GERM
00:00:09.440 – 00:00:10.880
My name is Germ.

WORM
00:00:10.960 – 00:00:11.920
I’m Worm.

GERM
00:00:12.080 – 00:00:27.600
Welcome to episode 84 of the Germ and Worm Travel Health Podcast. Air pollution in New Delhi. Say it ain’t so. It’s a big planet. See it in Good Health. I’m Dr. Paul Pottinger, also known as Germ. I’m a professor of Infectious Diseases at the University of Washington in Seattle.

WORM
00:00:27.960 – 00:00:35.640
Hi, I’m Dr. Christopher Sanford, Associate professor in the Departments of Family Medicine and Global Health, also at the University of Washington.

GERM
00:00:37.160 – 00:01:48.630
Chris, you and I get this fun experience of answering great questions from listeners across the country and around the world this week. Here’s a few of the ones we’ll talk about today. Is COVID 19 immunization safe during pregnancy? Just how bad is the air in New Delhi and what can I do about it? What antibiotics are best for sinusitis when I travel and how long should I take them? And new drugs for gonorrhea: Too good to be true or a real thing? These questions and many more. A reminder to our listeners.

Please contact us with your travel health questions, your stories, your tips for success, or just request for clarification on something you’ve heard elsewhere on our podcast. You can find us online germandworm.com or drop us an email germandwormmail@gmail.com. Before we jump in, here is our medical disclaimer.

This podcast is designed to inform, inspire and entertain. However, you should not use this podcast as clear as clinical care. Before you travel. Please see a qualified healthcare professional for recommendations specific to you and to your itinerary. Oh, and Chris, before we jump into our questions, I want to ask you to continue our series why you should go and I’m going to ask you today.

Why should our listeners consider going to visit the country of Japan?

WORM
00:01:49.030 – 00:07:37.770
Every country is unique, but one of the most unique countries in the world is Japan. It was isolated for centuries until the mid 19th century and evolved during that time without influence from other nations.

Japan is an island nation in East Asia. It’s comprised of four major islands and thousands of smaller islands. It’s not small if you put all that area together.

It’s a little smaller than the US State of California, but it’s more densely populated with a population of about 123 million. This is equivalent to about 40% of the population of the US. It’s a high income nation with a nominal GDP of about $35,000 per year.

Now most people who visit Japan fly into Tokyo, now ordinarily mega cities, cities of a population of more than 10 million people. I won’t name names, but they can be fairly dirty, miserable places. But Tokyo is polite, tidy, orderly and safe. In fact, it’s another planet.

It’ biggest city in the world by some calculations, with a metropolitan area of around 40 million people. A lot of it was destroyed in World War II, but it’s been rebuilt and it’s vibrant. The ward that I know, the best Tokyo has 23 wards is Shinjuku City.

And I love Shinjuku. It’s got wonderful, fantastic neon. If you’ve seen movies of Tokyo showing the tremendous neon, that’s probably Shinjuku.

It has the busiest rail station in the world. It has the Golden Gai, which is this really interesting neighborhood of about 100 tiny shanty bars all crammed together in little alleys.

In Tokyo, there’s this love of technology, this embrace of the artificial, and this is evinced by its capsule hotels, its high tech public toilets, and a pervasive love of vending machines. And these sell not only hot and cold food and beverages, but a bizarre variety of everything else.

And these are not only on streets and train stations, but also campuses and convenience stores and hotels and everywhere else you look. You get a bit of the flavor of this if you’ve seen that movie Lost in Translation, directed by Sofia Coppola. Now getting outside of Tokyo.

There’s Okinawa way to the south, hundreds of miles to the south. And it’s tropical, it’s different, it’s warm, and it’s known for its reefs and dive spots. Nagoya is a big city.

Maybe it’s an hour and 40 minutes out of Tokyo by high speed rail. It’s on the Pacific coast and a feature there that’s really interesting is the Nagoya Castle. I’ve been to Nagasaki recently.

This was founded by the Portuguese. It was a Portuguese and Dutch port for many centuries. I went to the Atomic Bomb museum there, which was really interesting.

It shows in some detail the effects of the atomic bomb on the residents of Nagasaki. I was glad I went. However, I haven’t been to a lot of places in Japan. I’ve never been to Mount Fuji, I’ve never been to Kyoto.

I’ve never been to the rural areas up north. So clearly I have to go back now. The cuisine there is really good. My favorite cuisine in the universe is sushi.

So I’m a very happy guy when I go to Japan. Ordering, though, at restaurants can be a little complex.

At some of the lower cost restaurants, you must put your money in a machine by the entrance and then you hit a button and then you get a Paper ticket that you give to a person and then you get your meal. And there’s no other way to do it. This can be problematic. If you don’t speak Japanese, which I don’t. It always works out.

I get help from someone who works there. But some of these, these customs are different. In terms of other pragmatics, it’s a pretty convenient place to go to. There are ATMs everywhere.

Every place takes credit cards. Wi Fi always works. There’s always electricity. Also, it’s surprisingly affordable. Even in Tokyo. You can spend a fortune if you want to.

But I’ve always been able to find accommodations that were reasonable. Public transportation is good. One tip. In a crowded city such as Tokyo, taking a subway is much cheaper and faster than taking a taxi.

The subways in Tokyo are co signed in English, which is really convenient. The high speed trains are really good. They’re fast and clean. Weather wise, it can be cool in the winter.

So outside of the southern areas like Okinawa, maybe the shoulder seasons are best. If you want to get a bit of a cultural sense of Japan. A good novel.

This was 1962 written by Kobo Ebe is the Woman in the Dunes said by some to be a critique of certain aspects of Japanese social behavior. Health wise, it’s a high income nation. You can drink the tap water you do want to get, of course, the usual vaccines, including influenza and Covid.

There’s no malaria there. There is one additional vaccine you may want to consider if you’re a short term urban visitor. This is a very low priority vaccine.

What I’m talking about is Japanese encephalitis. This is an illness spread by mosquitoes and it’s present in rural Japan.

However, if you are a rural visitor and if you’re there for one month, especially during the higher transmission season, which is August through September, you’ll want to talk with your pre travel provider about this immunization. So Japan is a fascinating country. It’s a complex melange of an ancient culture and modern innovations.

It’s the birthplace of karaoke, manga and ANIME. It has 21 UNESCO World Heritage sites, including temples, shrines and natural landscapes. It’s different, it’s lovely, it’s friendly.

I think if you haven’t gone that you should visit.

GERM
00:07:48.640 – 00:07:58.080
Chris, thanks so much for that. Here’s our first question for today’s Q and A session. Is there benefit to immunization for Covid before or during pregnancy?

WORM
00:07:58.479 – 00:09:07.800
A big study was published in JAMA, the Journal of the American Medical Association in December and it showed as did Prior studies on the same topic that there was significant benefit from to pregnant women being vaccinated for COVID 19.

They looked at maternal hospitalization, critical care, admission and preterm birth and found that basically both mom and baby did better if the mother was current on Covid immunization. And previous studies have been done on this and they found the same thing.

As a general rule, we like to avoid any kind of intervention for pregnant women. However, there’s a few exceptions.

So in addition to COVID 19 vaccine, it’s also beneficial to be current on influenza and tdap, tetanus, diphtheria, pertussis in pregnancy. Also, there’s benefit in taking a supplement folate. So this goes along with earlier studies? Basically, yes.

Immunization, COVID 19 before and during pregnancy appears to be a good idea.

GERM
00:09:08.360 – 00:11:36.760
Yeah, I agree. And it’s interesting. We’ve actually known this for quite some time.

Our experience here in the state of Washington was, my recollection was that back in the bad old days of those very first outbreaks of COVID when the virus was more severe, you know, the risk of dying as a pregnant woman was doubled for those who acquired COVID-19. That risk of death has, thank goodness, gone down over time due to Covid whether someone’s pregnant or not. But the benefit of vaccination is still there.

So this is something that ACOG, the American College of Obstetricians and Gynecologists, recommend strongly. Something that we recommend at the ID Society of America.

And I’m putting a light on this because we are going to see, I promise you, misinformation and disinformation coming from the highest levels of our federal government, including the Food and Drug Administration. I strongly suspect that they’re going to put a black box warning on this, urging pregnant women not to get this shot. They that is wrong.

If they do this or if they don’t do this, I don’t know, they shouldn’t because it is something that is definitely helpful. We think of pregnancy as a relatively immunosuppressed state.

The pregnant person has to be immunosuppressed, otherwise they would reject the pregnancy. That’s the idea. And so the risk of getting in trouble with an out of control Covid is higher during pregnancy.

That’s true for other infections as well. And I also want to just call pause for a moment and think about immunizations in pregnancy.

It’s a problem and it’s a societal gap that we need to fill. We need to include pregnant people in more clinical trials from earlier on in the clinical trial process.

One of my colleagues and friends who’s really smart and active in this area is Dr. Sylvia LaCourse and she can speak for herself very well. But just to summarize, this is a big feature of her career, is trying to get more involvement women who are pregnant into these clinical trials.

Not every pregnant person is going to want to be in a clinical trial, but a lot of them do. And I’m thinking, especially around COVID 19, when people were so frightened by this, appropriately so.

Unfortunately, it was difficult to find spots in clinical trials for people who are pregnant. I think that’s something we just need to talk about more. The concept that we want to protect the mom and the baby. I mean, that’s true.

Protect that pregnancy. It does have a certain paternalistic flavor though, doesn’t it, Chris?

Like let’s let women make up their own damn minds about what trials they do and don’t want to be even eligible to join. That’s my simple thought on this.

WORM
00:11:47.160 – 00:12:07.080
Okay, Paul, this question is for you. You two have talked about malaria in Washington State and on Long Island. Now I hear about somebody catching it in Westchester County, New York. I thought you had to leave USA to catch this infection. So what’s going on to catch the malaria?

GERM
00:12:07.080 – 00:14:38.250
It’s a great question. I like this. This is super interesting and it has caught the imagination in the lay press and you know, in the medical literature as well.

What we have is a very, very fascinating article. It’s so interesting coming to us in a journal called the Open Forum Infectious Diseases, a very good journal.

And the investigators here describe their experiences with a 65 year old person who lived in Westchester county in October of 2023. So this is more than two years ago. That’s how long it takes to do these investigations.

But this person was admitted to a hospital in Westchester county and they were diagnosed with falciparum malaria. As we’ve talked about, Chris, falciparum is our most serious and potentially life threatening form of malaria.

It is no longer endemic in that part of the world. So how did this happen? It was not clear. And it took this very exhaustive, multimodal, huge investigation to try to figure this out.

And we still don’t know exactly how this happened, but it looks like what almost certainly must have happened here is that this person was admitted to the hospital for a different reason and acquired malaria in the hospital almost certainly as a medical error and a bloodborne infection, meaning there was someone else in the hospital at the same time with this Infection not acquired in New York, but acquired overseas. Somehow the malaria seems to have gotten from that other person into the bloodstream of this patient.

So it’s just a sobering, which I’d never heard of happening on an accidental basis in the continental United States. It’s as rare as hen’s teeth, but it is a sobering reminder that malaria is a bloodborne pathogen.

And if there is unsafe needle sharing or IV tubing or something like this, it could be spread from one person to another. You know, before my current career as an ID clinician, I was a malaria researcher.

And so this is part of my job as someone who was funded by the National Institutes of Health. Thank goodness I was on something called a K08 award. And part of my job was to grow malaria in the lab.

Chris, you got to feed it, you got to give it human blood. You got to water it, you got to sing to it. You got to really, you got to baby it because it’s used to being, you know, in someone’s bloodstream.

When you take it out of the bloodstream, it doesn’t do well. So this seems like a very unlikely thing, but it. It happened here.

And, Chris, you might be aware of other instances where it may have happened before.

WORM
00:14:38.890 – 00:15:24.870
Yeah, usually malaria is transmitted by the anopheles mosquito. And tropical medicine trivia, it’s only female mosquitoes that bite people. The male mosquitoes, they’re more mellow. They eat nectar from flowers.

It’s the female mosquitoes that need the blood to form their eggs. Anyway, usually in the wild, it’s the mosquito that transmits malaria, but it can be transmitted by something like a dirty needle.

Usually we think of needle transmitted infections as being things like hepatitis B and C and hiv, but malaria is on that list, too. So this is one of the many reasons we encourage folks not to get a tattoo or perforation at a place where the needles might not be sterile.

GERM
00:15:25.430 – 00:16:12.650
I agree. And so, for the record to this nice questioner, hey, you can still totally visit Westchester County. That’s a nice place.

You’re not going to catch the malaria. That would be extremely unlikely. If you’re looking for an excuse not to go to Westchester, this, unfortunately would not pass muster. Please visit, enjoy yourself, and don’t worry about this particular problem.

Okay, Chris, in the context of where you and I live in Washington state, you know, we’ve recently gone through these very unprecedented, devastating, and unfortunately dangerous floods related to huge amounts of rainfall. So the question that I personally have for you is, if someone is traveling, what should they know about flood watch, flood safety. How can they keep themselves safe in this flooded world we live in?

WORM
00:16:12.810 – 00:17:14.600
When you’re traveling, there’s benefit in carrying a small radio, a AM, fm, battery powered radio, so that if there’s a disaster such as a flood or an earthquake and the power fails and the Internet goes down, you can still get information and warnings. In terms of floods, apparently the most dangerous thing you can do is get into your car and try to drive through floodwater.

Studies show actually that over half the deaths that occur in floods occur to people in cars who are trying to drive through floodwater. People get anxious, they want to find safety, and they think they can make it through the water.

There unfortunately was a death recently in Washington state, our home state, during floods. A guy drove around signs. There were signs in the road that said, stop here. He drove around the signs into the flood water.

His car was carried away and he drowned. So stay out of your car and obey the signs.

GERM
00:17:14.920 – 00:17:51.410
Yeah, this is horrible news that someone had lost their life. And as you point out, unfortunately, it happens again and again.

So if that’s in the context of danger, domestic life, US travel, or you’re traveling overseas, please, please be careful about this. And you know, here in the usa, we really are fortunate to have, you know, a good road safety system. It’s not perfect.

We do have people who are looking at the water and blocking off roads. You just may not have that benefit if you’re in a different country. You really do need to take care of yourself. Please, just. Just wait it out. Wait for the waters to recede, make that crossing, and come home safe.

WORM
00:17:58.770 – 00:18:23.830
All right, Paul, this next question is for you. And this comes from Raul in Palo Alto.

Raul writes, I am happy to read in the New York Times about two new antibiotics that can treat gonorrhea, even the kind resistant to treatment. Do you agree that these new drugs really work? Will this help keep me safe during my upcoming trip to Japan? I’m a gay man and I anticipate some new partners.

GERM
00:18:24.150 – 00:24:18.590
Okay, thanks. So to Raoul, this is a wonderful question. There’s two parts to it. First of all, do I think these drugs work? Yes. Yes, I do.

Will this keep you safe on your upcoming trip? That’s a slightly more nuanced question. Let’s begin briefly for some of our listeners who may not be familiar with gonorrhea.

Of course, this is a sexually transmitted infection. It’s caused by a bacteria. The bacteria is called Neisseria gonorrhoeae. Neisseria gonorrhoeae can, infect any mucous membrane.

So that could be the urethra in men or women. That could be the vagina and the cervix in women. This could be the rectum in women or men, the throat in women or men.

Regardless of what mucosal site it infects, it’s spread from one person to another. This is a person to person infection that’s usually spread by direct, intimate sexual contact.

And when the bacteria gets into a new part of a new person’s body, it causes a lot of inflammation for many of those people. And this can be a very unpleasant issue. Could be a rectal discharge syndrome. It could be urethral pain and discharge. It could be a sore throat.

It could also be rather subtle. And not everyone has a full minute overwhelming clinical illness. That’s the problem, isn’t it, Chris?

If everyone had a ton of symptoms, they would all seek treatment and we would be better. It can be a little bit stealthy, unfortunately.

And what it has done over many years is to become partially resistant to a whole bunch of antibiotics that we have relied upon over a great period of time. For example, there’s a medication called ceftriaxone, which is a third generation cephalosporin. Many of our listeners will have received ceftriaxone.

If they’re doctors, they will have prescribed it, I promise you. It’s a very, very commonly used antibiotic and a really good one.

And it has become necessary for us as physicians to prescribe higher and higher doses of ceftriaxone in treating gonorrhea because over time it has become genetically more and more relatively resistant to that medication.

And unfortunately, there are also some strains of gonorrhea that have become completely resistant not only to ceftriaxone, but to other second and third line treatments. This is a problem because an untreated STI is going to continue to spread. It doesn’t pay a substantial fitness cost.

These drug resistant forms of gonorrhea can still be spread person to person quite easily.

Actually, that does include the country of Japan, which by coincidence, our questioner Raul says he’s going to so great news that we have FDA approval of not one, but two new antibiotics for this purpose. And when I say new, I do mean new. These are new classes of medications. One is called gepotidacin, one is called zoliflodcin. Funny names.

Our listeners don’t need to remember that. They should know that these are not just a new flavor of something we’ve had before.

They go to a target that we’ve used in bacteria for a long time and that is the way that the DNA of the bacteria winds and unwind. This is the target, for example, of the fluoroquinolone antibiotics, cipro, levofloxacin.

But these new drugs, zoliflodacin, gepotidacin, they are not in that same fluoroquinolone family. They’re different, they’re molecularly separate.

And we have great experience with a small number of patients that it can definitely attack and destroy, at least heavily inhibit the winding and unwinding of DNA gonorrhea. And it’s for that reason based not only on its structure and its molecular action, but also clinical outcomes.

Working with people who have these difficult to treat infections. We have known for some time that these medications can work in this capacity.

Now the happy news that FDA agrees and that they have approval to be prescribed for US doctors to prescribe it for that reason. So this is great news. I love being able to prescribe something that is FDA approved for relatively or totally resistant gonorrhea infections.

To the question of whether this is going to protect the questioner, that’s a little bit different. This is not, for example, a group of medications that we are currently prepared to give on a preventative basis.

Rather, this is approved for the treatment, but not the prevention of these difficult infections. So that’s different from doxycycline. We’ve talked, haven’t we, Chris, about doxy pep taking doxycycline as post exposure prophylaxis.

So doxy pep really is doxycycline as post exposure prophylaxis that if someone has condomless sex with a new partner, if they take doxycycline soon after they have that exposure, they can reduce their risk of getting sexually transmitted infections. Chlamydia, syphilis and to a lesser degree, gonorrhea.

Unfortunately, some of these most difficult to treat strains of gonorrhea are resistant not only to ceftriaxone, but yes, also to doxycycline.

And so to this questioner, you know, if you are thinking about expanding your sexual network during the trip to Japan, please do consider a whole variety of options to keep yourself safe. Protection from hiv. That’s about HIV pre exposure prophylaxis, protection from syphilis and chlamydia. Doxycycline can be helpful in that regard.

But when it comes to these difficult to treat strains of gonorrhea, unfortunately, it really is about physical barriers. It’s the use of a condom that is going to be more reliable than the use of doxycycline or other medications.

All of which is to say the decision about what kind of protection plan you embrace it is individual. You should know that we do have treatment options, testing and treatment options.

If you come home with any kind of diet, genital syndrome, a urethral discharge syndrome, for example, rectal discharge syndrome, new sore throat, please do see your medical doctor and tell them about your new sexual network so that they can do specific testing looking for this and think about other treatment options. So happy days. But certainly not perfect. Chris, what’s your philosophy please?

WORM
00:24:18.670 – 00:24:45.330
I agree and I want to stress that you should take condoms. These are fully legal to take through customs in both countries. They should be latex and manufactured in a high income nation.

Also, if you do have a new partner, it’s important that you get screened when you come back. Some STIs such as Chlamydia, can have minimal or even no symptoms at all.

This could cause mischief for you later and of course you don’t want to transmit it to anybody else.

GERM
00:24:50.290 – 00:24:56.840
Chris, here’s a question from one of our listeners. Anonymous Is artificial intelligence ready for travel prime time?

WORM
00:24:57.480 – 00:26:24.340
No, but it can be useful. So I think it’s fully legit to go to AI. Tell it where you’re going. The more information you give it, the better.

Tell it your age, your health history, your itinerary, your activities, and it’ll give you some recommendations, including some vaccines. But it’s important to recall that whatever it gives you is not the full story. It it doesn’t have any perspective.

AI as I understand it is all about word frequency on the Internet. It lacks judgment. So it’s going to reflect the bias of what’s online.

For example, recently as a test, I went to an AI tool and I said, hey, I’m going to Europe. How do I stay safe? And the very first thing it mentioned was tick borne encephalitis.

Now this infection is there, it’s in a few countries for a few, travel at a few seasons, but it’s really not the most important concern. The AI tool then listed some other infectious diseases.

Some of them were common, some of them were obscure, but there was no mention of things like seat belts and helmets or avoiding risk of drowning or, you know, didn’t know my age. You didn’t talk about risk of heart attack and stroke. So I think you can use AI as an initial tool.

But whatever it tells you, really, you can’t tell if it’s important or trivial. So I think it is still important to after you use AI to get some initial information to see a pre travel provider in the flesh.

GERM
00:26:24.660 – 00:26:34.900
I think in a way I kind of like this. Right, Chris, because we have job security. Our AI overlords have not yet come for you and me.

But thanks for the question and I certainly appreciate your perspective.

WORM
00:26:37.070 – 00:26:57.150
All right, Paul, this is for you. And this comes from Anonymous. I am prone to sinus infections.

So I asked my PCP for an antibiotic prescription to take with me on my trip to Germany next month. They prescribed five days of amoxicillin just in case. Is this the right drug and is this duration long enough?

GERM
00:26:57.550 – 00:28:19.980
Oh, so hope you have a great time in Germany. It’s an interesting country. I’ve been a few times. That’s great. And if you know that you are prone to sinus infections.

Yes, this was a really smart thing to discuss with your primary care physician. So we’ve talked about this sinus health, nose health on a few occasions, including with a bonafide ENT doctor. Right. Dr. Greg Davis.

So that’s worth looking back at as well.

One of the things we emphasize is that most episodes of sinus infection are due to virus, typically the rhinovirus or something else in the respiratory virus family. That is important because unfortunately we lack specific antiviral treatment that helps. And antibiotics certainly are not in that class either.

Antibiotics don’t kill viruses. So usually we tell people that when they are beginning to have the symptoms that sound to them like a sinus infection.

There’s all kinds of supportive things that they can do to reduce the severity and the duration of that illness. So. So that includes the use of nasal decongestants, analgesics, fever reducing medications, neti pot, et cetera.

So with that in mind, what if the infection seems to get better and then gets worse? What if you have a persistent high fever? What if you have a lot of sinus pressure and fullness and congestion?

What if it feels exactly like a bacterial infection you’ve had before that responded to antibiotics? You may be right. This may evolve from viral into bacterial and in that case it’s.