With concerns about malaria in Punta Cana resort area of Dominican Republic and Zika virus throughout the Caribbean, many travellers are coming to the realization that travel to developing countries do pose some limited health concerns. This handout was designed to address some of the common concerns of travellers to the Caribbean and Central America.

Traveller’s Diarrhea

This most common affliction of travellers (up to 60%) results from ingesting food or water contaminated with viruses, bacteria, or parasites. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever), or liver damage (Hepatitis A and E). The simplest piece of advice is “Boil it, cook it, peel it, or forget it!” Never eat undercooked meats or seafood, raw eggs, or unpasteurized dairy products. Eat only thoroughly cooked food or fruits or vegetables that you have personally peeled. Drink only bottled or boiled water, or carbonated drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. Wash hands often with soap and water. Don’t eat food purchased from street vendors. Remember that most Caribbean countries are poor countries and the living conditions for the hotel/kitchen workers may be less than ideal. Their hygiene practice is purely dependent on the quality/control of the hotel management therefore if standards get lax, your bowels may suffer the consequence. A simple omission such as the waiter not properly washing his hands could result in a spoiled vacation.

There are three considerations with regards to food contamination. The first consideration is Hepatitis A, which is spread the same way as Traveller’s Diarrhea. If you have ever had diarrhea then you have risked getting Hepatitis A, which is three months of jaundice, nausea, diarrhea, weight loss, and extreme fatigue. It is a ‘souvenir’ that few could afford. The World Health Organization feels so strongly that they have given a blanket endorsement that “all travellers from developed countries staying in medium to high end hotels in developing countries should receive Hepatitis A vaccine.” These are a series of 2 shots six months apart which should give you life-long immunity. The first shot will give you adequate immunity within a week. These shots are extremely well tolerated with no significant side effects.

The second consideration is the vaccine Dukoral® which can help prevent Traveller’s Diarrhea. It is a cholera vaccine, which also protects against Enterotoxic E. coli - a common bacterial infection causing one of the more severe forms of Traveller’s Diarrhea. It involves taking 2 sachets of powder (mixed with water) at least one week apart and starting at least two weeks before departure. It is effective for three months. This vaccine is best suited for travellers particularly prone to Traveller’s Diarrhea e.g. patients taking anti-ulcer medications, or those who want to do everything to minimize the risk of spoiling their vacation. It is quite effective in the Caribbean and Central America. I regularly give it to my ‘Mexican Snowbirds’ for their winter trip South.

The third consideration is treatment for more severe diarrhea. In cases of severe diarrhea, especially those associated with bloody stools, fever, or incapacitation, the immediate use of Ciprofloxacin/Zithromax along with Imodium can be vacation-saving. We can provide a prescription of an antibiotic for your own personal first aid kit.

Malaria/Dengue/Chikungunya/Zika

Malaria is present in the Caribbean in Dominican Republic and Haiti. Central American countries include: Mexico, Guatemala, Honduras, Nicaragua, Belize, Panama, etc. Resort areas in the Dominican Republic have had small localized outbreaks involving tourists in recent years around the resort areas of Punta Cana and Bavaro. The Public Health Agency of Canada even recommended using anti-malarial medications for the Bavaro/Punta Cana resort area a number of years ago but now it depends on length and nature of your stay. Popular Central American tourist havens such as Roatan (Honduras), Corn Island (Nicaragua), Belize, and Panama have some malaria risks. In certain cases, anti-malarial medications may be recommended.

Dengue is a flavivirus transmitted by Aedes mosquito. They are tiny mosquitoes that feast on people during the daytime (first 2-3 hours after dawn and mid-late afternoon but all day on cloudy days). Symptoms usually occur within 4-7 days with sudden onset of high fever, severe muscle and joint pain (“breakbone fever”), eye socket pain, nausea, vomiting and generalized weakness. Average duration is 6 days. There is no present vaccine (being developed) or cure.

Chikungunya is an arbovirus transmitted by Aedes mosquito (daytime biter). It is often confused with Dengue. Incubation is 2-3 days. Onset is sudden with fever and joint pain that can be severe. Many joints are affected and it may migrate. Other features include headache, muscle pain, weakness, chills, and gastrointestinal symptoms. Most patients recover from the acute illness within 7-10 days. After 1 year more than 20% of patients still suffer recurrent joint pains. Symptoms can persist for 6 months or longer, especially in older patients, and can be disabling. There is no vaccine and limited treatments.

Zika is another flavivirus disease transmitted by the Aedes mosquito with only 1 in 5 being symptomatic. Flu-like symptoms are the norm and are confused with Chikungunya or Dengue. The concern comes from the potential association with pregnancy and congenital microcephaly.

Your best defense is to be aware of the limited risk and take appropriate anti-mosquito measures. These include avoiding being out between dusk to dawn (malaria), wearing long-sleeved light-coloured shirts and long pants, avoiding scented perfumes/shampoos/body lotions, and most importantly, using DEET insect repellents. Most resorts will have air-conditioned, screened rooms so the risk of being bitten by mosquitoes at night is minimized. If this is not the case then permethrin-treated bed nets are essential. The daytime biting Aedes mosquitoes pose a challenge in that you must protect yourself during the daytime. Get in the habit of applying SP30 sunscreen first, wait 15-20 minutes then apply DEET (Deep Wood Off 25% or Muskol 30% - lasts 4-6 hrs.

Other Considerations

Tetanus/Diphtheria: should be updated every 10 years for all travellers.

Pertussis: “whooping cough” – making a serious comeback in Canada in recent years – can be given together with tetanus/diphtheria booster (covered by Public Health)

Flu shot: recommended for the simple fact that someone in the airport or on the flight may have influenza and will potentially infect you and spoil your vacation.

Hepatitis B: transmitted by close contact – saliva, body fluids, blood, etc. If you engage in high risk behaviour then it is recommended but such things as poor medical care or dirty spa equipment may be a potential risk. Vaccine is lifelong but must be started at least one month (ideally 2 months) before you go. Younger travellers (less than 35 y/o from Ontario have usually been offered these shots in grade 7).

Rabies: stay away from all animals; especially stray dogs - a potential rabies threat. I have seen many ‘good Samaritans’ trying to save emaciated stray dogs unaware of the risk of contracting rabies. Generally stay clear of all animals in poor countries. Finding the vaccine in developing countries will be a considerable challenge.

Motor Vehicle Accidents: a leading cause of prematurely terminated holidays. Remember that driving in a developing country is a whole different "sport" full of unimaginable hazards e.g. aggressive drivers, un-roadworthy cars, goats crossing the road, poor roads, etc.

Assault/Rape/Robbery: tourists in "holiday" mode may be unaware of potentially dangerous situations. Inability to understand the language, ignorance of local customs/conditions, and general naivete can lead to potentially disasterous results.

Poor Medical Care: vacationers rarely consider the possibility of getting ill or injured. The reality is that up to 10-15% of travellers may end up seeking medical care, which poses many potential hazards. Poor hygiene techniques, lack of medical supplies, expired medications and vaccines, and generally substandard medical care, are all legitimate factors that can lead to a poor outcome. Best medical advice is to simply avoid getting sick or injured!

Remember that a safe trip is a happy trip. Enjoy your vacation but be smart!

Prepared by: John O. Lee, M.D., C.C.F.P., F.C.F.P., Certificate in Travel Medicine