vaccines. Guidelines for routine adult immunization have been published in a separate issue.2 Immunocompromised or pregnant patients generally should not receive live virus vaccines, such as those for measles and yellow fever, although in some situa tions the benefit might outweigh the risk.
CHOLERA -The risk o f cholera in tourists is very low. The parenteral vaccine previously licensed in the US is no longer available. An oral, whole-cell recom binant vaccine called Dukoral is available in some European countries (Crucell/SBL Vaccines) and in Canada (Sanofi Pasteur). It is not currently recom mended for routine use in travelers, but might be con sidered for those who plan to work in refugee camps or as healthcare providers in endemic areas.
HEPATITIS A -Hepatitis A vaccine, which is now part o f routine childhood immunization in the US, is recommended for all unvaccinated travelers going anywhere other than Australia, Canada, western Europe, Japan or New Zealand. 3 Vaccination o f adults and children usually consists of two IM doses separated by 6-18 months. Additional booster doses are not needed.4,5 Two hepatitis A vac cines are available in the US: Havrix and Vaqta.
Patients who received a first dose o f one vaccine will respond to a second dose o f the other. Second doses given up to 8 years after the first dose have produced protective antibody levels.6
Antibodies reach protective levels 2-4 weeks after the first dose. Even when exposure to the disease occurs sooner than 4 weeks after vaccination, the traveler is usually protected because o f the relatively long incu bation period o f hepatitis A (average 28 days). For immunosuppressed patients and those with chronic liver disease who will be traveling to an endemic area in 3 months. For travel durations o f >5 months, the dose should be repeated.7

# HEPATITIS B -Vaccination against hepatitis B is recommended for travelers going to intermediate-or high-risk areas (see Table 2 for low-risk areas).
Travelers going anywhere who engage in behaviors that may increase the risk o f transmission, such as unprotected sexual contact with new partners, dental treatment, skin perforation practices (tattoos, acupunc ture, ear piercing) or invasive medical treatment (injections, stitching), should be immunized against hepatitis B. Two hepatitis B vaccines are available in the US: Engerix-B and Recombivax-HB. Primary immuniza tion usually consists o f 3 doses given IM at 0, 1 and 6 months. An alternate schedule o f 3 doses given at 0, 1 and 2 months, followed by a fourth dose at 12 months, is approved for Engerix-B in the US. A 2-dose sched ule o f adult Recombivax-HB at 0 and 4-6 months is approved in the US for adolescents 11-15 years old. An Not approved for 3 yrs 0.5 mL SC 1 mL SC 0, 28  2. According to the CDC it is safe for children < 2 years old who require vaccination for the Hajj. 3. Repeat after three years for children vaccinated at 2-6 years of age. 4. Regimen for pre-exposure prophylaxis. If a previously vaccinated traveler is exposed to a potentially rabid animal, post-exposure prophylaxis with 2 additional vaccine doses separated by 3 days should be initiated as soon as possible. 5. Minimal acceptable antibody level is complete virus neutralization at a 1:5 serum dilution by the rapid fluorescent focus inhibition test. accelerated schedule of 0, 7 and 14 days, followed by a booster dose at 6 months, can also be used with either vaccine, but is not FDA-approved.
An interrupted hepatitis B vaccination series can be completed without being restarted. A 3-dose series started with one vaccine may be completed with the other. Post-vaccination serologic testing is recommend ed for healthcare workers, infants born to HBsAg-positive mothers, hemodialysis patients, HIV-infected and other immunocompromised patients, and sex-and nee dle-sharing partners o f HBsAg-positive patients.

# HEPATITIS A/B -A combination vaccine (Twinrix)
containing the same antigenic components as pediatric H avrix and Engerix-B is available for patients >18 years old. It is given in 3 doses at 0, 1 and 6 months. An accelerated schedule o f 0, 7 and 21-30 days with a booster dose at 12 months is also approved.8
The combination vaccine can be used to complete an immunization series started with monovalent hepatitis A and B vaccines. Twinrix Junior is available outside the US for children 1-15 years old. INFLUENZA -Influenza may be a risk in the trop ics year-round and in temperate areas o f the Southern Hemisphere from April to September. Outbreaks have occurred on cruise ships and on organized group tours in any latitude or season.9
Seasonal influenza vaccine directed against strains in the Northern Hemisphere is sometimes available in the US until the end o f June and the US Advisory Committee on Immunization Practices (ACIP) recom mends that persons for whom seasonal influenza vac cine is indicated10 consider being vaccinated before travel to the Southern Hemisphere during influenza season or to the tropics at any season, or when travel ing in a group with persons from the Southern Hemisphere during their influenza season (April-September).11 In some years, the vaccine strains are the same in both hemispheres. If the vaccine strains are different, high-risk patients from the N orthern Hemisphere who travel to the Southern Hemisphere during that region's influenza season could also con sider being immunized on arrival because the vaccine active against strains in the Southern Hemisphere is rarely available in the Northern Hemisphere.
A monovalent vaccine is available to protect against the currently (2009) circulating pandemic influenza A (H1N1) virus.12 It can be given at the same time as the seasonal vaccine, except not the 2 live attenuated for mulations together. Both the seasonal and monovalent influenza vaccines are prepared in eggs. Hypersensitivity reactions could occur.
There is no commercial influenza vaccine available for pathogenic strains o f avian influenza (H5N1, H7N2, H9N2, H7N3, H7N7), but an inactivated vaccine against avian H5N1 is FDA-approved and is being included in the US Strategic National Stockpile.

# JAPANESE
ENCEPH ALITIS -Japanese encephalitis is an uncommon but potentially fatal m os quito-borne viral disease that occurs in rural Asia, especially near pig farms and rice paddies. It is usual ly seasonal (May-October), but may occur year-round in equatorial regions. The attack rate in travelers has been very low. 13 Vaccination is recommended for travelers >1 year old who expect a long stay (>1 month) in endemic areas or heavy exposure to mosquitoes (such as adventure trav elers) during the transmission season. Vaccination also should be considered for travelers spending less than a month in endemic areas during the transmission season if they will be sleeping without air conditioning, screens or bed nets, or spending considerable time outside in rural or agricultural areas, especially in the evening or at night.14 Some Medical Letter consultants suggest that, given the rarity o f the disease in US residents, compul sive use of insect repellents and judicious avoidance of exposure to mosquitoes might be reasonable alternatives to vaccination for short-term travelers.
Two formulations are FDA-approved in the United States: JE-Vax, which is a mouse-brain preparation, and the recently approved Ixiaro, a non-mouse-brain vac cine, which is preferred for use in adults, but has not been approved for use in children in the US. 15 In clini cal trials, 2 doses o f Ixiaro (one is not enough) appeared to be as effective as JE-Vax, and considerably safer.16 MEASLES -The measles vaccine is no longer avail able in a monovalent formulation. It is available as an attenuated live-virus vaccine in combination with mumps and rubella (MMR). Adults born in or after 1957 (1970 in Canada) and healthcare workers o f any age who have not received 2 doses o f live measles vac cine (not the killed vaccine that was commonly used in the 1960s) after their first birthday and do not have a physician-documented history o f infection or laborato ry evidence o f immunity should receive two doses of M M R vaccine, separated by at least 28 days. 17 Previously unvaccinated children >12 months old should receive 2 doses o f M M R vaccine at least 28 days apart before traveling outside the US. Children 6-11 months old should receive 1 dose before travel ing, but will still need two subsequent doses for rou tine immunization, one at 12-15 months and one at 4 6 years.
MENINGOCOCCAL -A single dose o f m eningo coccal vaccine is recommended for adults and children >2 years old who are traveling to areas where epi demics are occurring, or to anywhere in the "meningi tis belt" (semi-arid areas of sub-Saharan Africa extend ing from Senegal and Guinea eastward to Ethiopia) from December to June. Saudi Arabia requires a cer tificate of immunization for pilgrims during the Hajj. Immunization should also be considered for travelers to other areas where Neisseria meningitidis is hyper endemic or epidemic, particularly for those who will have prolonged contact with the local population, such as those living in a dormitory or refugee camp, or working in a healthcare setting.  Two quadrivalent vaccines are available against N. meningitidis serogroups A, C, Y and W135. Menomune contains m eningococcal capsular polysaccharides. Menactra, which contains capsular polysaccharides conjugated to diphtheria toxoid, is preferred, but Menomune is an acceptable alternative. Neither vac cine provides protection against serogroup B, which does not have an immunogenic polysaccharide capsule. Group B infections are rare in sub-Saharan Africa.
The most common adverse reactions to M enactra have been headache, fatigue and malaise in addition to pain, redness and induration at the site of injection. The rates o f these reactions are higher than with M enomune, but similar to those with tetanus toxoid. Guillain-Barre syndrome has been reported rarely in adolescents who received M enactra, but cause and effect have not been established.21 POLIO -Adults who have not previously been immunized against polio should receive a primary series o f inactivated polio vaccine (IPV) if traveling to areas where polio is still endemic (Nigeria, India, Pakistan, Afghanistan) or to areas with documented outbreaks or circulating vaccine-derived strains (see Table 3). 22 Previously unimmunized children should also receive a primary series o f IPV If protection is needed within 4 weeks, a single dose o f IPV is recommended, but provides only partial pro tection. Adult travelers to risk areas who have previ ously completed a primary series and have never had a booster should receive a single booster dose o f IPV.

# RABIES -Rabies is highly endemic in parts of
Africa, Asia (particularly India) and Central and South America, but the risk to travelers is generally low. Pre exposure immunization against rabies is recommended for travelers with an occupational risk o f exposure, for those (especially children) visiting endemic areas where immediate access to medical treatment, particu larly rabies immune globulin, tends to be limited, and for outdoor-adventure travelers.23,24 The 2 vaccines available in the US (Imovax, RabAvert) are similar; both are given in the deltoid (not gluteal) muscle at 0, 7 and 21 or 28 days.
After a bite or scratch from a potentially rabid animal, patients who received pre-exposure prophylaxis should promptly receive 2 additional doses o f vaccine at days 0 and 3. Without pre-exposure immunization, the ACIP recommends rabies immune globulin (RIG) and is now recommending the US are acceptable alternatives to FDA-approved vaccines; neural tissue vaccines have high rates o f seri ous adverse effects.26 RIG is a blood product, and its purity and potency may be less reliable, if it is avail able at all, in developing countries.

# TETANUS, DIPHTHERIA AND PERTUSSIS -
Previously unimmunized children should receive 3 or (preferably) 4 doses o f pediatric diphtheria, tetanus and acellular pertussis vaccine (DTaP) before travel.
An accelerated schedule can be used beginning at age 6 weeks, with the second and third doses given 4 weeks after the previous dose, and the fourth dose 6 months after the third.
Adults with an uncertain history o f primary vaccina tion should receive 3 doses o f a tetanus and diphtheria toxoid vaccine. One meta-analysis found that combinations of an anti bacterial plus loperamide were more effective than an antibacterial alone in decreasing the duration of illness.42
Packets o f oral rehydration salts (Ceralyte, ORS, and others) mixed in potable water can prevent and treat dehydration, particularly in children and the elderly. They are available from suppliers of travel-related products and some pharmacies in the US, and from pharmacies overseas.
Prophylaxis -Medical Letter consultants generally do not prescribe antibiotic prophylaxis for travelers' diar rhea, but rather instruct the patient to begin self-treat ment when symptoms are distressing or persistent. Some travelers, however, such as immunocompro mised patients or those with time-dependent activities who cannot risk the temporary incapacitation associat ed with diarrhea, might benefit from prophylaxis. 43 In such patients, ciprofloxacin 500 mg, levofloxacin 500 mg, ofloxacin 300 mg or norfloxacin 400 mg can be given once daily during travel and for 2 days after return and are generally well tolerated. In one 2-week study among travelers to Mexico, rifaximin (200 mg 1-3x/d) was effective in preventing travelers' diarrhea. 44 Bismuth subsalicylate (Pepto-Bismol, and oth ers) can prevent diarrhea in travelers who take 2 tablets 4 times a day for the duration o f travel, but it is less effective than antibiotics. It is not recommended for children <3 years old.

# MALARIA
No drug is 100% effective for prevention o f malaria; travelers should be told to take protective measures against mosquito bites in addition to medication. 45 Countries with a risk of m alaria are listed in Table 5.   Some countries with endemic m alaria transmission may not have m alaria in the most frequently visited major cities and rural tourist resorts. Travelers to malarious areas should be reminded to seek medical attention if they have fever either during their trip or up to a year (especially during the first 2 months) after they return. Travelers to developing countries, where counterfeit and poor quality drugs are common, should consider buying antimalarials before travel.

# TRAVELERS' DIARRHEA

# CH LO RO QUINE-SENSITIVE M ALARIA -
Chloroquine is the drug o f choice for prevention of malaria in the few areas that still have chloroquinesensitive m alaria (see Table 5, footnotes 4, 6 and 7). Patients who cannot tolerate chloroquine should take atovaquone/proguanil, doxycycline, mefloquine or, in some circumstances, primaquine in the same doses used for chloroquine-resistant m alaria (see Table 6).

# CH LO RO QUINE-RESISTANT M ALARIA -
Three drugs o f choice with similar efficacy, listed with their dosages in Table 6, are available in the US for prevention o f chloroquine-resistant malaria.
A fixed-dose com bination o f atovaquone and proguanil (Malarone) taken once daily is generally the best tolerated prophylactic,46 but it can cause headache, insomnia, GI disturbances and mouth ulcers. Single case reports o f Stevens-Johnson syndrome and hepatitis have been published. Atovaquone/proguanil should not be given to patients with severe renal impairment (CrCl <30 mL/min). There have been iso lated case reports of treatment-related resistance to ato vaquone/proguanil in Plasmodium falciparum in Africa, but Medical Letter consultants do not believe there is a high risk for acquisition o f resistant disease.47-50 In one study o f malaria prophylaxis, atovaquone/proguanil was as effective and better tolerat ed than mefloquine in nonimmune travelers. 51 The pro tective efficacy o f atovaquone/proguanil against P. vivax is variable ranging from 84% in Indonesian New Guinea52 to 100% in Colombia.53 Some Medical Letter consultants prefer other drugs if traveling to areas where P. vivax predominates.
Mefloquine has the advantage o f once-a-week dosing, but is contraindicated in patients with a history of any psychiatric disorder (including severe anxiety and depression), and also in those with a history of seizures or cardiac conduction abnorm alities.54 Dizziness, headache, insomnia and disturbing dreams are the most common CNS adverse effects. The drug's adverse effects in children are similar to those in adults. If a patient develops psychological or behav ioral abnormalities such as depression, restlessness or confusion while taking mefloquine, another drug should be substituted. Mefloquine should not be given together with quinine, quinidine or halofantrine due to potential prolongation o f the QT interval; caution is required when using these drugs to treat patients who have taken mefloquine prophylaxis. Doxycycline (Vibramycin, and others), which fre quently causes GI disturbances and can cause photo sensitivity and vaginitis, offers an inexpensive once-  360:58).
3. P rim aquine is given for prevention of relapse after infection w ith P vivaxor P ovale. Som e expe rts also prescribe prim aquine phosphate 30 mg base/d (0.6 mg base/kg/d for children) for 14d after dep arture from areas w h ere these species are endem ic (P resum ptive A nti-R elap se The rap y , "term in al prophylax is"). S ince this is not always effective as prophylaxis (E S ch w artz et al, N Engl J M ed 2003; 349:1510), others prefer to rely on surveillan ce to detect cases w hen th e y occur, particularly w hen exposure w a s lim ited or doubtful. See also footnote 11. 4. Alternatives for patients who are unable to take chloroquine include atovaquone/proguanil, mefloquine, doxycycline or prim aquine dosed as for chloroquine-resistant areas. 5. C hloroquine should be taken w ith food to decrease gastrointestinal adverse effects. If chloro quin e phosphate is not available, hydroxychloroquine sulfate is as effective; 400 mg o f hydroxychloroquine sulfate is equivalent to 500 mg of chloro quin e phosphate. 6. A tovaqu one/proguanil is available as a fixed-dose com bination tablet: adult table ts (Malarone; 250 mg atovaquone/100 mg proguanil) and pediatric tablets (Malarone Pediatric-; 62.5 mg atovaquone/25 mg pro g u a n il).T o enh ance absorption and reduce nausea and vom iting, it should be taken w ith food or a m ilky d rin k .T h e drug should not be given to patients w ith severe renal im pairm ent (crea tinine clearance <30 m L/m in). 7. D oxycycline should be taken w ith ade quate w ater to avoid esophageal irritation. It can be taken w ith food to m inim ize gastrointestinal adverse effects. It is con traindicate d in children < 8 years old. 8. In th e US, a 250-m g tablet of m efloquine contains 228 mg m efloquine base. O utside th e US, each 275-m g tablet contains 250 mg base. M efloquine can be given to patients taking B-blockers if they do not have an underlying arrhythm ia; it should not be used in patients with conduction abnorm alities. M efloquine should not be taken on an em pty stom ach; it should be taken w ith at least 8 oz. of water. 9. M ost adverse events occur w ith in 3 doses. Som e M edical Letter consu ltants favor starting m efloquine 3 w eeks prior to travel and m onitoring th e patient for a dverse events; this allow s tim e to change to an alternative regim en if m efloquine is not tolerated. 10. For pediatric doses < 1 /2 tablet, it is advisable to have a pharm acist crush the tablet, estim ate doses by w eighing, and package them in gelatin capsules. T h e re is no d a ta for use in c hildren < 5 kg, but based on d o s a g e s in o ther w e ig h t groups, a do se of 5 m g/kg can be used. 11. P a tients sh ou ld be scre e n e d for G -6-P D d e fic ie n c y before tre a tm e n t w ith prim a q u in e . It s h ou ld be ta k e n w ith food to m inim ize n a u s e a and abd o m in a l pain. 12. Not F D A -approved for th is in dicatio n. daily alternative. Doxycycline should not be taken concurrently with antacids, oral iron or bismuth salts A fourth drug, primaquine phosphate, can also be used for prophylaxis, especially in areas where P. vivax is the predominant species, but in other areas should be reserved for travelers unable to take any other drug; it is somewhat less effective than the alternatives against P falciparum. However, several studies have shown that daily primaquine can provide effective prophylax is against chloroquine-resistant P falciparum and P. vivax.55 Some experts also prescribe primaquine for prophylaxis after departure from areas where P. vivax and P. ovale are endemic (see Table 6, footnote 3).
Primaquine can cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, which is most common in African, Asian, and M editerranean peoples. Travelers should be screened for G-6-PD deficiency before treatment with the drug. Primaquine should be taken with food to reduce GI effects. PREGNANCY -Malaria in pregnancy is particular ly serious for both mother and fetus; prophylaxis is indicated if travel cannot be avoided. Chloroquine has been used extensively and safely for prophylaxis of chloroquine-sensitive m alaria during pregnancy. Mefloquine is not approved for use during pregnancy. It has, however, been reported to be safe for prophy lactic use during the second or third trimester of preg nancy and possibly during early pregnancy as w ell.56,57 The safety o f atovaquone/proguanil in pregnancy has not been established, and its use is not recommended. However, outcomes were normal in 24 women treated w ith the com bination in the second and third trimester,58 and proguanil alone has been used in preg nancy without evidence o f toxicity. Doxycycline and primaquine are contraindicated in pregnancy.

# MEFLOQUINE-RESISTANT

# PREVENTION OF INSECT BITES
To minimize insect bites, travelers should wear lightcolored, long-sleeved shirts, pants, socks and covered shoes. They should sleep in air conditioned or screened areas and use insecticide-im pregnated bed nets. Mosquitoes that transmit m alaria are most active between dusk and dawn; those that transmit dengue fever bite during the day, particularly during early morning and late afternoon.59 DEET -The most effective topical insect repellent is N, N -diethyl-m -toluam ide (D eE T ).60 Applied on exposed skin, DEET repels mosquitoes, as well as ticks, chiggers, fleas, gnats and some flies. DEET is available in formulations of 5-100% even though increasing the concentration above 50% does not seem to improve efficacy. Medical Letter consultants prefer concentrations o f 30-35%. A long-acting DEET for mulation originally developed for the US Armed Forces (US Army Extended Duration Topical Insect and Arthropod Repellent -EDTIAR) containing 25 33% DEET (Ultrathon) protects for 6-12 hours. A microencapsulated sustained-release formulation con taining 20% DEET (Sawyer Controlled Release) is also available and can provide longer protection than similar concentrations o f other DEET formulations.
According to the CDC, DEET is probably safe in chil dren and infants >2 m onths old; the Am erican Academy o f Pediatrics recommends use o f concentra tions containing no more than 30%. One study found that applying DEET regularly during the second and third trimesters o f pregnancy did not result in any adverse effects on the fetus.61 DEET has been shown to decrease the effectiveness o f sunscreens when it is applied after the sunscreen; nevertheless, sunscreen should be applied first because it may increase the absorption o f DEET when DEET is applied first.62 PICARIDIN -Picaridin has been available in Europe and Australia for many years. Data on the 7% and 15% formulations (Cutter Advanced) currently sold in the US are limited. The 20% formulation (Natrapel 8 Hour; GoReady) has been shown to pro tect for up to 8 hours; in clinical trials it has been about as effective as 20% DEET.63-65 PERMETHRIN -An insecticide available in liquid and spray form, permethrin (Duranon, Permanone, and others) can be used on clothing, mosquito nets, tents and sleeping bags for protection against mosqui toes and ticks. After application to clothing, it remains active for several weeks through multiple launderings. Using permethrin-impregnated mosquito nets while sleeping is helpful when rooms are not screened or airconditioned. If bednets or tents are immersed in the liquid, the effect can last for about 6 months. The com bination o f DEET on exposed skin and permethrin on clothing provides increased protection.

# SOME OTHER INFECTIONS
DENGUE -Dengue fever is a viral disease transmit ted by mosquito bites that occurs worldwide in tropical and subtropical areas, including cities. Epidemics have occurred in recent years in Southeast Asia (especially Thailand), South Central Asia, sub-Saharan Africa, the South Pacific and A ustralia, Central and South America and the Caribbean. It has also been reported in travelers from the US vacationing at popular tourist destinations in Puerto Rico, the US Virgin Islands and Mexico.66 Prevention o f mosquito bites during the day, particularly in early morning and late afternoon, is the primary way to protect against dengue fever; no vac cine is currently available.
LEPTOSPIROSIS -Leptospirosis, a bacterial dis ease that occurs in many domestic and wild animals, is endemic worldwide, but the highest incidence is in tropical and subtropical areas. Transmission to humans usually occurs through contact with fresh water or damp soil contaminated by the urine o f infected ani m als.67 Travelers at increased risk, such as adventure travelers and those who engage in recreational water activities, should consider prophylaxis with doxycycline 200 mg orally once a week, beginning 1-2 days before and continuing throughout the period o f expo sure. No human vaccine is available in the US.

# NON-INFECTIOUS RISKS OF TRAVEL
Many non-infectious risks are associated with travel. Injuries, particularly traffic accidents and drowning, which account for the majority o f travel-related deaths, and sunburn occur in many travelers.
HIGH ALTITUDE ILLNESS -Rapid exposure to altitudes >8,000 feet (2500 meters) may cause acute mountain sickness (headache, fatigue, nausea, anorex ia, insomnia, dizziness); pulm onary and cerebral edema can occur.68 Sleeping altitude appears to be especially important in determining whether symp toms develop. The most effective preventive measure is pre-acclimatization by a 2-to 4-day stay at interme diate altitude (6000-8000 feet) and gradual ascent to higher elevations.
Acetazolamide, a carbonic anhydrase inhibitor taken in a dosage o f 125-250 mg twice daily (or 500 mg daily with the slow-release formulation Diamox Sequels) beginning 1-2 days before ascent and continuing at high altitude for 48 hours or longer, decreases the inci dence and severity o f acute mountain sickness. 69 The recommended dose for children is 5 mg/kg/d in 2 or 3 divided doses. Although acetazolamide, a sulfone, has little cross-reactivity with sulfa drugs, hypersensitivity reactions to acetazolamide are more likely to occur in those who have had severe (life-threatening) allergic reactions to sulfa drugs.70 Symptoms can be treated after they occur by descent to a lower altitude or by giving supplemental oxygen, especially during sleep. W hen descent is impossible, dexamethasone (Decadron, and others) 4 mg q6h, acetazolamide 250-500 mg q12h, or the two together, may help. Nifedipine (Procardia, and others), 20-30 mg twice daily may also be helpful. A variety of interventions have been tried, but none is proven to be effective. Shifting daily activities to cor respond to the time zone o f the destination country before arrival along with taking short naps, remaining well hydrated, avoiding alcohol and pursuing activities in sunlight on arrival may help. The dietary supple ment melatonin (0.5-5 mg started on the first night of travel and continued for 1-5 days after arrival) has been reported to facilitate the shift of the sleep-wake cycle and decrease symptoms in some patients. A pro gram o f appropriately timed light exposure and avoid ance in the new time zone may adjust the "body clock" and reduce jet lag.75 In one study, zolpidem (Ambien, and others) started the first night after travel and taken for 3 nights was helpful.76 MOTION SICKNESS -Therapeutic options for motion sickness remain limited.77 A transdermal patch or oral formulation o f the prescription cholinergic blocker scopolam ine can decrease symptoms. Transderm Scop is applied to the skin behind the ear at least 4 hours before exposure and changed, alternating ears, every 3 days. The oral 8-hour tablet (Scopace) is taken 1 hour before exposure. Oral promethazine (Phenergan, and others) is a highly sedating alterna tive. Over-the-counter drugs such as dimenhydrinate (Dramamine, and others) or meclizine (Bonine, and others) are less effective, but may be helpful for milder symptoms.
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