelling abroad.

The new training location at Hainan Medical University is host to international students from all over the world. Since its inception in 1993, students from 150 countries have been taught by professors and staff who have studied and trained abroad. It is the only university in China offering a degree in tropical medicine. Located on the island of Hainan in the South China Sea, Haikou and the surrounding area are a popular international vacation destination with much need for travel medicine providers.

Our goal was always to expand our scholarship and grant program. In May, during a trip to southeast Asia to inspect IAMAT affiliated clinics, president Assunta Uffer-Marcolongo visited Hainan Medical University to explore the possibility of expanding the scholarship program. Under the guidance of Professor Huamin Wang and his staff, the university is now accepting scholarship applications for this independent course offered through their medical program. The two chosen IAMAT scholars will take courses in microbiology, immunology, environmental health, emergency medicine, epidemiology, disease prevention, international travel medical insurance, international travel and health, and food safety and hygiene. All courses are taught in English.

Wondering what the goals of the IAMAT Scholarship Fund are?
Since 2002, IAMAT has awarded 17 scholarships to international scholars. The aim of our scholarships is to:

• Provide orientation and training in clinical best practices, including:
- Pre-travel health advice for international travellers.
- Attending to the medical needs of travellers away from home.
- Post-travel consultations and medical diagnosis
• Foster leadership skills for scholars to become a travel health resource person in their country.
• Promote cross-cultural exchanges of medical knowledge, processes, and procedures.
• Practice English language skills necessary for accurate communication.
• Prepare scholars for certification in travel health.

We'll be announcing the IAMAT-Hainan Scholarship recipients in the coming weeks. For more information, go to:

• Hainan Medical University: 2012 IAMAT-Hainan Travel Medicine Scholarship.
• IAMAT International Travel Medicine Education Program.

To contribute to the IAMAT Scholarship Fund, you can donate here.

Guest post by Professor Larry Goodyer, Head of the Leicester School of Pharmacy at De Montfort University in England. Dr. Goodyer is Immediate Past Chair of the International Society of Travel Medicine's Pharmacist Professional Group.

One of the most frequent questions asked by travellers relate to carrying medicines for their own personal use across international borders. This is often prompted when stories hit the headlines describing individuals who have been imprisoned and prosecuted for being found in possession of medicines that are freely available in their country of origin. What are the laws regulating carrying medications abroad and what are the risks to travellers?

Which medications can be a problem? Two classes of medicines – narcotics and psychotropics – are under the purview of international law. This covers any medicine that can have an effect on the Central Nervous System (CNS) and the potential to be abused. The narcotic class mostly relates to analgesic opioids and their derivatives (e.g. morphine and codeine) which tend to be highly regulated. Psychotropics are all those medications likely to be used to treat mental disorders such as anxiety, depression, and psychotic conditions.

Photo by Gravity X9 courtesy of stock.xchng

In practice, some countries will include a range of medications used to treat neurological conditions such as epilepsy and Parkinson's disease to their regulated list. Others would even include sedating antihistamines as a banned substance. The message is therefore to be wary of carrying any medicine with the potential to affect the Central Nervous System. However, a few countries such as the United Arab Emirates also include a range of non-CNS items such as contraceptive hormones.

What does international law say?
To view the international agreements governing the transportation of medications across borders check the International Narcotics Control Board (INCB) website. An independent and quasi-judicial organization, the INCB is responsible for international drug control. Their site contains statements and broad principles relating to travellers intending to travel with narcotics and psychotropics, mainly:

> That travellers should be allowed to carry quantities of such substances for personal use, usually for use of up to one month.
> That travellers have a letter or prescription from their doctor if travelling with a narcotic substance (but not necessarily for pyschotropics).

The INCB also requires countries to submit their own individual regulations which can be viewed here. The problem is that not all of them have submitted entries; many are quite vague, and most deviate in some way even from the two INCB principles described above.

Know your risk
Searching out the true regulations of your destination country can be extremely difficult. Country websites that might deal with questions relating to medicine regulations abroad are also quite hard to interpret. The often quoted suggestion of contacting embassies and consulates directly can equally be very frustrating in attempting to identify the correct official and obtaining consistent advice.

So what are the most practical suggestions to minimise the risks? There do appear to be some countries where regulations are quite strictly applied; the United Arab Emirates and Japan are the two best known examples. Otherwise take note of the tip points below. Despite this seeming confusion there do appear to be very few cases of travellers encountering serious problems, given that a large number of travellers must carry medicines for personal use across international borders every day.

Travelling with medicines checklist:

• Check the International Narcotics Control Board website if travelling with medications that are narcotics or psychotropics.
• Be aware of medications with potential for abuse (e.g. anabolic steroids).
• Be aware that many countries permit taking only a 30-day supply of certain medicines and require carrying a prescription or an import license certificate.
• Keep the tablets together with the original packaging and information leaflet. Carry a copy of your prescription, particularly for prescribed medicines that act on the Central Nervous System.

Before You Leave

• Find out which travel health vaccinations you may need for you trip and that they do not interfere with your current medication. Seek alternative medication regimen and protection mechanisms.
• Ask your doctor how to adapt your medication regimen across different time zones.
• Bring enough medication to last the whole trip; ask your doctor for an additional dose in case of an emergency. Be aware of false or mislabelled medication being sold in pharmacies around the world.
• Pack your medication in your carry-on bag. If you are travelling with someone else split the medication to minimize loss or theft. Don't pack medication in checked luggage or send it by post to your destination since it may get lost.
• Learn how to safely store medication and check if it requires refrigeration. Use insulated wallets or containers during transit (ask your pharmacist for recommendations) and make arrangements at your destination for safe storage. Keep in mind that extreme heat also impacts the medicine's effectiveness.
• Bring a copy of your original prescription and, if possible, keep the medication in its original packaging. Ensure that it is clearly labelled with your full passport name, doctor's name, generic and brand name, and exact dosage.
• Carry a letter from your doctor (preferably translated in the language understood at your destination) or an IAMAT Traveller Clinical Record describing your condition and the treatment plan. This will facilitate border crossing and help the attending physician abroad.
• If you need syringes, get a note from your doctor explaining their use. Find out from your airline or other transportation company about the use of syringes during transit.

During Your Trip

• Take your medication routinely and consistently. Do not reduce or stop taking your medication.
• If you require an emergency refill, show the attending physician the copy of your original prescription and letter from your doctor to facilitate the consultation. Be aware that some medications will not be available in your host country or that they may not come in exactly the same dosage that you require.

When You Return

• Follow-up with your doctor if you needed a prescription refill abroad to ensure continuity of care back home.

Did You Have Problems Travelling With Your Medications?
Professor Goodyer wants to hear from you. He's working on a project that is gathering stories from travellers who have had negative experiences (such as having medications confiscated, being reprimanded, fined or detained) while carrying medicines across international borders. Contact Dr. Goodyer with your story.