Welcome back. In this section we'll be talking about rabies, altitude and sun exposure. I know seems like a really weird matching, but I promise they're all important considerations for travel health. Rabies a zoonotic disease the affects a number of wild mammals in most parts of the world. And if I remember my tropical disease class right, I think it used to be that bats and dogs were the number one carriers of rabies. But now it's cats. So, just be on the lookout for wild mammals while you're traveling. Transmission of rabies occurs through the bite of an infected animal, but it can also occur through other contact like a penetrating scratch, or even the licking of broken skin. You should avoid contact with free-roaming animals, especially dogs and cats, and with wild, free-ranging or captive animals. Rabies is an acute viral disease which is almost always fatal. And approximately 55,000 human deaths are due to rabies each year, mostly in Africa and Asia. The risk to travelers in areas where rabies occurs is really proportional to the probability of contact with rabid mammals. This really goes back to that concept of your risk profile, where you're going to be, and whether you plan on touching animals while you're there. Since rabies is a lethal disease, medical advice should be sought immediately at a medical center if you suspect that you've had any contact with an infected animal. And one thing that you should think about as soon as you get in country is asking where, if anywhere in the country you could get rabies post exposure prophylaxis. There is a rabies vaccine, but this vaccine is a little bit of a bear. It can be used in two situations, so it can be used to protect those who are at risk of exposure to rabies as a pre-exposure vaccination. And it can be used the prevent the development of clinical rabies after exposure has occurred. So this is generally after you've been exposed through the bite of an animal or a scratch, and this is post-exposure. The vaccines are the same but they're on different schedules, and even if you've had pre-exposure vaccination and you become exposed to rabies, you will still need post-exposure vaccinations. You can see how this is a little bit of a confusing vaccine. There's a lot of steps and a lot of considerations. And then of course because there are so many series in the vaccine whether pre-exposure or post-exposure, and the availability is so limited, this can be an expensive vaccine. So you have to take into consideration what your risk profile is, if you actually think it's something you might encounter depending on how long you're going to be somewhere, where you're going to be. And then also think about whether your insurance will cover it, So if it covers it, for me it's a bit of a no-brainer, you should go ahead and get it. As I just mentioned, the post-exposure vaccination which includes rabies immunoglobulin is in short supply and it's not often available even in urban centers. So I've known people who have had to be flown out from West Africa to Europe in order to get post exposure vaccine, and this is really scary when you know that clinical onset can happen quite rapidly. Next, we'll talk briefly about sun exposure. And one of the reasons why I wanted to pair rabies with sun exposure is because I think rabies is this really complicated issue where you're thinking about, money, your risk level. There's just a lot of factors. But with sun exposure, it's quite simple. The likelihood is that as you travel you will have increased exposure to the sun and to UV radiation. Increased exposure to UV radiation occurs near the equator during Summer when many of you are likely to travel, and at high elevation. Photo sensitivity is also increased by several medications, including some malaria prophylaxis, which we talked about in a different section. Antibiotics, and acetazolamide which helps to reduce altitude illness. So how do you prevent sun exposure? Well, you can avoid over exposure to the sun, wear protective clothing, so long sleeve clothing. I mean, a lot of the things we talked about to prevent vector borne diseases really apply to preventing sun exposure as well. And using sunscreen is really important. But remember that if you are using both sunscreen and DEET-containing insect repellents that there is a weird interaction that happens between these two. And DEET can decrease the SPF of sunscreens by one-third. So if you're going to be using both at the same time, you should apply sunscreen before applying DEET, and then remember to reapply your sunscreen more often. We'll wrap up this section by discussing altitude illness. High altitudes expose travelers to increased UV radiation, which we just talked about with sun exposure, decreased air pressure, cold, and hypoxia. And symptoms of having altitude illness can often include headaches, fatigue, a loss of appetite, nausea and lethargy. So if you're at high altitude, be aware of some of these symptoms and just be mindful. The best indication for how you will perform at high altitude, whether you're going to have those symptoms that I mentioned on the previous slide, is how you've performed at high altitude in the past. Acclimatization generally takes three to five days as you're getting used to a new altitude. And you can use Acetazolamide to help prevent altitude medication if you don't have time to ascend to a location slowly. And this will make sense for a number of you who are flying in to a new location. And I also recommend avoiding alcohol for the first 48 hours when you're in a high altitude location where you haven't been previously. Remember that acetazolamide can affect UV radiation and how photosensitive you are. But then also remember that when you're at high altitude, you're more exposed to the sun. So these things all play a role. They all intermingle with one another. And it's just an important considerations, especially for those of you traveling to higher altitudes.
