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Travel Health Myths with Dr. Christopher Sanford

06/24/19 Christopher Sanford, MD, MPH, DTM&H, University of Washington;

Season 1 | Episode 6

Description: When traveling to foreign lands, you want to embrace local customs and “do as the locals do.” But is it safe? Dr. Christopher Sanford, the author of “Staying Healthy Abroad: A Global Travel’s Guide,” discusses common myths about staying safe and healthy while traveling abroad. 




>> Dr. Christopher Stanford: I saw, for example, recently a young man,he’d been in Bangkok, and he had some GI upset nothing too bad, and then he said “Oh and by the way, I ate some barbecue bat on a stick, is that a problem?” And I said, “Oh goodness,well at least tell me it was well cooked” and he was like “Oh no, no, no it was almost raw, it was juicy, bloody, really tasty with some spice.” That’s problematic because mammals can transfer rabies and I think he ended up spending about 2500 dollars on rabies post-exposure treatment.

>> Narrator:    Welcome to the Medical Myths podcast where we set the record straight on today’s most talked about medical topics and questions. On every episode, you’ll hear stories from the frontlines of medical care to help dispel common myths and answer some questions you’ve been itching to ask your doctor. Remember, you can always find more information on this week’s topic and hundreds of others on Now, here’s your host, editor in chief of the Merck Manuals, Dr. Robert Porter.

>> Dr. Robert Porter: I’m your host, Dr. Robert Porter, editor in chief of the Merck Manuals- one of the world’s most trusted medical resource. On this episode, we welcome Dr. Christopher Stanford, associate professor in the departments of family medicine and global health at the University of Washington. His guide for travelers, Staying Healthy Abroad: The Traveler’s Guide, just published in December. Dr. Stanford also authors the travel health section of the Merck Manual.

>> Dr. Stanford: Rob, thanks so much for having me as a guest today.

>> Dr. Porter: We’re so glad you could join us today, Dr. Stanford! Now when people are planning a trip abroad, a lot of people have visions of embracing local customs, eating unique and exotic foods, and having new experiences. The last good trip I took was to New Zealand, and I did bungee jumping and jet boat riding, but then there are other people who are just worried about traveling abroad, and they are so concerned that they even hesistate to leave their big chain hotel, much less go on an adventure. So, Dr. Stanford is here to help us figure out what’s the right balance of risk vs. worry when getting ready for trips and while they’re traveling.

>> Dr. Stanford: I think travel is almost always a good idea, so I think many people are concerned especially when they go to low-income countries that they’re intrinsically dangerous which I don’t think is true, but I think most of the risk to the extent it is there determined by what you do and what you don’t do and not so much where you go to.

>> Dr. Porter: What kind of things might somebody do that would get them into trouble? How about my bungee jumping?

>> Dr. Stanford: I have not read extensively in the bungee jumping literature- I don’t do it myself, and I don’t think injuries are very common. The things that are more common would be the more mundane things like automobile accidents, motorcycle accidents. In terms of embracing what the locals do, some people think like “oh if it’s done there that means it’s safe.” But you need to judge these things on a case by case basis, and there is a general rule that if something is unsafe at home that it is also unsafe abroad and this would be, for example, riding a motorcycle without a helmet or riding on the roof of a bus or riding on the roof of a train. Some people want to join the locals, but if it’s dangerous here, then it is also dangerous for the locals to do that around the world.

>> Dr. Porter:  So then, traumatic injuries may be a bigger concern than some of the exotic infections?

>> Dr.Stanford: Well you know very much, sort of counterintuitively when I see someone for a pre-travel encounter, I certainly talk about the certain infectious topics. I talk about immunization, bug bite avoidance, and malaria medication when appropriate, but I always leave time to talk about thing like, car crash avoidance because when you look at the rare bad things that happen to travelers, things like car crashes are much more common than serious illnesses or infectious diseases.

>> Dr. Porter: What about people who have a medical condition and are trying to travel?

>> Dr. Stanford: The good news is that most people with most medical problems can go to most destinations. So if someone has anything from diabetes to epilepsy, As long as the conditioned are well controled at home, I think it is reasonable to travel to most destinations, but some additional preparations may be necessary. So for example, if someone has coronary artery disease or chronic constructive pulmonary disease, they can travel, but they maybe can have limitations on high altitudeor on hiking. Another exclusion would be it is abosolutely a bad for any pregnant woman at any stage of pregnancy to scuba dive. That could be bad for the fetus, bad for the mom so you can snorkel but I would not recommend scuba diving if you are pregnant or potentially pregnant. Also, if a condition is not well controlled, if someone is in the Emergency Room once a month, then it is probably not a good idea to go to low-income countries where there can be significantly less medical care.

>> Dr. Porter: Wow, that’s interesting Dr. Stanford! So we’re talking about the special cases, let’s add a different one to that, what about the extremes of age. Travel for the really young infant and the elderly, do they have special considerations?

>> Dr. Stanford: You bet. Babies below certain ages can’t get vaccines for certain illneses, so they are a little more elevated risk of some infectious things. It’s a case by case basis, if I see someone who is very young, the most important thing I talk about is something like a car seat, because like adults their biggest risk is not infectous things like car crashes. Elderly people tend to be a little more frail, but increasingly people are in their 80s and beyond are going around the world and I would often see people in their late 80s going on a safari, and most of the time I say “This sounds like a great idea, and how can I help?” They should take a few things with them, they should take all their medications of course with them, and they should pack that in their carry-on and not their checked luggage, and all medications should be labeled and left in their original bottle, so there are no questions at customs. If someone has a chronic cardiac condition, then it is a good idea for them to bring a copy of their most recent EKG so if there is any episode or  need for medical care the doc can compare that to the one back home.

>> Dr. Porter: I wish patients in America would keep their medicine in their original containers; I know many times in the ER I’ll ask a patient “Well what are you taking?” and they pull out a bottle with 8 different colored pills in it and, “I take the pink one in the morning and the blue one in  the afternoon…”

>> Dr. Stanford: It’s not a bad idea for someone with a complex medical history to take a one-page summary that either they’ve written up or their doctors written up with a list of medical conditions and medication

>> Dr. Porter: And I guess all the relevant phone numbers for their clinicians so that caregivers abroad could contact them if they need.

>>Dr.Stanford: You bet, and if appropriate fax numbers and emails.

>>Dr. Porter:   One common travel myth is that if you’re staying at a really fancy hotel or only traveling for a day or two on business that you’re not really at any risk, is that true?

>> Dr.Stanford: Well certainly not and certainly is that risk is dependent on the duration of stay, so a short stay person has lower risk, but not so low that you don’t want to do the usual precautions. There have been studies on where people get diarrhea and not only does a 5-star hotel not reduce your risk of getting traveler’s diarrhea, some studies show that is may even slightly elevate it relative to a standard routine. That may be due to the phenomena of the buffet where you have 3 or 4 mystery liquids bubbling under lights all day, and that’s a pretty good way to grow different bacteria.

>> Dr. Porter: Ah, something else to avoid. Let’s talk about getting ready for a trip – certainly the first thing I think of in a trip is shots. What kind of immunizations do people need to think about?

>> Dr.Stanford: Well of course it depends on where they are going. For the whole planet, I recommend the standard US schedule as put out by the CDC so even if someone is going one state over or even if they’re not I thing it’s a good idea to be current on the standard schedule. A lot of people come in to me and the first thing they want to talk about is the travel vaccines and that would include thing like typhoid fever and yellow fever. But the first thing I want to talk about when it comes to vaccines are the domestic standard vaccines because when you look at what illnesses people get when they have not been vaccinated for anything the things on the routine schedule are actually much more common on the travel vaccines. So, for example, you have people who have had no vaccines, and they travel by far the two most common vaccine preventable illnesses are influenza and hepatitis A, and especially influenza, but also more recently hepatitis A are both routine US schedule, so the first thing to do is do all the domestic things, and that will actually give you a significant amount of protection. But then other ones that I commonly talk about would include typhoid fever which is the most common of the travel vaccines that I give, but also depending on itinerary and activities, yellow fever, Japanese encephalitis one or two more.

>> Dr. Porter: Okay so people really need to talk to their doctor based on where they are going so, we can guide them.

>> Dr.Stanford: And a helpful thing to bring in along when they see the doc would be their past vaccines because the computer systems in the US don’t talk to each other such that  If you’ve been somewhere besides my university, and they have not seen your vaccine record and that can entail to a lot of deaths and duplication, so bring your vaccine record in. Also, take your itinerary. Some people say,“oh my spouse scheduled the trip, I’m just going somewhere outside of South East Asia,” and that helps me less than knowing names of countries and names of cities and exact dates. Because for example in Thailand, there is malaria in some areas and no malaria in others, so I really need to know pretty exactly where people are going to if I want to address that problem accurately.

>> Dr. Porter: What should people know about malaria prevention when they are traveling abroad, how do they deal with that?

>>Dr. Stanford: Malaria is a protozoan illness, a one-celled organism that it is spread by mosquitos; it is a life-threatening illness,  it is present in about 100 countries around the world. It is a fair generalization to say it is present everywhere in or near the tropics and it’s life threatening if don’t take medication and you go where there is malaria, you may get malaria which kills people. So I recommend taking a medication, there is medications with these days that have very low side effect and they take the medication and they don’t get malaria which depends on the type of medication they get. There are two big categories of malaria: chloric and sensitive & chloric and resistant. Used to be, about 50 years ago that chloric used to work everywhere around the whole planet, but now it works in about ten countries. But for most of the world, most of Latin America, most of Africa and most of Asia, we have to give one of three drugs to present chlorical resistant malaria.

>> Dr. Porter: Do people have to start taking malaria medicine before they go?

>> Dr. Stanford: They do. Each of these is taken a brief duration before entering the malaria area, how long depends on which medication. So if they are going to a chloric and sensitive area such as Haiti, then they are taking a chloric one, they need to start one to two weeks before they go. If they are taking Malarone, which one of the drugs for chloric and resistant Malaria, they start one or two days before they enter the area in addition to taking it then once a day while they are there and also for seven days after they leave. Each drug has a particular schedule.

>> Dr. Porter: So, we’ve been talking about prescription preventatives, but what can people take in their own personal medical kit that they can just get on their own?

>> Dr. Stanford: Well quite a few things, I always travel, I go to Uganda every year to teach a tropical medicine course, and most drugs that I use here over the counter things are not available in most of the world. So think about the drugs you’ve used in the last 12 months, have you used hydrocortisone cream for a rash, have you taken ibuprofen for a headache.  Anything like that you’ll want to pack with you. Of the over the counter nature those would be a few thing. I take an anti-fungal cream, an anti-inflammatory cream, maybe an antibiotic cream, Tylenol, advil, maybe some diphenhydramine which is an antihistamine; just a few things that may come up I take some bandaids and such. I don’t take a ton, this whole kit might end up weighing one pound but I think about the common things that might happen and I’ve found that to be very convenient while traveling.

>> Dr. Porter: How about for diarrhea, do you recommend people take an anti-diarrhea with them?

>> Dr. Stanford: You bet, I kind of recommend a four-stage plan for diarrhea. For your basic healthy traveler, I don’t recommend anything preventatively. Although if you want to take something preventatively actually, Pepto Bismol works, Bismuth subsalicylate, but you have to take two pills four times a day for the entire trip and it reduces your risk of diarrhea. But it’s hard to remember something four times a day plus you get a black tongue which looks kind of weird. In terms of what I recommend, is that you take nothing if you feel good, for mild diarrhea a very good drug is called loperamide served under the brand name Imodium which we call a gut anti-mobility agent. Make you a little tired, it slows down your gut and is good for mild diarrhea. If you get bad diarrhea, diarrhea so bad it’s watery and limits your mobility then you could take one or two drugs – you could take Imodium by itself, or you can add an antibiotic, and one we commonly prescribe for that is Azithromycin. The final stage in that plan is if you’re sicker than usual like blood in your stool or you have a fever, don’t take the Imodium, go see a doctor because we might not be dealing with routine traveler’s diarrhea.

>> Dr. Porter: How can you rehydrate especially if you’re supposed to avoid the water?

>> Dr. Stanford: Generally, you can rehydrate with pretty much anything safe that would be bottled water or even soda pop or weak tea, I would avoid tap water for that. Now an exception to that is if people of extremes age like babies or people over 65 indeed might get depleted of electrolytes and they would do better with oral rehydration solutions per se. But for healthy adults outside of extreme age, they can rehydrate which pretty much anything and they have to drink a lot, you know a several glasses to a point of where your urine should be close to colorless.

>> Dr. Porter: Should parents travel with some packets of oral rehydration solution if they have young children?

>> Dr. Stanford: If they are traveling with a kid under the age of two I would. You can mix it on the spot; there are some recipes for that or just take some packets which parents find convenient

>> Dr. Porter: How about long-distance jet travel, is dehydration a concern there?

>> Dr. Stanford: Well again it depends on what you do but for many people, yes. A lot of people treat jet travel like a party, and instead, I would encourage them to treat it like an endurance, athletic event. By which I mean wear comfortable clothes, drink a lot of water, sleep when you can and stay well-hydrated. The air on a jet can get very dry so you can get a little dehydrated, so drinking a lot of water and avoid alcoholic drinks, and people typically feel a lot better when they get to their destination.

>> Dr. Porter: Thanks Chris. Let’s stop here for a quick break and hear a few words about the Merck Manuals.

>> Commercial: Today, is the best first place to go for information on hundreds of medical topics... and do you want to hear the best part? There’s no sign-in required, and we won’t clutter your inbox with emails. Now back to Dr. Porter and the Medical Myths podcast.

>> Dr. Porter:  We are back with Dr. Stanford. When people are taking their medications overseas are there any concerns medications being restricted in some countries that are perfectly valid here?

>> Dr. Stanford: For most travelers, most of their medications are no issue. Like I said keep them in the original container from things like an antibiotic to blood pressure medication should be fine, it is a good idea to go on to a website and check it out before you go because there are some idiosyncratic rules. So for example, Adderall, amphetamine, which is taken for attention deficit disorder is illegal in a number countries around the world. And there is some quirky stuff like coming up in 2020, the Olympics are going to be in Tokyo, and a lot of people are going to be going there a good place to find out information is to search Japanese consultant or Japanese embassy and there will be a statement in English.  One of the over the counter things they ban there is pseudoephedrine which is for head colds and is the active ingredient for Sudafed. But it is banned, and they will take it away from you at a minimum. So it is better to read that in advance, so you aren’t startled when you get there. Things you have to be careful of would be like a large number of narcotic pills. If you have a chronic pain condition and you have a lot of controlled opioids, pain pill you probably want to take a letter from your doctor about what you’re taking, explaining the duration why you are taking it for. Because if there is any suspicion of you taking them recreationally, then you are going to be spending more time with customs than you want to.

>> Dr. Porter: Well that’s important to know, I think the last time I went to Japan on business, I think I did have pseudoephedrine in my medical kit, so I’m glad they didn’t search me.

>> Dr. Stanford: Oh, wow you could’ve spent time in prison… I’m exaggerating, but they would have taken it from you, frown on you and given you a big lecture about it

>> Dr. Porter: Now one of the things I know I suffer from and our listeners suffer from when traveling is jet lag. What advice can you give us on jet lag?

STOP 18:29

>> Dr. Stanford: Jet lag is really common when you travel more than 3 or 4 time zones away from home and we all know it we’ve all felt it, you feel spacey a few days, you are sleepy at the wrong time, and you are awake at the wrong time. It goes away if you do nothing but is still very bothersome. Strategies to deal with it would be to leave it alone and ignore it or get something over the counter like melatonin. Or there is another method that not many people do where you alter your sleep schedule before the trip to match the time zone you are entering, but people are usually busy before a trip, so they don’t really have time to do that. A couple of things I recommend is either nothing which is reasonable or melatonin which is sold by most health food stores. And another thing that might be useful for a few nights would be something like Ambien.  It’s a prescription medication that people can take that causes sleepiness. Similarly, to melatonin they can take this for a few nights at their destination, and some people get benefit from that, and some people don’t, but it is certainly reasonable to try.

>> Dr. Porter: When people come to you before a trip what is their understanding of medical care? Do they usually think their insurance covers it?

>> Dr.Stanford: A lot of people do make that assumption and some people ask me, but rules are different per insurance plan. For example, Medicare does not cover care outside the country – a really good thing to do is to call the member services phone number on your insurance card and see if you’re covered or not, some do, and some don’t, some want you to bring your receipts back, and some don’t. They’re all different, and it’s a good idea to get a couple of different types of insurance. Say your insurance does not cover you outside the country; it is a good idea to buy a temporary insurance plan for medical care and often a separate plan for emergency medical evacuation. Some airline tickets include that, a lot don’t, so suppose you are in Kenya, and you’re in a car crash and break your femur, the big bone in your thigh, it could easily be $75,000 to $100,000 to fly you to a different country for treatment. It is beneficial to buy insurance to save a little money, and if you need emergency evacuation, they pay for it at no additional charge.

>> Dr. Porter: Yeah that’s a bill you wouldn’t want to get.

>> Dr. Stanford: Yeah, no joke.

>> Dr. Porter: Now, we’re both physicians, so we tend to focus on the medical aspects of travel, but in your experience in travel what are things you like to tell your patients about non-medical things when it comes to travel?

>> Dr. Stanford: Yeah it is a good idea to read about where you are traveling to. People have different assumptions and different patterns around the world and if you don’t know that about the place you’re going to you could commit a faux pas without realizing it. So, I recommend that when you leave the country, especially from a high-income country, that you buy a guidebook like the Lonely Planet series or Frommers – most of those have sections on appropriate actions, and there are a million little rules that are not intuitive around the world. For example, if you’re in Asia and giving someone your business card, it is a good manner to do it with two hands and not with one hand. If you are in a Muslim populated country dressing conservatively is a good idea, and if a woman is entering a mosque, dress covering her hair is a must. So doing the reading before is a must. And if you’re part of the LGBTQ community, it is a good idea to read how friendly or unfriendly the country is because while places like in Western Europe are very inclusive a lot of Saharan and sub-Saharan African countries are not and it is good to know that before you go.

>> Dr. Porter: Now, some people like eating local delicacies and local foods, are you an adventurous eater when you travel?

>> Dr. Stanford: Good question, the short answer is no I’m a pretty boring eater, I follow that standard rule boil it, peel it, cook it or forget it and so things I would avoid is tap water when I am outside of high-income countries. So I’ll drink the tap water in France or Germany, but not in most of Africa or most of Latin America. I avoid roadside food, raw food – I like sushi, but I eat it in the US and also ice. Ice does not kill most microorganisms uh so I avoid those things.

>> Dr. Porter: What’s the most unusual thing you’ve ever eaten abroad?

>> Dr. Stanford: Well I met with doctors in China and I just trusted them and ate whatever was put in front of me. I remember having chewy jellyfish and crisp jellyfish and other things I’m not sure what they were. But if you’re at a nice place like that, I think it’s a personal call, but I highly doubt your host is going to give you something that is going to give you diarrhea.

>> Dr. Porter: Yeah, my rule in those situations is to just not ask what it is, if the other people are eating it then I’m going to eat it, and we are all happier that way. One time when I was traveling in India there were street vendors with hand-cranked presses, and they had a little wagon load of sugar cane sitting there and a bucket with a big chunck of ice and some limes and to me that looked like the best drink in the world. It was summer, it was hot, I was thirsty, and it took all my will power to not drink that limeade. So, what are some things that people have eaten abroad that are trouble?

>> Dr. Stanford: One part of my practice that I enjoy, is that I do post-travel medicine. If someone gets a fever or a rash or diarrhea or something abroad, they will tend to see me in consultation when they come back. And one thing I like about that is that I get to hear what people do abroad that is sometimes eccentric or something I wouldn’t have done. And recently I saw, for example, a young man, he was recently in Bangkok, and he had some GI upset nothing too bad, and then he said: “Oh and by the way, I ate some barbecue bat on a stick, is that a problem?” I was like, “oh well at least tell me it was well cooked” and he was like “oh no, no, no it was almost raw- really bloody really tasty with some spice.”  That’s problematic because not just because of the diarrhea risk but mammals can transfer rabies so after a lot of talk with him we had to give him a shot of rabies immune and then do the whole rabies series, and I think he ended up paying 2500 dollars on rabies post-exposure treatment. So, in general, if things are well cooked, they are safe, heat pretty much boils and kill anything.

>> Dr. Porter: That’s a great story and a great example to watch what you eat when traveling abroad. We like to close out by asking our guest their three major takeaways for listeners so what are the biggest things you’d like everyone to remember?

>> Dr. Stanford: The first would be that risk is more determined by what you do rather than where you go. So I think it is reasonable to travel to 99% of the planet and you can make any place safe or unsafe based on what you do. So just remember that you are the master of your own fate and your behavior will determine if you are safe or not. My second point would be that the noninfectious causes would be the ones to be concerned about so I think a seatbelt or a car seat would be the most helpful thing, helmet when riding a bike, flotation device if you aren’t a good swimmer – that sort of thing. My third and final point would be that travel is almost always a good idea. I am a great travel enabler whenever I see someone, no matter where they tell me I often say “that sounds like a great idea and how can I help you do that.” I think that I and a lot of the travelers that I see think that traveling is one of the most enriching things in their lives and I try to facilitate the process whenever I can.

>> Dr. Porter: So that was a lot of really good information, I certainly learned a lot. Now, why don’t you tell our listeners where they can go to get more information about this?

>> Dr. Stanford: A really good one is actually the CDC they have a lot on disease prevention, and they have a lovely website,, and they have something called traveler’s health, and you can search by either country you’re going to or by a medical problem. It is very elusive high-grade information that has a lot of evidence on everything from diarrhea to malaria to dengue fever. Another site is it is the US state department, and they have a statement on every country in the world about crime, security, terrorism and it is pretty pragmatic and has ways to enlist in their program and places in towns to avoid and things like that. And the final site is a Canadian non-profit called IAMAT, the international association for medical assistance travelers, and they give a list of certified English speaking travelers around the world should you need emergency assistance. And then, of course, there is the Merck manuals, it has high-quality information on pretty much any medical topic and has chapters on travel medicine. 

>> Dr.Porter:   And I’d like to add if you need any more information Dr. Stanford has a new book Staying Healthy Abroad: The Global Traveler’s Guide and has things that we talked about today. So, thank you, Dr. Stanford, for your time and expertise everything you’ve said today we certainly learned about travel and as we say at the Merck Manuals:

>> Dr. Stanford: Medical knowledge is power, pass it on.