GERM
00:00:09.200 – 00:00:11.040
Oh, hi there. My name is Germ.

WORM
00:00:11.280 – 00:00:12.160
I’m Worm.

GERM
00:00:12.320 – 00:00:25.520
Welcome to episode 109 of the Germ and Worm Travel Health podcast, how to avoid Cyclospora. It’s a big planet. See it in Good Health. I’m Dr. Paul Pottinger, also called Germ. I’m an infectious diseases specialist at the University of Washington.

WORM
00:00:25.830 – 00:00:31.190
Hi, I’m Dr. Chris Sanford, also known as Worm Family Medicine Doctor, also at the University of Washington.

GERM
00:00:31.190 – 00:01:07.970
Okay, Chris, here are some of the exciting questions we’re going to tackle today.
What is going on with cyclospora in the United States?
Is it safe to travel to the Middle east right now?
And can human beings catch screwworm or just livestock?

These questions and many more, a reminder to our listeners. Please contact us with your travel health questions, stories and tips for success.

Just Visit us online germandworm.com or send us an email germanwormmail.com first. As always, our medical disclaimer. This podcast is designed to inform, inspire and entertain. But before you travel, please see a qualified healthcare professional recommendations specific to you and to your itinerary.

WORM
00:01:08.290 – 00:01:10.530
So, Paul, any upcoming travel for you?

GERM
00:01:10.770 – 00:01:27.090
Upcoming travel? Yeah, all kinds of stuff. This is summertime in Seattle. I always swear to God I’m not going to leave because it’s so beautiful here.

But yes, there’s always something that comes up. So European travel is coming, including Mallorca and Copenhagen, maybe Dublin, some London time. So I’m excited about that. What about you? What’s coming up?

WORM
00:01:27.320 – 00:01:53.840
Yeah, like you, I like to stay here in the summer because the weather is so perfect. It’s payback for our winters. But yeah, several upcoming trips, going to a wilderness medicine conference in Big Sky, Montana.

Then in early September, I’m going to be a doc at Burning man for a week, which I’m really curious about. It’ll be my first Burning Man. And then later a month later, October, I’m going to Bhutan. Actually going on a 12 day trek there.

So very curious be my first trip to Bhutan.

GERM
00:01:53.840 – 00:02:04.420
I’ve not visited Burning man or Bhutan. Both of those sound super exciting. Okay, so there’s going to be a lot of content coming to our listeners. That’s exciting.

We’ll both be bringing in some notes from the field while we’re traveling.

WORM
00:02:04.420 – 00:02:04.900
You bet.

GERM
00:02:04.900 – 00:02:06.820
I’m looking forward to that. Thanks for sharing.

WORM
00:02:07.060 – 00:02:30.420
And we both want to thank our recent interviewee, Dr. Karen Tang. Dr. Tang is a very articulate gynecologist in Eastern Pennsylvania. She’s the author of It’s Not Hysteria.

Everything you need to know about your reproductive health, but we’re never told. She did an interview with Paul recently. It’s episode 107, so check out that episode for her thoughts on the traveler with menopause.

GERM
00:02:31.100 – 00:02:58.940
Yeah, it was such a great conversation. I learned so much from her. She’s not only articulate, she’s brilliant. Oh, and she has a new book coming out soon called It’s Probably Hormones.

It’s all about the hormonal system in people, women of all ages. And so I really enjoyed that conversation.

Please check out 107 if you have any questions about what it means to travel as a woman, whether you’re experiencing menopause or just menopause curious. Or if you’re a man with women who are actually going through this, please check it out. We have tips for success for you as well.

WORM
00:02:58.940 – 00:03:01.740
Yeah, tips. Basically how to support a woman with menopause.

GERM
00:03:02.520 – 00:03:06.280
Exactly right. This is important. We’re in it together, I promise you. At least we should be.

WORM
00:03:06.440 – 00:04:23.710
Also, want to give an update on another interviewee Back on episode 68, we interviewed Tom Sanford, MD. He’s a urologist also, though he is an expert on bicycle safety. He’s published medical articles on that topic.

And heck, Tom was recently minding his own business on a bicycle in Honolulu and was struck by a car. He was on a road with a broad shoulder, but the car drifted and smacked him. And bottom line, he’s going to be okay.

But he fractured his scapula, a comminuted fracture. And comminuted means broken into more than two pieces. So he had to have a metal plate and a bunch of screws placed surgically in his scapula.

He broke at the time of the accident, his helmet into two pieces. And he has no head injury at all, no concussion, nothing. And of course, he has road rash scrapes from head to toe.

And he’s going to be okay, but he’s really sore. So Tom, wishing you a quick recovery. Also, during his Inter, made two good points, both of which were relevant.

One, 90% of bicycle fatalities come from collisions with motor vehicles such as cars. What happened to him? Number two, wear a helmet.

You can just imagine, had he not had that helmet on, that would have been his skull and not the helmet that broke into two. So, Tom, thinking about you here.

GERM
00:04:23.870 – 00:04:52.010
I am so sorry to hear this. And if it can happen to him, it can happen to anybody. This is the safest, most sensible cyclist I’ve ever seen. I promise you it wasn’t his fault.

I mean, I don’t know the details. I’m just hearing this right now, but I betcha it was someone who’s impaired or distracted was probably a driver who doing the wrong thing with their car. So folks, if you’re a cyclist, please be careful. And if you’re a driver, please be very careful.

This is really a shared situation, but man, please keep your eyes and ears peeled when you’re operating any kind of vehicle and hopefully we can all survive this.

WORM
00:04:52.090 – 00:05:18.520
Yeah, I did a video, an Instagram thing recently and I talked about a secret compartment in your car that can save your life.

And basically you approach your car, you open the trunk, you put your cell phone in the trunk, you close the trunk, you get in the car, you drive to where you’re going. Then when you get out at your destination, after you stopped, you take your cell phone out.

But looking at your cell to change the music station or whatever when you’re driving, it’s bad for you. Is bad for people like those on bicycles.

GERM
00:05:18.920 – 00:05:26.040
Amen, brother. Do as I say and not as I do. I don’t. I’m not a trunk person, but I am an eyes up person, that’s for sure, when I’m driving.

WORM
00:05:26.920 – 00:05:38.760
All right, let’s get into it. Paul, first question for you.

There’s been a lot of press recently about this big Cyclospora outbreak in the US Midwest, west, making a lot of people miserable. Can you tell us a bit?

GERM
00:05:39.780 – 00:10:37.900
Yeah, we were just talking about cyclists. Now we’re talking about cyclospora. They’re not the same, they’re both dangerous. This is really a huge issue for us. So what is what’s going on?

What we have is a number of states and it’s not just the Midwest. We’re talking about Michigan, we’re talking about Texas, New York, Pennsylvania, West Virginia. It’s all over the place.

And people are being diagnosed with Cyclosporiasis. Cyclosporiasis is the disease that’s caused by cyclospora. The Latin name is Cyclospora cayatenensis.

We’ll call it Cyclo for short. What is cyclo?

It’s a microscopically small parasite, a single celled parasitic infection that we get when we eat food that’s been contaminated with human feces. I don’t know how else to say it. This is a germ that comes from the buttholes of other people. Could be someone in food processing or food prep.

There are other ways to catch it. You could get it through intimate sexual Contact, for example. But generally speaking, this is a classic foodborne illness.

And what happens is of course we consume these infectious particles as soon as they leave the body of one person, person in the feces, they are infectious. They don’t have to go to the ground, they don’t have to incubate inside another animal. They’re just ready to infect the next person.

And they’re pretty hardy in the environment. So they can really cause these explosive outbreaks of explosive diarrhea. You might have cyclospora if number one, you get explosive watery diarrhea.

There’s nothing too specific about that.

It could be very similar to enterotoxigenic E. Coli or some other foodborne illnesses, but it tends to be more tenacious, it can last for a longer period of time and it also tends to outbreaks. So you can have it as a one off.

But oftentimes this will be in clusters where other people who’ve gone to a picnic or a particular restaurant had some single point source may get infected at the same time.

So it’s one of the epidemiologists nightmares when this happens because it tends to run around in not just in one person at a time, but in multiple people at a time. And in fact that’s exactly what’s happened. The state of Michigan seems to be the epicenter. Currently we’re recording this mid July 2026.

At the moment, state of Michigan’s reported more than a confirmed cases this year alone. Now in any given year, there’s usually just maybe a dozen or two dozen of these cases at most. This is an explosion of explosive diarrhea.

God help the people of Michigan. It just sounds like you’re in a, it’s a shit show down there. And I’m sorry about this, but it’s not unique to Michigan.

It’s happening, as I mentioned, in other states too. This is probably more than one point source. This is probably multiple different ways of food getting contaminated with Cyclospora.

In one case it may be from a food processing plant where a bunch of lettuce is going to be process.

For example, we have such an industrial complex with our food distribution system in the US that’s great when it comes to cheap food, but it’s bad when something gets infectious because things tend to spread all around the country. So in some cases there are people who say they went to particular restaurants or restaurant chain. In other cases it may be bagged lettuce.

There’s a number of different exposures. At least we think that’s the case. I’m going to ask you in a minute, Chris, your thoughts about our infrastructure for how we’re tracking this.

The bottom line is how do you avoid this? Be choosy about where you’re e. This tends to come in fresh fruits and vegetables.

And that really breaks my heart because those are foods that we really want people to eat more of. But anything that can trap human waste, for example, that can get trapped onto the surface of these berries.

If you’re going to have a blueberry or raspberry, wash it carefully before you consume it. I say raspberries in particular because back in the 1980s, that was one source of cyclosporasis, raspberries imported from Guatemala, as it happened.

But it doesn’t have to be just that. Could be lettuce, could be berries, leafy greens, any kind of vegetable, especially those vegetables that are grown well in the ground. Right.

Something that’s earthbound is more likely to be infectious. And anything that has a rough surface or a little crevice. The raspberry, one of my favorite fruits. But it’s got those little, little.

What do they call those? Little pips, Little ball seeds. Whatever they are, the rough surface of those berries is a place for, well, for poop to stick to it.

So that makes it harder to. To get rid of. You’ll know you have this if you’re sick with watery diarrhea.

And it’s something that we can test for by doing a fecal specimen crap in a cup. And a doctor can send a PCR test, for example, or do a direct stain, although frankly, molecular testing is easier. It’s treatable.

There is an old school antibiotic called Trimethoprim sulfa or Bactrim. We can give people, it can dramatically reduce the duration of their illness. You probably do not have to receive antibiotics.

The body should eventually clear this infection. But boy, antibiotics can help in this particular case. In many cases of diarrhea, we do not like to give antibiotics. This is a different one.

We do try to treat to, number one, make people feel better. Number two, reduce the chance of it spreading to other fol.

So it’s a problem for the individual patient, it’s a problem for the food industry, and it’s a problem for epidemiology. Let me ask you this, Chris.

What’s your level of confidence that we currently know the full story about what’s happening with this particular outbreak?

WORM
00:10:37.900 – 00:11:51.810
You know, great question. And as big as this thing is, the answer is we have no idea how big it is. Because tracking has been curtailed over recent months.

Obviously, with any disease, it’s super important to track it.

You have to know how many cases are going on, and then that information has to be passed up the information chain so that people know if there’s higher than a usual prevalence of a particular disease.

What’s happened, unfortunately, since July of 2025, is that FoodNet, which is the main foodborne illness surveillance arm of the cdc, the center for Disease Control and Prevention in Atlanta, they made tracking cyclospora optional, so they still look for some pathogens, some bacteria that cause illnesses, but not cyclospora. This is probably a mistake.

You need to know how many cases there are even in the boring baseline years, so that when something like this happens, you know to look for a source. So something’s going on somewhere. We don’t know where the source of this is yet.

But if you don’t even count the number of cases, you don’t even know how big it is or where to look.

So this is one of the many things that have happened recently at the CDC that Paul and I have been railing against, where you cut a little bit of money and it could lead to something large and disastrous and making a lot of people sick as a result.

GERM
00:11:52.370 – 00:12:24.630
When it comes to public health, prevention is everything. And the price of success is vigilance and sustained surveillance. I just don’t know how else to say it. So I hope that we get past this.

No doubt this will flame out in time, but it’s just. It’s a source of suffering and I’m sorry that it’s happening.

Please be careful and please do wash your veggies before you eat them, especially if you eat them raw. So, Chris, a question to you from Ricky of Saskatchewan.

Is it currently safe for someone from Canada or the United States to travel to the Middle East?

WORM
00:12:25.420 – 00:14:13.930
The question is, and let me expound on that a little bit, certainly I wouldn’t go to Iran. And a good place to start in terms of safety and levels in your plans should be the U.S. state Department. They have a travel advisory system.

We’ve talked about this, levels one through four. One being like your country, Canada. Four, they flatly say do not travel. And there’s currently 19 countries on that in terms of the Middle East.

Currently US State Department has a level four for Iran, Iraq, Lebanon, Syria, Gaza, and Yemen. But they’ve recently bumped up several countries from level two to level three. And the definition for level four is do not travel.

Level three is reconsider travel. So you can interpret that as you will.

But countries on that include Bahrain, Israel, the West Bank, Jordan, Kuwait, Oman, Qatar, Saudi Arabia and the Emirates. Nobody’s targeting currently jetliners. Nobody is targeting tourists. However, the Dubai airport was hit by munitions a few months ago.

There have been a few missiles or projectiles that have hit Iran and Kuwait and Bahrain. So what does that mean if you’re a tourist or a business person or see in your family? I don’t really know exactly.

I certainly would have more caution in this era with this current war between the Iran and the US Than I would usual. But I can’t say what your risk is.

I don’t think it’s high, but I’m concerned anytime there’s active warfare and two, it’s unpredictable, the war could get hotter and expand unpredictably at any time or there could be protests. So I know that’s a large hedge, but I guess I would say I would drag my feet more than usual until the war is over.

But now, Paul, I’m going to ask you for something more definitive.

GERM
00:14:14.410 – 00:15:25.720
We’ve talked about this. There may indeed be circ. I’m against travel to these areas just for personal safety reasons. As you said, someone may find that they have no choice.

Perhaps they have family reasons, pressing reasons to travel to these areas. Certainly it can be done. We have people who do that for humanitarian reasons, diplomatic reasons.

I think what the Department of State is trying to say is, hey, in general, these are less safe areas and you should reconsider or just don’t go flat out. I think even within that level four category, honestly, there probably are level fours and level four plus right.

To me personally, like, I will not visit North Korea because they tend to take people hostage and beat them to death. Like, that’s just not my way. But is it possible that there might be another level four country that I might consider going to if I had to? Sure.

You know, I just think this is a great starting point.

As you correctly said, if listeners out there are thinking about making these trips in spite of US Department of State warnings like this, this whether you’re originating from the US or another country. Thank you, Canada, for reaching out.

Please let us know if you’ve made this decision to make a trip anyway, let us know why you’re traveling, how you’ve chosen to do it, and hopefully with a very happy and easy outcome.

WORM
00:15:30.120 – 00:15:38.490
Paul, this is coming to you. Tell us a bit about screwworm and particularly is this a livestock thing only or can humans be affected by this as well?

GERM
00:15:39.120 – 00:19:13.670
Yeah, thanks. Good question. We’ve talked about New World screwworm before, as you recall. It’s a fly. It’s a fly.

It’s a fly that is called Cochleomia ominivorax, meaning the man eater. And there are other flies that can go through this process of putting maggots into warm blooded mammals, including people.

But Cochleomia is, is worse because it’s very aggressive once it gets inside the flesh of an animal. And by the way, human beings are animals. Yes, it can happen to people, although it’s very rare.

Once that happens, it likes to just keep eating and eating. It’s much more aggressive carnivore when it’s underneath the skin of its host.

So that’s different, for example, from Dermatobia hominis or even the tumbu fly. So there’s different maggots that can get into the human body, and some of them are worse than others. Spoiler alert.

We actually use some of these clinically and therapeutically. I’ve done this with gnotobiotic green bot flies to put them into wounds intentionally to eat away dead tissue.

I’m one of the few people who does this anymore. Anyway, the point is Cochleomia omnivorax, the New World screwworm, it’s worse. This is different.

That’s why it is such a big concern, because it tends to get into relatively healthy animals, usually through a wound.

It could even be a minor cut or scrape, but it could potentially even get in through any other body orifice and get into the subcutaneous tissues, the meat under your skin, and start eating you alive. This happens usually with livestock and potentially with pets. Could it happen with human beings, as this questioner has asked? Yes, it can.

In fact, I’ve seen a case of someone who fell asleep in a tropical country in the Caribbean, and they fell asleep on the beach after consuming a certain amount of alcohol and woke up with an earache. And it turned out that they actually had the growth of these particular maggots in the ear.

This is a major catastrophe because they started eating the inner ear, which of course impairs the ability to hear. So it was a big deal for that person. We had to approach them surgically. You remove them surgically and that’s what you do.

Medical treatment is not enough. This is a surgical issue. So I have seen this in a human being. That’s very uncommon.

If you’re going to a Caribbean beach, please do not fall asleep drunk on the beach for a bunch of reasons. This is one of probably number 19 on a list of 20. But there’s a bunch of reasons not to fall asleep drunk on the beach.

But generally speaking, it’s a much bigger concern in agriculture and also in, you know, domestic pets. If there’s a wound on your pet dog or cat or something, do you have to keep them indoors?

Well, if you’re down in those border areas, Texas, I’m looking at you, I might consider really making sure that that wound is carefully attended to and wrapped up. You should do that for your little doggie anyway or your pet cat. But it’s really for cattle which tend to get injured on their skin, right Chris?

And they also then get moved around from state to state. There’s a small whole cattle trade. Screwworm is currently in the border areas closer to Mexico, but that will not stay that way.

Can absolutely transfer on cows from place to place. How do we fix this?

You inspect your cows, you tend to them, you make sure that they are, if they have wounds, that they are dealt with, decontaminated, because that’s usually how these flies will be attracted and lay their maggot eggs into those open wounds. So this is about good animal husbandry. And that comes to Department of Agriculture, USDA and other inspection processes.

We talked a moment ago, didn’t we, about cyclospora and diarrhea spreading around? Same story here. Vigilance is the price. Sustained vigilance is the price of success.

And if we cut back on these particular public health and agricultural inspection processes, the chance of it propagating will be.

WORM
00:19:13.670 – 00:19:31.690
Higher in terms of bringing risk down. As Paul said, primarily it’s a livestock issue, but people are rarely infected.

If you’re in a high prevalence area, you want to make your risk even smaller. Usual insect measures give some benefits. Usual permethrin to close DEET or picaridin to exposed skin.

GERM
00:19:37.290 – 00:19:42.730
Chris, here’s a question from an anonymous listener. What is lockjaw and how can I prevent it?

WORM
00:19:43.370 – 00:21:13.790
Yeah, lockjaw has been around for forever. It’s tetanus is the other name for it. Terrible illness caused by a bacteria and a toxin.

When you get infected with it, it’s life threatening, it can kill you. You basically all your muscle spasms and you have trouble breathing and people often die. There’s a great vaccine for it. It’s been around forever.

You get one every 10 years. Reduces your risk tremendously. Most people in the US get the vaccine, which is why lockjaw is rare in the United States.

However, it’s concerning in the current era because while it’s A rare disease. There are current generally anti vaccine people in the current political administration, both in the White House and as of Health and Human Services.

And with this fanning of anti vaccine feelings, the rate of vaccination is slowly coming down, which means we’re probably going to see more cases of this in the future. And I’ve seen clinical cases of this.

When I was in Haiti after the 2010 earthquake, I actually saw three cases of this, two in adults and one in a newborn. Newborn had a thing called neonatal tetanus. Came in at about 10 days of age.

Probably what happened is the umbilical cord was cut with a knife, which was not sterile. And because of the low vaccination rate, people die and it’s a miserable way to go. You stiffen from head to toe, you have trouble breathing, you die.

So it’s still a thing.

It’s rare in the US because of vaccination, but it’s one of the standard childhood vaccines that make this a very rare disease in high income nations like the United States.

GERM
00:21:14.510 – 00:21:57.130
I’m stunned that you’ve seen a case. Of course, I never have. It’s just heartbreaking that you had to go through that. And thank you for helping take care of those people.

Prevention is ev everything. If someone does develop tetanus, we do have treatment, right?

We give antibiotics to kill the clostridium bacteria and we give antitoxin as a form of an antibody that helps to neutralize that toxin. But that’s the great thing about a toxoid, which is a vaccine against a toxin which is part of the tdap. It works great.

So if anybody out there has questions about their own status, are they up to date? You know, do I need a booster? Please talk with your qualified healthcare professional.

This is one that is utterly safe, free and works beautifully, beautifully well.

WORM
00:21:57.290 – 00:22:10.250
And you get a three in one if you get it in the form of tdap, tetanus, diphtheria, pertussis.

You also get protection for diphtheria and pertussis, which actually both of which are way more common in low income countries around the world and not unheard of in the United States.

GERM
00:22:10.410 – 00:22:11.290
That’s correct.

WORM
00:22:17.220 – 00:22:27.540
Paul, a reader writes in. Hey, I read something about a brain eating amoeba in India. Is this real? I’m planning on going to India. Should I cancel my trip, question mark?

GERM
00:22:27.700 – 00:25:07.600
Yeah. Thank you. So it is real and hopefully you do not cancel your trip. What are we talking about? This is pam primary amoebic meningoencephalitis.

What are amoebae? These are little microscopic creatures that live in the water.

If any of you, like me, are friends of Gary Larson, he used to draw amoebas all the time in his cartoons. They’re the thing that has a pseudopod. It moves around by putting a piece of itself forward and then crawling into that. A false foot or pseudopod.

And so they have a sort of squishy looking surface. They’re not well organized, but boy, there’s many of them. And typically they’re quite harmless.

They just live out in the water and they don’t cause humans grief at all. But some of these FLA: Free living amoeba, they can in rare circumstances, get into the wrong place and cause terrible catastrophes.

And the wrong place, of course, is in our brains. They can eat your very living brains. We’ve talked about this here on the podcast previously.

But as friendly reminder, these are microscopic organisms that live in fresh water and they tend to get into our brain through the nose.

Somebody is water skiing in a stagnant pool or they’re skinny dipping in Florida or something and they kick up the the muck and the mud at the bottom of a clear water pool. That muck and mud is full of amoeba. And if they get in through your nose, you wipe out when you’re jet skiing something like this.

Or if you do a neti pot with water that has not been adequately boiled and sterilized ahead of time.

Yep, the amoeba get in there and they crawl into your brain through the cribriform plate through the back of the nose where the olfactory bulb comes out. And once it’s in there, it’s a catastrophe. We do have treatments. They do not work particularly well. You do not want this infection too. So to.

Nice questioner, is it in India?

So yes, there actually is recent report in late June of 26 of a significant increase in primary amoebic amingoencephalitis in the state of Kerala where there have been approximately 70 confirmed cases and 22 of those individuals have died. Unfortunately, that’s just Since April of 26, again, just in Kerala.

And it was linked, of course, to people who were swimming in ponds and rivers and lakes, people who might be using neti pot nasal wash technique without first boiling and sterilizing that water. This is a rare disease. It’s catastrophic. Please visit Kerala if that’s where you’re headed.

It’s meant to be a beautiful place, but if you do so, please do not swim in these untreated natural bodies of water. What if you have to do that. Can you prevent this literally by plugging your nose and wearing a nose clip? You might reduce the risk of that happening.

But the safest thing to do in those contexts, whether we’re talking Florida or Kerala, is stay out of those freshwater pools.

WORM
00:25:07.840 – 00:25:12.240
Yeah, agree. If it was me, I’d go to pretty much anywhere in India in a heartbeat.

GERM
00:25:12.320 – 00:25:51.770
I mean, it’s the most interesting, fascinating country. I’ve only been a few times. I would love to go back and I would not let the amoeba keep me away.

Everybody, that’s a wrap for episode 109 of Germ and Worm. Thank you as always for joining us. We appreciate your questions on travel health. It’s easy to reach us.

Just Visit us online germandworm.com or send us an email germandworm gmail.com if you enjoy what you hear, please subscribe, rate us favorably on your device and spread the word with friends, family and on the socials. Those are free ways to support this podcast.

WORM
00:25:51.770 – 00:25:55.150
I’m Germ, I’m Worm. It’s a big planet. See it in good health health and.

GERM
00:25:55.150 – 00:26:14.350
We’ll see you next time.

This podcast is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and so it should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions you hear belong to Dr. Sanford and Dr. Pottinger alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.