Jackson Hole Travel & Tropical Medicine
Call Dr. Shlim to schedule an appointment. Dr. Shlim schedules pre-travel appointments, and can also arrange to see people who are recently returned from travel and may need medical advice.
Jackson Hole Travel & Tropical Medicine provides pre-travel advice, immunizations, and prescriptions for any travel destination in the world. We also provide diagnosis and treatment if you return from your travels with a travel-related medical condition. We have all travel-related vaccines in stock.
Each appointment is approximately forty-five minutes and covers immunizations, medications, travelers’ diarrhea, rabies, other disease risks, and—if relevant—malaria or altitude illness.
Please call: (307) 201-1480 to make an appointment.
After you’ve made your appointment, try to find any records that you have for previous travel-related immunizations. Some vaccines last for life, and some need to be repeated regularly, so knowing the dates of your previous immunizations will be a big help. Try to find out when you last had a tetanus booster (this may be listed as Td, or TDAP in your records).
Try to have the information about your exact itinerary available for your appointment. If you don’t have an exact itinerary, that’s fine, just let us know where you think you may be traveling so that we can give you the best advice we can.
If you travel to a developing country, the risk of acquiring diarrhea from eating
contaminated food or water is much higher than here in the United States. Most of the
risk is from poor restaurant hygiene practices. All tap water should be assumed to be
contaminated. Water can be purified by chemical means, or by boiling. Filtration works
only if associated with a chemical method.
Ninety percent of traveler’s diarrhea is due to bacteria that can be treated with an
antibiotic. The sudden onset of relatively uncomfortable diarrhea is caused mainly by
bacteria. If you experience sudden, uncomfortable diarrhea, you can take an antibiotic
right away to shorten the illness to one day in most cases. These are the two most
commonly used antibiotics:
• Ciprofloxacin 500mg—take one pill to start, and a second pill 8-12 hours later.
This is the drug of choice for most destinations.
• Azithromycin 500mg—take 1 pill per day for 1 to 2 days. This drug is necessary
in countries where the bacteria have become resistant to ciprofloxacin.
If your schedule requires traveling away from a toilet while experiencing diarrhea, you
can take Imodium (loperamide) 2 mg. Imodium is available without prescription, and is
taken as follows:
• Imodium 2 mg—take two pills to start, then one pill after each loose bowel
movement until the bowel movements stop. This is usually achieved with 3-4
pills total. Do not exceed 8 pills in any 24 hour period.
Imodium can sometimes stop the bowels for longer than one wants, so it is prudent to
reserve its use for situations involving travel away from a toilet. It is safe to use if taken
along with an antibiotic.
On longer journeys it is possible to develop infections with other organisms, such as
Giardia and amoebas. These organisms generally cause infections that start more
gradually and are less severe, but longer lasting. A stool exam is often needed to make a
clear diagnosis, but treatment can sometimes be based on symptoms alone.
Treatment for Giardia: Tinidazole 500 mg (four pills all at once each day for two days)
For further information read: The Health and Safety Section of Trekking in the Nepal
Himalaya, published by Lonely Planet. Or visit the website of the CIWEC Clinic in
Traveling abroad can make you susceptible to respiratory infections. Most respiratory
infections begin as viral infections of the nose and throat—what we think of as the
common cold. Ordinarily, we can fight off these infections within a few days. However,
under the stress of travel or living in a developing country, or changing many time zones,
our immune system can also be under stress. Travelers with respiratory infections
accounted for 25% of our medical practice when I practiced in Nepal.
There is no specific treatment for a cold in its early stages, and giving antibiotics early in
the course of a cold has no value, either in treating the current infection, or preventing a
complication, such as sinusitis or bronchitis. However, the virus that causes the common
cold is almost always gone within seven days. At that point, if your cold is getting worse
instead of better, or simply not improving, taking an antibiotic can be a big help.
Persistent sinus symptoms and cough that result from a common cold are almost always
caused by bacteria that live full time in your nose and throat. The viruses that cause colds
can allow these bacteria to move into your sinuses or lungs and set up their own
infection. That’s why antibiotics can be of benefit after the virus is gone—it is now the
bacteria that are causing the problems.
A convenient antibiotic to carry in case of a prolonged cold is azithromycin 500 mg
(Zithromax). If you decide to treat your persistent respiratory infection, take one pill
per day for three days. Remember to wait at least 6-7 days after your cold begins
before starting the antibiotic. If you suspect pneumonia—a serious lung infection
associated with fever—seek medical advice as soon as you can.
When traveling it is possible to get severe bacterial skin infections from minor skin
wounds, such as a bug bite or minor scratch. Although this is relatively rare, it can be
very uncomfortable, and require treatment with antibiotics. If you develop swelling,
redness, and pain around a wound, it may be worth treating with an antibiotic.
Azithromycin 500 mg once a day for three days will treat the bacterial skin infection.
Rabies Prevention in Travelers
Rabies is a uniformly fatal viral infection of the brain that is transmitted by the bite or
scratch of an infected mammal. Dogs are the source of 96% of human rabies cases. Semidomesticated
urban and rural dogs are the main reservoir for rabies in developing countries.
Rabies infection can be avoided by not getting bitten in the first place. Being very aware
of dogs can keep you from accidentally wandering into their space, or not seeing a dog
approaching you. If a dog is charging you, pick up a rock—or even pretend to pick up a rock—
and the dog will likely turn around immediately and run away. When visiting temples in Asia that
have monkeys nearby, avoid carrying any food with you.
If you are bitten by a potentially rabid animal, you will need to obtain human rabies
immune globulin (HRIG), plus 5 doses of rabies vaccine over a period of one month. HRIG is
virtually unavailable in most developing countries. This means you may have to fly to get the
treatment that you need. One can avoid the need for HRIG by receiving 3 doses of rabies
vaccine before you travel. If you have pre-exposure rabies immunization, you do not need HRIG
after a bite. However, if you are bitten after a pre-exposure series, you still need 2 doses of
rabies vaccine, 3 days apart as a booster. Good quality rabies vaccines are often available in
developing countries, which means that you may be able to obtain the two booster doses without
leaving the country.
If you are bitten by a mammal while traveling, you need to think WAR. WAR stands for:
Rabies virus does not travel to the brain via the bloodstream. It stays in the area of the wound
until it can enter a nerve ending. The virus can be washed out of the wound, or killed in the
wound with betadine or another antiseptic. Wash the wound with soap and water as soon as
possible, then pour betadine (povidone-iodine) straight in the wound. Irrigate thoroughly with
water afterwards. If the wound is large, avoid suturing the wound initially. It can be closed after
a few days, if cosmetically or functionally necessary.
If you have never had rabies vaccine, you must get human rabies immune globulin (HRIG)
injected into and around the wound. The amount of HRIG needs to be carefully calculated,
based on your weight, not on the size of the wound. If all of the HRIG cannot be injected
around the wound, the remainder is given in the buttocks or deltoid muscle. If you have been
pre-immunized against rabies, you do not need HRIG.
There are three rabies vaccines in the world that are acceptable: human diploid cell vaccine,
purified chick embro cell vaccine, and purified vero cell vaccine. There are other versions of
rabies vaccine in some developing countries, but these should be avoided. If you are preimmunized
against rabies, you just need two doses of rabies vaccine, 3 days apart. If you are
not pre-immunized, then you must obtain HRIG as above, and start a series of 5 rabies vaccine
injections on days 0, 3, 7, 14, and 28. Different brands of vaccines can safely be used in the
Because HRIG is in short supply around the world, you may experience a delay between
the bite and getting definitive treatment. Generally speaking it is safe to start the post-exposure
treatment 4-5 days after the bite although earlier is, of course, better.
Malaria is a serious disease that is transmitted by mosquitoes in certain parts of the world. In order to prevent malaria, where the risk exists, you need to avoid mosquito bites as much as possible, and take an oral medication while you are traveling.
The risk of malaria can be described in three general ways:
1. The risk is great enough that everyone should take malaria pills.
2. The risk may exist, but it is so low that many people would choose not to take malaria pills, but some may choose to do so.
3. There is no risk of malaria
If you are traveling to a malaria area and the decision is made to take malaria pills, the most commonly prescribed pill is called Malarone, also known as atovaquone/proguanil. This is a remarkably well-tolerated medication with few side effects, highly effective at preventing malaria, and only has to be taken while traveling and for a few days after.
Malarone should be taken starting the day you enter the malaria risk area, and taken once a day while you are there, and then for three days after you leave.
You should be aware that when Malarone was first licensed, it was recommended to be taken two days before you enter the malaria area, and for seven days after. This is probably longer than is necessary, and subsequent studies have shown that the shorter duration of time taking the medication will be just as effective, and easier to comply with.
Malarone is absorbed better when taken with food, but it is safe, and still effective to take it on an empty stomach. My recommendation is to take it with breakfast each morning, so you don’t have to remember to take it at night when you are tired, or have had a few drinks.