travel medicine dukoral

CDC recommends vaccination for people traveling to or living in areas of active cholera transmission. Check CDC’s Travel Health Notices  website to identify areas with active cholera transmission.

The World Health Organization (WHO)  recommends cholera vaccination in these circumstances:

• In areas where local transmission of cholera occurs
• During humanitarian crises with a high risk of cholera
• During cholera outbreaks

Visit a doctor or travel clinic to talk about vaccination if you will be traveling to or living in one of these areas. You can discuss options with a healthcare provider.

Several vaccines can help prevent cholera and improve health outcomes. But cholera vaccines are not 100% effective. Follow CDC’s cholera prevention tips  to help keep safe when visiting or living in an area with cholera.

Check CDC’s Travel Health Notices website to identify areas with active cholera transmission. Talk to your doctor about vaccination if you will be traveling to one of these areas.

Vaxchora (lyophilized CVD 103-HgR) is a single-dose, oral vaccine FDA- approved in the United States for use in people aged 2–64 who are traveling to an area of active cholera transmission.

Vaxchora should be taken at least 10 days before travel to an area of active cholera transmission.

The vaccine manufacturer reports Vaxchora reduces the chance of moderate and severe diarrhea in people by 90% at 10 days after vaccination and by 80% at 3 months after vaccination. It is unknown how long protection lasts beyond 3–6 months after vaccination.

Learn more about the vaccine at the maker’s website at  www.vaxchora.com .

Dukoral, ShanChol, and Euvichol-Plus

Three other oral cholera vaccines have been approved by the World Health Organization (WHO). These vaccines are not available in the United States. They are:

• Euvichol-Plus/Euvichol

To learn more about these vaccines, visit the World Health Organization Cholera Vaccines page.

* Shanchol and Euvichol-Plus use the same vaccine formula but are produced by different makers. These vaccines are currently available for mass vaccination campaigns.

• Cholera Vaccine
• Five Basic Cholera Prevention Steps
• How Family Members Can Prevent Infection
• Infection Control for Cholera in Health Care Settings

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Active Substance: recombinant cholera toxin B subunit / vibrio cholerae 01 Common Name: cholera vaccine (inactivated, oral) ATC Code: J07AE01 Marketing Authorisation Holder: Valneva Sweden AB Active Substance: recombinant cholera toxin B subunit / vibrio cholerae 01 Status: Authorised Authorisation Date: 2004-04-28 Therapeutic Area: Cholera Immunization Pharmacotherapeutic Group: Vaccines

Therapeutic indication

Dukoral is indicated for active immunisation against disease caused by Vibrio cholerae serogroup O1 in adults and children from 2 years of age who will be visiting endemic/epidemic areas.

The use of Dukoral should be determined on the basis of official recommendations taking into consideration the variability of epidemiology and the risk of contracting disease in different geographical areas and travelling conditions.

Dukoral should not replace standard protective measures. In the event of diarrhoea measures of rehydration should be instituted.

What is Dukoral?

Dukoral is a vaccine that is given by mouth. It is available as a suspension in a bottle together with effervescent granules in a sachet. The granules are dissolved in water and mixed with the vaccine before intake.

The vaccine contains four different inactivated strains (types) of the bacterium Vibrio cholerae ( V. cholerae ) serotype O1, and part of a toxin from one of these strains as active substances.

What is Dukoral used for?

Dukoral is used to protect against cholera (a very serious disease caused by V. cholerae , which is caught from contaminated food or water and causes severe diarrhoea). Dukoral is used in adults, adolescents and children from two years of age who will be visiting high-risk areas. Dukoral should be given according to official recommendations, taking into account where cholera is found and the risk of contracting the disease. Dukoral should not replace standard protective measures against cholera, including advice on diet and hygiene.

The vaccine can only be obtained with a prescription.

How is Dukoral used?

In adults and children from six years of age, Dukoral is given as two doses, one to six weeks apart. Children aged between two and six years should receive three doses, with an interval of one to six weeks between each dose. The course should be completed at least one week before potential exposure to cholera. For continuous protection against cholera, a single booster dose is recommended within two years for people from six years of age, and within six months for children aged between two and six years. The course should be repeated in adults who have not been given a booster within two years and in children not given a booster within six months.

The vaccine is made up by dissolving the granules in a glass of water to prepare an effervescent (sparkling) solution, and adding the contents of the bottle. Once prepared, the suspension should be drunk within two hours. Food, drink and other medicines taken by mouth should be avoided for one hour before and one hour after each dose of Dukoral.

How does Dukoral work?

Dukoral is a vaccine. Vaccines work by ‘teaching’ the immune system (the body’s natural defences) how to protect itself against a disease. Dukoral contains small amounts of inactivated (killed) cholera bacteria and a part of the cholera toxin called the ‘B subunit’. This subunit is not toxic by itself. When a person is given the vaccine, the immune system recognises the bacteria and the toxin, and makes antibodies against them. In the future, the immune system will be able to produce antibodies more quickly when it is exposed to cholera bacteria. These antibodies will help to protect against cholera by preventing the bacteria and the toxins from attaching to the walls of the gut and entering the body’s cells.

How has Dukoral been studied?

Because Dukoral has been in use in Sweden since 1991, the company presented the results of three main studies that had already been carried out in order to support the use of Dukoral. The company also presented data from the published literature.

The three main studies involved a total of almost 113,000 people. In all three studies, Dukoral, given as either two or three doses, was compared with placebo (a dummy vaccine). The studies took place in areas where cholera is found. The first study involved over 89,000 people in Bangladesh and compared Dukoral with the same vaccine without the toxin and with placebo. In this study, Dukoral was made using cholera toxin extracted from cholera bacteria in place of the newer recombinant toxin. The other two studies compared Dukoral (containing recombinant cholera toxin) with placebo in over 22,000 people in Peru. The people in the final study also received a booster dose 10 to 12 months later.

In all three studies, the main measure of effectiveness was the ‘protective effectiveness’ of the vaccine, calculated by comparing the number of people in the studies who developed cholera after receiving Dukoral and after receiving placebo.

A further study was carried out to show that Dukoral could produce antibodies in people who do not come from areas where cholera is found. The company also presented information on the use of Dukoral for the prevention of a severe type of traveller’s diarrhoea caused by a bacterium called ‘enterotoxigenic Escherichia coli’.

What benefit has Dukoral shown during the studies?

In the study in Bangladesh, the protective effectiveness of Dukoral was 85% over the first six months of follow-up. The length of protection was different for adults and children, lasting for six months in children and for two years in adults. In adults, two vaccine doses were shown to be as effective as three. In the first of the two studies in Peru, the protective effectiveness of Dukoral was 85% for the first five months of follow-up. The other study in Peru showed that after a booster dose, the protective effectiveness of Dukoral during the second year of follow-up was 61%.

The information presented was not sufficient to support the use of Dukoral in traveller’s diarrhoea.

What is the risk associated with Dukoral?

Side effects with Dukoral are not common. However, the following side effects are seen in between 1 and 10 patients in 1,000: headache, diarrhoea, and abdominal (tummy) pain, cramps, gurgling (gas) or discomfort. For the full list of side effects reported with Dukoral, see the package leaflet.

Dukoral should not be used in people who may be hypersensitive (allergic) to any of the active substances, to any of the other ingredients or to formaldehyde. Its use should be postponed in patients with a short-lived illness affecting the stomach or gut, or with a fever.

Why has Dukoral been approved?

The CHMP noted that the risk of cholera for regular tourists is minor, but that Dukoral could be important for certain groups, such as healthcare workers in cholera epidemics. The Committee decided that Dukoral’s benefits are greater than its risks and recommended that it be given marketing authorisation.

Other information about Dukoral

The European Commission granted a marketing authorisation valid throughout the European Union for Dukoral on 28 April 2004.

For more information about treatment with Dukoral, read the package leaflet (also part of the EPAR) or contact your doctor or pharmacist.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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Everything You Need to Know About Dukoral

People love to travel for a lot of different reasons, whether it be for relaxation, adventure, or escape. Many of us live for the vacation time we get to take each year, allowing us to escape the mundanity of everyday life to have a truly rejuvenating experience.

There are few things that can put a wrench in your travel plans like experiencing gastrointestinal issues. Can you imagine spending a year planning out your dream vacation only to spend much of your trip in the bathroom?

Dukoral is a drug that is used to help prevent both cholera and the type of traveller's diarrhea that is caused by E. coli. Depending on where you are travelling, taking the medication can be good insurance against getting sick while you're abroad.

What is Dukoral, though, and do you need it for your upcoming trip? Let's take a look at everything you need to know.

What Is Dukoral and Why Do You Need It?

Dukoral is a vaccine that can be taken to help prevent cholera and traveller's diarrhea when you are travelling. Whether or not you will be at risk for developing either of these conditions while you are abroad depends on where you are travelling.

What Is Cholera?

Usually spread through contaminated water, cholera is a disease caused by certain bacteria. When a person has cholera they can experience severe dehydration and diarrhea. If cholera is not treated quickly, it can be fatal.

Cholera is basically nonexistent in industrialized countries due to modern water treatment and sewage systems. However, this disease still exists in Southeast Asia, Africa, and Haiti. While a cholera epidemic can be disastrous for a region, this condition can be treated easily. With an inexpensive and simple rehydration solution, deaths caused by severe dehydration are preventable.

In addition to diarrhea and dehydration, cholera can cause nausea and vomiting, fatigue, irritability, dry mouth, sunken eyes, shriveled and dry skin, low blood pressure, extreme thirst, and irregular heartbeat, or little to no urinating.

What Is Traveler's Diarrhea?

Traveller's diarrhea is the name for when a person who is travelling experiences diarrhea when they are visiting a place that has poor public hygiene. This condition typically occurs within 10 days of visiting the location.

While traveller's diarrhea can be caused by a wide variety of bacteria, parasites, and viruses, it is most commonly caused by bacteria such as E. coli.

Water and food can become infected by bacteria, parasites, and viruses that can cause traveller's diarrhea when people:

• Store food unsafely
• Prepare and handle food unsafely
• Don't wash their hands after using the bathroom
• Don't clean utensils and dish ware safely.

The risk for developing traveller's diarrhea is present when you travel to a country that has poor hygiene and poor public sanitation. Some of the highest risk places tend to be developing countries in Asia, Africa, the Middle East, and Central and South America.

While diarrhea is the most common symptom of this condition, individuals can also experience symptoms such as bloating, nausea, vomiting, blood in the stool, abdominal cramps or pain, feeling tired, urgency with their bowel movement, and fever.

How Do You Buy Dukoral?

It's important that you discuss travel to an at-risk area with your doctor before taking Dukoral.

A prescription is not necessary in order to obtain Dukoral to help prevent enterotoxigenic E. coli-diarrhea unless you live in Quebec. Otherwise, your local travel clinic or local pharmacy will have Dukoral you can purchase.

However, if you're taking Dukoral for cholera, you will need to receive a prescription from a doctor or medical professional.

What Form Does Dukoral Come In? How Do You Take Dukoral?

Dukoral is an oral vaccine. It is available in the form of a suspension that is combined with a sachet of effervescent granules. These granules are first dissolved in water and then mixed with the vaccine before orally taking the medicine.

After the medication has been prepared, it needs to be consumed within two hours. You'll want to avoid eating, drinking, or taking any other oral medication for the hour before and after you take each of your doses.

For both adults and children that are six years or older, Dukoral is taken in two doses that are spread apart by six weeks. Children who are between the ages of two and six years old take the medicine in three doses with 1 to 6 weeks in between each dose.

When taking Dukoral, the course should be completed before the potential exposure to cholera by at least one week. In order to receive continuous protection against this condition, is recommended that individuals over the age of six receive a single Dukoral booster dose within two years. For children between the ages of two and six, this booster should be taken within six months.

If an adult hasn't received the booster in two years or a child hasn't received the booster within six months, the full course will have to be repeated.

If you're taking a trip, you might want to learn about trip cancellation and trip interruption insurance. Check out our article on the topic here.

Who Shouldn't Take Dukoral?

This medication is not recommended for use during pregnancy. If you are pregnant and travelling to a country where you're at risk of developing cholera or diarrhea caused by ETEC, you'll want to take to your doctor about the possible risks.

Dukoral is also not recommended for individuals who are suffering from an acute gastrointestinal illness or a fever. If you are experiencing either of these illnesses, you'll want to wait until the illness has passed before taking this medication. If you have a mild illness, such as a cold, however, then you may take the vaccine.

Any individuals that have an allergy to formaldehyde, any ingredient in this medication, or any ingredient in its container should not take this vaccine.

How Does Dukoral Work?

Since Dukoral is a vaccine, it works in the same way that other vaccines do. This is by essentially teaching the body's immune system how it can protect itself from a disease.

This medication contains small amounts of cholera bacteria that has been inactivated as well as a part of the cholera toxin. The body creates antibodies against the bacteria and the toxin which allows the immune system to produce these antibodies is essentially what fights off the bacteria should it enter your body. The way that these antibodies can help protect you from cholera is by preventing both the toxins in the bacteria from attaching to the walls of your digestive system and approaching or entering the cells of your body.

How Long Does Dukoral Last?

The protection against cholera and enterotoxigenic E. coli (ETEC) begins roughly one week after you've taken your last dose.

You'll be protected for about three months from diarrhea caused by ETEC. You will be able to renew your protection for another three months with a single dose if you've taken Dukoral in the last three months to five years. If you are going to take this single dose, you should make sure that you take it at least one week before you go on your travels.

For adults and children that are at least six years old, the protection against cholera lasts for about two years. For children between the ages of two and six years old, the protection lasts for about six months.

Adults and children over the age of six can take one booster dose in order to renew protection against cholera if they've received the last dose between two and five years previously. If your child between the ages of two and six has had a course of Dukoral between six months and five years ago, they will be able to take one Dukoral booster dose to renew protection against cholera.

Are There Side Effects to Taking Dukoral?

There are some common side effects to taking this medication. It is possible to have an allergic reaction to Dukoral. Some people might experience diarrhea, abdominal pain, vomiting, nausea, or feeling feverish.

Rarely, serious side effects can occur including shortness of breath and dehydration. If you are experiencing any of these side effects, it's important that you see a doctor or a healthcare professional.

Are There Any Other Warnings or Precautions For Dukoral?

You always want to talk to your doctor before you start taking any medication. You can let your doctor know about:

• Other medications you are taking
• Any allergies or medical conditions you might have
• Whether you are pregnant or breast-feeding
• If there are other significant pieces of information regarding your health

Your doctor can take this information and determine if it should affect how you take this medication if at all.

Can Dukoral Interact With Other Medications?

Like many medications, Dukoral can interact with certain other drugs.

Dukoral shouldn't be taken within 8 hours of taking an encapsulated oral typhoid vaccine. It can also negatively interact with immunosuppressants.

If you are taking other medications or vaccines, make sure that you don't take them within one hour of taking the Dukoral vaccine.

You'll want to let your doctor or health care provider know what medications you are taking. They will tell you whether you should make changes to your medications or how to safely proceed.

Just because two medications interact does not necessarily mean that you have to stop taking them. This is why it's important to consult your doctor, as they will be able to advise you.

There might be more types of medication that Dukoral can interact with that we haven't listed here. When you are discussing taking Dukoral with your doctor, you'll want to mention all of the medications you take, including prescription, over-the-counter, and herbal or nutritional supplements. You'll also want to let your prescriber know if you drink caffeine, smoke cigarettes, or use street drugs.

Should I Get Dukoral For My Trip?

Whether or not you should get Dukoral in Canada before travelling largely depends on your specific circumstances.

The first thing you'll want to look at is the details of your trip. If you are going to an all-inclusive resort for one week and you don't plan on leaving the resort, you might not be at nearly as high a risk as someone who is backpacking in Southeast Asia for a few months. While this doesn't necessarily mean that you shouldn't take Dukoral if you're going to an all-inclusive resort, it's just important to understand where and how your risks are higher.

Another thing that you will want to consider is your past history. Have you ever had gastrointestinal troubles on previous trips that you had? If you are prone to having stomach issues, then it might make sense for you to seriously consider taking Dukoral before travelling.

Another question you'll want to ask yourself is how important it is to you to decrease the risk of getting sick. For example, are you travelling for work and it's important that you can stay focused and be in your best health? If so, you'll probably want to take Dukoral.

Lastly, you'll want to think about your budget. For the initial two doses, the Dukoral cost in Ontario is $90. For the single booster dose, it costs $50. If you bring your drug plan information with you when you go to get the vaccines, you can find out how much of your Dukoral doses your drug plan will pay for.

Are you looking to get away but can't put your job on hold just yet? Take a look at this article on planning the perfect workation .

Is It Time For You to Find Affordable Health Insurance in Canada?

Getting sick from cholera or traveller's diarrhea can be seriously disruptive to your travel plans and in some cases quite dangerous. Taking Dukoral can help to prevent the occurrence of these issues, allowing you to carry on with your trip as planned.

When you have health insurance, it can help to ensure that you and your family are not put under financial stress if someone you love experiences a medical emergency or faces health issues. It can also help out when you are buying preventative vaccines or other medications like Dukoral.

Is it time for you to find affordable health insurance in Canada? At Insurdinary, we offer free quotes to help you find the right health and dental insurance for you and your family.

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This medicine is authorised for use in the European Union

Dukoral is a vaccine that is given by mouth to protect people against cholera, a serious disease that causes severe diarrhoea. It is used in people aged from 2 years who will be visiting areas with high risk of cholera. Cholera is caused by the bacterium Vibrio cholerae (V. cholerae), which is caught from contaminated food or water.

Dukoral should be used according to official recommendations, taking into account where cholera occurs and the risk of catching the disease.

The vaccine contains 4 different inactivated strains (types) of V. cholerae serotype O1, and part of a toxin from one of these strains as active substances.

How is Dukoral used?

Dukoral can only be obtained with a prescription. It is available as a liquid mixture in a bottle together with powder in a sachet. The powder is dissolved in water to make an effervescent solution and the Dukoral liquid is added to this solution before the person drinks it. Food, drink and other medicines should be avoided for 1 hour before and 1 hour after taking the vaccine.

In adults and children from 6 years of age, Dukoral is given as two doses, 1 to 6 weeks apart. Children aged between 2 and 6 years should receive three doses, with an interval of 1 to 6 weeks between each dose. The course should be completed at least 1 week before potential exposure to cholera. For continuous protection against cholera, a single booster dose is recommended within 2 years for adults and children from 6 years of age, and within 6 months for children aged between 2 and 6 years.

For more information about using Dukoral, see the package leaflet or contact your doctor or pharmacist.

How does Dukoral work?

Dukoral is a vaccine. Vaccines work by preparing the immune system (the body’s natural defences) to defend the body against a specific disease. Dukoral contains small amounts of inactivated (killed) bacteria that cause cholera and a fragment of the cholera toxin called the ‘B subunit’. When a person is given the vaccine, the immune system recognises the killed bacteria and the toxin fragment in the vaccine as ‘foreign’ and makes antibodies against them. If, later on, the bacteria (from contaminated food or drink) enter the gut of a vaccinated person, the antibodies will be able to prevent the bacteria and their toxin from attaching to the walls of the gut and entering the body’s cells.

What benefits of Dukoral have been shown in studies?

The company presented data from the published literature as well as results of 3 main studies, involving a total of almost 113,000 people, to support the use of Dukoral. In all 3 studies, Dukoral, given as either two or three doses, was compared with placebo (a dummy vaccine). The studies took place in areas where cholera is found. The main measure of effectiveness was the ‘protective effectiveness’ of the vaccine, calculated by comparing the number of people in the studies who developed cholera after receiving Dukoral and after receiving placebo.

The first study involved over 89,000 people in Bangladesh and compared Dukoral with the same vaccine without the toxin and with placebo. In this study, Dukoral was made using cholera toxin extracted from cholera bacteria in place of the newer recombinant toxin. The protective effectiveness of Dukoral was 85% over 6 months. Protection lasted for 6 months in children and 2 years in adults. In adults, 2 doses of the vaccine were as effective as 3.

The other two studies compared Dukoral (containing recombinant cholera toxin) with placebo in over 22,000 people in Peru. In the first of the two studies, the protective effectiveness of Dukoral was 85% for the first 5 months. The people in the second study also received a booster dose 10 to 12 months later. The protective effectiveness of Dukoral after the booster dose was 61% during the second year of follow-up.

The company also presented information on the use of Dukoral for the prevention of a severe type of traveller’s diarrhoea caused by a bacterium called ‘enterotoxigenic Escherichia coli’. However, the information was not sufficient to support the use of Dukoral in traveller’s diarrhoea.

What are the risks associated with Dukoral?

Side effects with Dukoral are not common and those that can affect up to 1 in 100 people are headache, diarrhoea, and abdominal (belly) effects such as pain, cramps, gurgling (gas) or discomfort.

Dukoral must not be used in people who are hypersensitive (allergic) to any of the active substances, to any of the other ingredients or to formaldehyde. Its use should be postponed in patients with fever or short-lived illness affecting the stomach or gut.

For the full list of side effects and restrictions of Dukoral, see the package leaflet.

Why is Dukoral authorised in the EU?

The risk of cholera for regular tourists is minor, but the European Medicines Agency considered that Dukoral could be important for certain groups, such as healthcare workers in cholera epidemics or travellers visiting areas where cholera is present. Side effects with Dukoral are uncommon and generally mild. The Agency therefore decided that Dukoral’s benefits are greater than its risks and it can be authorised for use in the EU.

What measures are being taken to ensure the safe and effective use of Dukoral?

Recommendations and precautions to be followed by healthcare professionals and patients for the safe and effective use of Dukoral have been included in the summary of product characteristics and the package leaflet.

As for all medicines, data on the use of Dukoral are continuously monitored. Side effects reported with Dukoral are carefully evaluated and any necessary action taken to protect patients.

Product details

• recombinant cholera toxin B subunit
• vibrio cholerae 01
• Immunization

Pharmacotherapeutic group

Therapeutic indication.

Dukoral is indicated for active immunisation against disease caused by Vibrio cholerae serogroup O1 in adults and children from 2 years of age who will be visiting endemic/epidemic areas.

The use of Dukoral should be determined on the basis of official recommendations taking into consideration the variability of epidemiology and the risk of contracting disease in different geographical areas and travelling conditions.

Dukoral should not replace standard protective measures. In the event of diarrhoea measures of rehydration should be instituted.

Authorisation details

S-105 21 Stockholm Sweden

Assessment history

Changes since initial authorisation of medicine.

Dukoral : EPAR - Procedural steps taken and scientific information after authorisation

English (EN) (230.23 KB - PDF)

Initial marketing authorisation documents

Dukoral : EPAR - Procedural steps taken before authorisation

English (EN) (91.19 KB - PDF)

Dukoral : EPAR - Scientific Discussion

English (EN) (331.43 KB - PDF)

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Travel vaccines: Update

We have read with great interest the article entitled “Travel Vaccines: Update for Canadian Pharmacists” published in the November/December issue of the Canadian Pharmacists Journal . We share the author’s view that pharmacists are in a unique position to provide guidance on safe and healthy travel practices, including immunization and personal protective measures. However, to do so, pharmacists must have access to the most accurate information. To this end, please allow us to provide some comments and clarifications regarding the approved product information for both the cholera/enterotoxigenic Escherichia coli (ETEC)–diarrhea vaccine (DUKORAL) and the Japanese encephalitis vaccine (IXIARO).

Travellers’ diarrhea and cholera

• 1. The article states that the oral cholera/ETEC-diarrhea vaccine (DUKORAL) is “promoted in Canada to protect travellers against TD but may provide a false sense of security, as the actual efficacy of this vaccine for the prevention of all-cause TD is quite low, at only 6%.” 1

DUKORAL is not promoted to prevent all-cause travellers’ diarrhea (TD). DUKORAL is indicated specifically for the prevention of and protection against cholera and ETEC-producing heat-labile enterotoxin (LT) for adults and children 2 years of age and older. 2 Similar to a meningococcal serogroup C vaccine, which is not expected to protect against all-cause meningitis, DUKORAL would not be expected, nor is it indicated, to protect against all-cause TD.

As outlined in the Canadian product monograph, the efficacy of DUKORAL against LT-producing ETEC has ranged from 60% to 67% during the initial 3 months of follow-up. In 1 study, the protective efficacy against clinically severe episodes of LT-producing ETEC diarrhea was 86%. 2 Protective efficacy with reference to all-cause diarrhea will vary depending on the prevalence of LT-producing ETEC at destination.

The Committee to Advise on Tropical Medicine and Travel (CATMAT) mentions that certain selected short-term travellers at high risk for health complications or serious inconvenience from diarrhea during travel may be considered for immunization with the oral cholera/ETEC-diarrhea vaccine—namely,

• those for whom a brief illness cannot be tolerated (i.e., elite athletes, some business or political travellers),
• those with increased susceptibility to TD (e.g., due to achlorhydia, gastrectomy, history of repeated severe TD, young children >2 years),
• those who are immunosuppressed due to human immunodeficiency virus (HIV) infection with depressed CD4 count or other immunodeficiency states, and
• those with chronic illnesses for whom there is an increased risk of serious consequences from TD (e.g., chronic renal failure, congestive heart failure, insulin-dependent diabetes mellitus, inflammatory bowel disease). 3

The inconvenience and cost of an episode of diarrhea during travel, particularly in those who accord great value to their trip, may mean that the uptake of the vaccine for travellers in good health is also worth considering. Vaccination with the oral cholera/ETEC-diarrhea vaccine has been shown to be cost-effective (saving) at incidence rates of diarrhea caused by ETEC above about 13% and 9% for leisure and business travellers, respectively. 4 The perceived value of avoiding a case of diarrhea is an important influencing factor in the decision to seek vaccination prior to travel, and it is dependent on an individual traveller’s circumstances and the value accorded to his or her trip.

• 2. The article also states that “the commercially available preparation in Canada does not protect against V. cholera O139, most commonly found in India and Bangladesh.” 1

While it is correct to point out that DUKORAL has not been demonstrated to protect against cholera caused by Vibrio cholera serogroup O139, this serogroup is currently seldom isolated and has remained confined to sporadic cases in India and Bangladesh since the early 1990s. 5 , 6

• ETEC-diarrhea: up to 3 months
• Cholera for children 2 to 6 years of age: 6 months
• Cholera for adults and children 6 years and older: 2 years 2

Japanese encephalitis vaccine

• Contrary to the statement in this article (and footnotes in Table 1) that the use of the Japanese encephalitis vaccine (IXIARO) in children >2 months of age would be considered “off-label” in Canada, IXIARO has been indicated for active immunization against Japanese encephalitis for persons 2 months of age and older since March 2018. 7
• Also, for adults 18 to 65 years of age who may face time constraints in completing the primary series, a rapid immunization schedule (day 0, day 7) would not be “off-label” in Canada as stated. Rather, this rapid immunization schedule has also been approved in Canada since March 2018. 7

Canadian pharmacists have increasingly become a trusted source of health care information and services. We agree with the author that the expanded scope of pharmacy practice presents an opportunity for pharmacists to play a greater role in providing immunization services for travellers. We hope that the above information will help support pharmacists in counselling their travelling patients appropriately.

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INTRODUCTION

Immunization needs are based on the traveler's prior immunizations, health conditions, and likely exposures while traveling ( table 1 ). Those exposures depend upon the countries and regions to be visited and on the nature of potential exposures to infectious agents. For example, travelers with short-term tourism itineraries may have different requirements from those with longer-term occupational exposures. A pretravel consultation enables updating of routine immunizations to protect against illness due to infections for which there is an increased risk of exposure during travel (such as diphtheria, measles, mumps, and varicella) [ 3 ].

Issues related to immunizations for travelers are reviewed here. Other travel-related medical issues and measures to prevent malaria are discussed separately. (See "Travel advice" and "Prevention of malaria infection in travelers" .)

WEBSITES FOR ADDITIONAL GUIDANCE

● United States Centers for Disease Control and Prevention (CDC) – Information on the indications, dosing, side effects, timing, and contraindications for immunizations in travelers are provided by the CDC in a biennial, Health Information for International Travel [ 4 ], with ongoing updates in an online version.

● World Health Organization (WHO) – The WHO also has online information that includes vaccines or dosing regimens approved outside the United States [ 5 ]. Information may be found on the CDC website and the WHO website . Guidance may also be found via GlobalTravEpiNet (GTEN), which has web-based tools for providers and patients based on CDC recommendations.

Travellers’ Diarrhea Medicine and Remedies

What is Travellers’ Diarrhea?

Travellers’ diarrhea is the most common illness affecting international travellers. The symptom is so well known that it has earned many nicknames, including “Montezuma’s Revenge”, “Pharaoh’s Revenge,” and “Delhi Belly”. Recent studies show up to 70 percent of travellers will come down with diarrhea symptoms during their trip.

Often, travellers’ diarrhea itself is not an illness. It is usually a symptom of infection like food poisoning or e. coli . The best way to avoid travellers’ diarrhea is to avoid these diseases.

Where Does Travellers’ Diarrhea Occur?

Travellers’ diarrhea can occur anywhere, at home or abroad. Eating at a less clean restaurant or drinking unfiltered water can lead to the symptom. The regions with the highest risk are:

• Latin America
• Middle East

While these regions have an increased risk, travellers’ diarrhea can occur anywhere.

People with a high risk of becoming ill include young adults, immunosuppressed persons, people with chronic diseases such as Crohn’s disease or diabetes, and those who are taking H-2 blockers or antacids that lower the stomach’s ability to kill germs.

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Passport health – travellers’ diarrhea prevention, how does travellers’ diarrhea spread.

Travellers’ diarrhea is caused by eating or drinking contaminated food or water. Most often, the infection is from e. coli , but other diseases like cholera , typhoid or norovirus can cause the symptom. Bacterial infections are responsible for up to 80 percent of travellers’ diarrhea cases.

Most often, these infections spread through a food worker not washing their hands before preparing a meal. Improper sanitation within a kitchen or other similar area can also lead to infection. Fruit, vegetables and other items should be washed with clean water before eating to avoid contamination.

What Are the Symptoms of Travellers’ Diarrhea?

Travellers’ diarrhea can show symptoms just a few hours after exposure. But, they usually appear within one to two days. It is possible to have more than one bout of travellers’ diarrhea during a trip.

The most common symptoms of travellers’ diarrhea are:

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• Passing three or more loose stolls in 24 hours
• An urgent need to defecate
• Abdominal (stomach) cramps
• Fever and/or vomiting

Bacterial diarrhea lasts three to seven days. Viral diarrhea lasts two to three days. Protozoal diarrhea can last months without treatment.

Travellers’ diarrhea kits can help you overcome symptoms quickly. Call or book online now to get yours from a local Passport Health.

How Do I Prevent Travellers’ Diarrhea?

As with many infections, it is easier to prevent travellers’ diarrhea than treat it. Prevention comes in two forms, medication or vaccination and good travel habits.

The PHAC advises travellers to take care when selecting food or drink. Only drink or use safe drinking water. This water should be bottled or filtered. Wash your hands often with sopa and water.

Be sure any food you eat has been cooked well. Peel any fruits or vegetables you may eat and be sure to wash them with clean water. While street food can be tempting, it is best to avoid vendors. Use your hotel conceirge or other services to learn where are the safest and best places to eat in your destination.

Medications like Travelan can help prevent travellers’ diarrhea if exposed. Vaccinations against food- or waterborne infections like typhoid , cholera or hepatitis A are another great form of protection. These vaccines provide the best protectation against their respective diseasese.

How Is Travellers’ Diarrhea Treated?

Most cases of travellers’ diarrhea resolve themselves within a few days. But, travellers don’t have time to wait for the problem to go away.

There are a variety of options available to help fight travellers’ diarrhea when it occurs. These include:

• Antibiotics – These are commonly prescribed for the treatment of travellers’ diarrhea. The specific antibiotic chosen is based on the likelihood a person is infected with an invasive organism, and how resistant the organism is to antibiotics. Both factors are largely determined by the travellers’ destination. For more information on travellers’ diarrhea antibiotics, contact Passport Health, or your local physician.
• Oral Rehydration Tablets – Also known as oral rehydration salts, these will help with keeping a person hydrated during infection.
• Anti-Motility Medications – Are not recommended for use in self-treatment for travellers’ diarrhea. This is due to the risk of side effects and complications.

Various combinations of the above items are available in Passport Health travellers’ diarrhea kits. Call or book online now to get yours .

If the diarrhea continues for more than one or two days after beginning treatment, you may need additional medical care, follow up with a primary care provider.

On This Page: What is Travellers’ Diarrhea? Where Does Travellers’ Diarrhea Occur? How Does Travellers’ Diarrhea Spread? What Are the Symptoms of Travellers’ Diarrhea? How Do I Prevent Travellers’ Diarrhea? How Is Travellers’ Diarrhea Treated?

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Find a Clinic

There are several places you can get vaccines and medicine before you travel.

Call your doctor or local health department to see if they can provide pre-travel advice, vaccines, and medicines.

List of health departments

If you want to see a travel medicine specialist, the International Society of Travel Medicine (ISTM) can help you find a clinic.

Directory of travel clinics

If you need yellow fever vaccine you must get vaccinated at an authorized yellow fever vaccine clinic. Many of these clinics also give other shots and medicines.

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• About the Handbook

Details for Dukoral vaccine and its components.

Recently added

This page was added on  04 June 2018 .

Updates made

This page was updated on [date-counter-updated-date] .  View history of updates

Registered for use in people aged ≥2 years.

Each 3.0 mL liquid vaccine dose vial contains:

• inactivated whole-cell Vibrio cholerae O1 Inaba, Ogawa, classic and El Tor strains (31.25 x 10 9 vibrios of each)
• 1.0 mg recombinant cholera toxin B subunit (rCTB)

The buffer is in a sachet of effervescent granules containing:

• anhydrous sodium carbonate
• sodium bicarbonate
• anhydrous citric acid
• sodium citrate
• saccharin sodium
• raspberry flavour

This formulation does not contain aspartame.

For Product Information and Consumer Medicine Information about Dukoral visit the Therapeutic Goods Administration website .

Additional vaccine information

For detailed advice on vaccine dosage, administration, contraindications and precautions, and variations from product information, please visit the relevant disease chapter/s.

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Claudia Looi

Touring the Top 10 Moscow Metro Stations

By Claudia Looi 2 Comments

Komsomolskaya metro station looks like a museum. It has vaulted ceilings and baroque decor.

Hidden underground, in the heart of Moscow, are historical and architectural treasures of Russia. These are Soviet-era creations – the metro stations of Moscow.

Our guide Maria introduced these elaborate metro stations as “the palaces for the people.” Built between 1937 and 1955, each station holds its own history and stories. Stalin had the idea of building beautiful underground spaces that the masses could enjoy. They would look like museums, art centers, concert halls, palaces and churches. Each would have a different theme. None would be alike.

The two-hour private tour was with a former Intourist tour guide named Maria. Maria lived in Moscow all her life and through the communist era of 60s to 90s. She has been a tour guide for more than 30 years. Being in her 60s, she moved rather quickly for her age. We traveled and crammed with Maria and other Muscovites on the metro to visit 10 different metro stations.

Arrow showing the direction of metro line 1 and 2

Moscow subways are very clean

To Maria, every street, metro and building told a story. I couldn’t keep up with her stories. I don’t remember most of what she said because I was just thrilled being in Moscow.   Added to that, she spilled out so many Russian words and names, which to one who can’t read Cyrillic, sounded so foreign and could be easily forgotten.

The metro tour was the first part of our all day tour of Moscow with Maria. Here are the stations we visited:

1. Komsomolskaya Metro Station  is the most beautiful of them all. Painted yellow and decorated with chandeliers, gold leaves and semi precious stones, the station looks like a stately museum. And possibly decorated like a palace. I saw Komsomolskaya first, before the rest of the stations upon arrival in Moscow by train from St. Petersburg.

2. Revolution Square Metro Station (Ploshchad Revolyutsii) has marble arches and 72 bronze sculptures designed by Alexey Dushkin. The marble arches are flanked by the bronze sculptures. If you look closely you will see passersby touching the bronze dog's nose. Legend has it that good luck comes to those who touch the dog's nose.

Touch the dog's nose for good luck. At the Revolution Square station

Revolution Square Metro Station

3. Arbatskaya Metro Station served as a shelter during the Soviet-era. It is one of the largest and the deepest metro stations in Moscow.

Arbatskaya Metro Station

4. Biblioteka Imeni Lenina Metro Station was built in 1935 and named after the Russian State Library. It is located near the library and has a big mosaic portrait of Lenin and yellow ceramic tiles on the track walls.

Lenin's portrait at the Biblioteka Imeni Lenina Metro Station

5. Kievskaya Metro Station was one of the first to be completed in Moscow. Named after the capital city of Ukraine by Kiev-born, Nikita Khruschev, Stalin's successor.

Kievskaya Metro Station

6. Novoslobodskaya Metro Station  was built in 1952. It has 32 stained glass murals with brass borders.

Novoslobodskaya metro station

7. Kurskaya Metro Station was one of the first few to be built in Moscow in 1938. It has ceiling panels and artwork showing Soviet leadership, Soviet lifestyle and political power. It has a dome with patriotic slogans decorated with red stars representing the Soviet's World War II Hall of Fame. Kurskaya Metro Station is a must-visit station in Moscow.

Ceiling panel and artworks at Kurskaya Metro Station

8. Mayakovskaya Metro Station built in 1938. It was named after Russian poet Vladmir Mayakovsky. This is one of the most beautiful metro stations in the world with 34 mosaics painted by Alexander Deyneka.

Mayakovskaya station

One of the over 30 ceiling mosaics in Mayakovskaya metro station

9. Belorusskaya Metro Station is named after the people of Belarus. In the picture below, there are statues of 3 members of the Partisan Resistance in Belarus during World War II. The statues were sculpted by Sergei Orlov, S. Rabinovich and I. Slonim.

10. Teatralnaya Metro Station (Theatre Metro Station) is located near the Bolshoi Theatre.

Teatralnaya Metro Station decorated with porcelain figures .

Taking the metro's escalator at the end of the tour with Maria the tour guide.

Have you visited the Moscow Metro? Leave your comment below.

January 15, 2017 at 8:17 am

An excellent read! Thanks for much for sharing the Russian metro system with us. We're heading to Moscow in April and exploring the metro stations were on our list and after reading your post, I'm even more excited to go visit them. Thanks again 🙂

December 6, 2017 at 10:45 pm

Hi, do you remember which tour company you contacted for this tour?

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