Chapter 14: Travel medicine

With over 600 million international trips being taken annually, the health problems faced by travellers are considerable and variable depending on the countries visited and the lifestyle adopted by the traveller.¹ Travellers to North America, Europe and Australasia are usually at no greater risk of getting an infectious disease than they would be at home, but those visiting the less developed tropical and subtropical countries of Africa, Central and South America and South-East Asia are at significant risk of contracting infectious diseases. The immunocompromised are those at greatest risk.

Problems range in complexity from the most frequent and usually benign problems, such as traveller's diarrhoea, to more exotic and potentially fatal infections such as malaria, Japanese encephalitis and HIV. It must also be remembered that in some countries with volatile political changes there is the possibility of injury, incarceration or being left stranded. Travel means transport and thus the potential for accidents and crippled body and bank balance. Insurance for such contingencies is as important as preventive health measures.

• Advise the patient to plan early—at least 8 weeks beforehand.

• Register with Smartraveller (provided by the Australian Department of Foreign Affairs and Trade (DFAT)).

• Advise a dental check.

• Allow adequate time for consultation (e.g. 30–45 minutes).

• Individualise advice.

• Provide current information.

• Provide written as well as verbal advice.

• Provide a letter concerning existing medical illness and treatment.

• Encourage personal responsibility.

The commonest problem facing travellers is traveller's diarrhoea but other important diseases caused by poor sanitation include hepatitis A, and worm infestations such as hookworm and schistosomiasis.

Contamination of food and water is a major problem, especially in third world countries.

Reputable soft drinks, such as Coca-Cola, should be recommended for drinking. Indian-style tea, in which the milk is boiled with tea, is usually safe, but tea with added milk is not. The food handlers can be infected and the water used to wash food may be contaminated.

Traveller's diarrhoea

Traveller's diarrhoea is a special problem in Mexico, Nepal, India, Pakistan, South-East Asia, Latin America, the Middle East and Central Africa and its many colourful labels include ‘Bali Belly’, ‘Gippy Tummy’, ‘Rangoon Runs’, ‘Tokyo Trots’ and ‘Montezuma's Revenge’. It occurs about 6–12 hours after taking infected food or water.

The illness is usually mild and lasts only 2 or 3 days. It is unusual for it to last longer than 5 days. Symptoms include abdominal cramps, frequent diarrhoea with loose, watery bowel motions and possible vomiting. Very severe diarrhoea, especially if associated with the passing of blood or mucus, may be a feature of Shigella sp or Campylobacter sp infections and amoebiasis.

Most traveller's diarrhoea is caused by enterotoxigenic E. coli (ETEC), Campylobacter sp, Shigella sp and Salmonella sp. Travellers are infected because they are exposed to slightly different types or strains of E. coli from the ones they are used to at home.²

The possible causes of diarrhoeal illness are listed in TABLE 14.1.

Treatment³

Refer to FIGURE 14.1.^2,3

The key factor in treatment is rehydration.

Mild diarrhoea

• Maintain fluid intake—Gastrolyte.

• Antimotility agents (judicious use: if no blood in stools)—avoid in children.

  loperamide (Imodium) 2 caps statim then 1 after each unformed stool (max. 8 caps/day)

  or

  diphenoxylate with atropine (Lomotil) 2 tablets statim then 1–2 (o) 8 hourly

  Imodium is the preferred agent.

Moderate diarrhoea³

• Attend to hydration.

• Patient can self-administer antibiotic—e.g. single dose norfloxacin or azithromycin (especially in India, Nepal and Thailand).

• Loperamide in adults.

Severe diarrhoea (patient toxic and febrile)

• ?Admit to hospital.

• Attend to hydration—use an oral hydrate solution (e.g. Gastrolyte).

• Loperamide in adults.

• Antibiotic: norfloxacin (first choice), ciprofloxacin or azithromycin (usually 3 days).

Note: There is increasing resistance to doxycycline and cotrimoxazole, especially in South-East Asia.

Persistent diarrhoea

Any travellers with persistent diarrhoea after visiting less-developed countries, especially India and China, may have a protozoal infection such as amoebiasis or giardiasis. If the patient has a fever and mucus or blood in the stools, suspect amoebiasis. Giardiasis is characterised by abdominal cramps, flatulence, and bubbly, foul-smelling diarrhoea persisting beyond 2 to 4 days. Take three specimens of faeces for analysis. In some cases serology may be helpful (e.g. amoebiasis).

Treatment

• Giardiasis: tinidazole or metronidazole

• Amoebiasis: metronidazole or tinidazole

Patients can self-administer these drugs and carry them if visiting areas at risk, but they can have a severe disulfram-like adverse reaction with alcohol.

Preventive advice

The following advice will help prevent diseases caused by contaminated food and water. These ‘rules’ need only be followed in areas of risk such as Africa, South America, India and other parts of Asia. Only drink purified water and only eat well-cooked food.

• Purify all water by boiling for 10 minutes. Adding purifying tablets is not so reliable, but if the water cannot be boiled some protection is provided by adding Puratabs (chlorine) or iodine (2% tincture of iodine), which is more effective than chlorine—use 4 drops of iodine to 1 litre of water and let it stand for 30 minutes.

• Avoid ice in your drinks unless known to be safe. Drink only boiled water (supplied in some hotels) or well-known bottled beverages (mineral water, 7-Up, Coca-Cola, beer).

• Brush your teeth using purified water.

• Avoid fresh salads or raw vegetables (including watercress). Salads or uncooked vegetables are often washed in contaminated water. Bananas and fruit with skins are safe once you have peeled and thrown away the skin but care should be taken with fruit that may possibly be injected with water.

• Be wary of dairy products such as milk, cream, ice-cream and cheese.

• Avoid eating raw shellfish and cold cooked meats.

• Avoid food, including citrus fruits, from street vendors.

• Drink hot liquids wherever possible.

• Use disposable moist towels for hand washing.

• Vaccines against ETEC are in development.

Malaria

General aspects

• Travellers to all tropical countries are at some risk of this protozoal infection.

• Malaria is endemic in 102 countries;⁴ 2.3 billion people are at risk, with 500 million affected every year.

• The risk is very low in the major cities of Central and Southern America and South-East Asia but can be high in some African cities.

• In humans malaria is caused by four species of plasmodium:

  • – Plasmodium vivax and P. ovale—tertian malaria

  • – P. falciparum—malignant tertian malaria

  • – P. malariae—quartian malaria

  • – P. knowlesi—presents like vivax and falciparum

• Malaria is either benign (vivax, ovale) or malignant (falciparum).

• Resistance to many drugs is increasing:

  • – The lethal P. falciparum is developing resistance to chloroquine and the antifolate antimalarials (Fansidar and Maloprim).⁴

  • – Resistance is now reported to mefloquine and artemether.

  • – Resistance is common in South-East Asia, Papua New Guinea (PNG), northern South America and parts of Africa.

• Chloroquine is used infrequently as it is only effective in limited areas of the world but not PNG.

• The long-awaited vaccine will make all the complex drug management much simpler. However, it still appears to be many years away despite considerable research.

• Patients who have had splenectomies are at grave risk from P. falciparum malaria (PFM).

• People die from malaria because of delayed diagnosis, delayed therapy, inappropriate therapy and parasite–host factors.

• It is recommended that pregnant women and young children do not travel to malarious areas (if possible).

• Practitioners should follow updated recommended guidelines (e.g. WHO therapeutic guidelines (antibiotic)).

Malaria risk assessment

The risk of catching malaria is increased by:

• being in a malaria area, especially during and after the wet season

• a prolonged stay in a malaria area, especially rural areas, small towns and city fringes

• sleeping in unscreened rooms without mosquito nets over the bed

• wearing dark clothing with short-sleeved shirts and shorts

• taking inappropriate drug prophylaxis

• an incomplete course of prophylaxis

Malaria prevention

Travellers should be advised that malaria may be prevented by following two simple rules:

1. avoid mosquito bites

2. take antimalarial medicines regularly

In order to avoid mosquito bites, travellers are advised to:

• keep away from rural areas and avoid outdoor activities between dusk and darkness

• sleep in air-conditioned or properly screened rooms

• use insecticide sprays to kill any mosquitoes in the room or use mosquito coils at night

• smear an insect repellent on exposed parts of the body; an effective repellent is diethyl-m-toluamide (Muskol, Repellem, Rid)

• use mosquito nets (tuck under mattress; check for tears)

• impregnate nets with permethrin (Ambush) or deltamethrin

• wear sufficient light-coloured clothing, long sleeves and long trousers to protect whole body and arms and legs when in the open after sunset

• avoid using perfumes, cologne and after-shave lotion (also attract insects)

Important considerations in malaria prophylaxis

1. Minimise exposure to mosquitoes and avoid bites.

2. Know areas of risk:

   • tropical South America (southern Mexico to northern half South America)

   • tropical Africa (sub-Sahara to northern South Africa)

   • Nile region, including remote rural Egypt

   • Southern Asia, especially tropical areas

3. Know areas of widespread chloroquine resistance:

   • Asia, tropical South America (rare north of Panama Canal), sub-Sahara, East Africa

4. Consider several factors:

   • intensity of transmission

   • season and length of stay

   • itinerary

     • urban—hotel

     • urban—non-hotel

     • rural—housing

     • rural—backpacking

   • resistance patterns

   • host factors

     • – age

     • – pregnancy

     • – associated illness

     • – compliance

5. Know the antimalarial drugs (see TABLE 14.2).

6. Balance risk benefit of drug prophylaxis: drug side effects versus risk of PFM.

7. Visiting areas of PFM does not automatically require the use of potentially harmful drugs.¹

8. Those at special risk are pregnant women, young children and the immunocompromised. Advise against travel.

9. No drugs give complete protection.

Drug prophylaxis

Refer to WHO guidelines (www.who.int/ith/en).

• Accommodation in large, air-conditioned hotels in most cities of South-East Asia (dusk–dawn) for <2 weeks: no prophylaxis required.

• For low-risk travel (urban: dusk–dawn) in areas of high resistance for <2 weeks: doxycycline is adequate; use a treatment course of Malarone if necessary (see TABLE 14.3).

• Chloroquine is no longer recommended because of the global spread of resistance.

• For short- and long-term travel to rural areas of high resistance (e.g. South-East Asia including Thailand, Kenya, Tanzania, Ecuador, Venezuela, Brazil): doxycycline daily alone or mefloquine (once a week). Atovaquone and proguanil (Malarone) is also very useful for short-term travel.

Protection from many types of infection is available through immunisation. All travellers should be immunised against tetanus, polio and diphtheria and measles. Protection against tetanus requires an initial course of three injections followed by a booster every 10 years.

Vaccinations are required for special circumstances. Yellow fever vaccination is a legal requirement for any travellers returning from a yellow fever endemic area. Cholera is not usually required.

Some travellers may be exposed to tuberculosis, hepatitis, plague, rabies, typhoid, typhus and meningococcal infection. Immunisation against these is available and recommended for those at risk. Smallpox has now been eradicated from the world and therefore smallpox vaccination is no longer required for any traveller.

Japanese B encephalitis presents as a special problem to the traveller.

TABLE 14.4 outlines a summary of recommendations to consider.^7,8

The two vaccinations that may be required before visiting ‘at risk’ areas are yellow fever and meningococcus.

Yellow fever

Yellow fever is a serious viral infection spread by Aedes mosquitoes and, like malaria, is a tropical disease. Yellow fever vaccination, which is the only WHO-required vaccine, is essential for travel to or through equatorial Africa and northern parts of South America, and for re-entry to Australia from those countries.

One injection only is required and the immunisation is valid for 10 years. Children aged less than 9 months should not be given this vaccine. It should not be given within 3 weeks of cholera vaccine.

Note: It is important to check specific country requirements in the WHO book on vaccination requirements.⁹

According to the WHO a certificate against yellow fever is the only certificate that should be required for international travel. The requirements of some countries are in excess of international health regulations. However, vaccination against yellow fever is strongly recommended to all travellers who intend to visit places other than the major cities in the countries where the disease occurs in humans.

Meningococcal infection

Meningitis due to this organism is a contagious lethal disease. It is common in Nepal, Mongolia, Vietnam and parts of Africa and Asia, especially in the dry season. Travellers trekking through the Kathmandu valley of Nepal and those attending the Haj pilgrimage to Saudi Arabia are at special risk and should have the vaccine. However, some countries require immunisation for entry.

Precautions against the following diseases are recommended for those travellers who may be at special risk.⁵

Hepatitis A, B

Hepatitis A is a common problem in rural areas of developing countries. There is a declining level of antibodies to hepatitis A in developed countries and adults are at special risk so one or two doses of hepatitis A vaccine should be given. A blood test for hepatitis A antibodies can be carried out to determine a person's immunity.

Prevention

The rules of avoiding contaminated food and water apply (as for traveller's diarrhoea). Hepatitis A vaccine is given as a course of two injections.

Hepatitis B is endemic in South-East Asia, South America and other developing countries. Vaccination is recommended, especially for people working in such countries, particularly those in the health care area or those who may expect to have sexual or drug contact. If patients have a ‘negative’ HBV core IgG titre, then vaccination would be worthwhile (three doses: 0, 1 and 6 months). Hepatitis E has a high mortality rate in pregnant women.

The usual approach for non-immunised people is to give the combined hepatitis A and B vaccine (Twinrix) as a course of three injections.

Typhoid

Typhoid immunisation is not required for entry into any country but is recommended for travel to third world countries where the standards of sanitation are low. It should be considered for travellers to smaller cities, and village and rural areas in Africa, Asia, Central and South America and Southern Europe.

The parenteral (subcutaneous) vaccine can be used but the single dose typhi Vi vaccine or the oral vaccine, which have fewer side effects, are generally preferred. The oral vaccine, which is given as a series of three or four capsules, appears to afford protection for about 5 years but is contraindicated in the immunocompromised.

Cholera

Cholera vaccination is not officially recommended by the WHO because it has only limited effectiveness. It is advisable for health care workers or others at risk entering an endemic area. Cholera is given as an oral vaccine (Dukoral) over 1 week prior to exposure. It is not recommended in children under 5 years or pregnant women.

Japanese B encephalitis

This mosquito-borne flavivirus infection presents a real dilemma to the traveller and doctor because it is a very severe infection (mortality rate 20–40%) with high infectivity and high prevalence in endemic countries.

The disease is prevalent during the wet season in the region bounded in the west by Nepal and Siberian Russia and in the east by Japan and Singapore, especially in Nepal, Burma, Korea, Vietnam, Thailand, China, eastern Russia and the lowlands of India. Rice paddies and pig farms are areas of risk. The usual preventive measures against mosquito bites are important.

Rabies

Rabies vaccination is recommended for some international aid workers or travellers going to rabies-endemic areas for periods of more than 1 month or even for short periods of working with affected animals in those areas. The vaccination can be effective after the bite of a rabid animal, so routine vaccination is not recommended for the traveller. Affected animals include dogs, cats, monkeys, camels and feral (wild) animals. A traveller who sustains a bite or scratch or even is licked by an animal in countries at risk should wash the site immediately with soap or a detergent, and then seek medical help. The prebite vaccination does not remove the need for postexposure vaccination.

Plague

Plague is still prevalent in rodents in countries such as Vietnam, Brazil, Peru, Ecuador and Kenya. Although not compulsory, vaccination is recommended for those engaged in field operations in plague areas and rural health workers who may be exposed to infected patients. Two doses are given to adults (three to children <12 years) and a booster every 6 months.

Prevention of sexually transmitted infections

Casual sexual contacts place the traveller at risk of contracting a serious, perhaps fatal, sexually transmitted infection (STI). The common STIs, especially prevalent in South-East Asia and Africa, are non-specific urethritis (NSU), gonorrhoea (especially penicillin-resistant strains), hepatitis B and syphilis. HIV infection is a rapidly increasing problem, with heterosexual transmission common in Africa and in South-East Asia. Unusual STIs such as lymphogranuloma venereum, chancroid and donovanosis are more common in tropical developing countries. A practical rule is to assume that all ‘at risk’ travellers are both ignorant and irresponsible and advise accordingly.

Exposure to STIs

If a patient has had unprotected intercourse and is at definite risk of acquiring an STI, such as penicillin-resistant gonorrhoea or NSU, the following may be appropriate:¹

• ceftriaxone 250 mg IM (as a single dose)

• doxycycline 100 mg (o) for 10 days or azithromycin 1 g (o) statim

Drugs

Possession of and trafficking in drugs is very hazardous and many people are held in foreign prisons for various drug offences. The penalty for carrying drugs can be death.

Countries that currently may enforce the death penalty are Burma, China, Indonesia, Malaysia, Singapore, Thailand and Turkey. Travellers should be warned about taking cannabis while in a foreign country, as it can cause profound personality changes in the user.

Drug addicts should under no circumstances travel. Young travellers should be wary about accepting lifts or hitchhiking in countries ‘at risk’.

Most international airlines do not allow passengers to travel after the 36th week of pregnancy and may require a doctor's certificate after 28 weeks. Air travel is contraindicated in the last month of pregnancy and until the 7th day after delivery. The past obstetric history should be taken into account. The same health risks apply except that most antimalarial tablets and vaccinations are not recommended. Live vaccinations (measles, rubella, influenza) are generally contraindicated⁹ but the WHO considers it safe to have polio vaccine. Administration of killed or inactivated vaccines, toxoids and polysaccharides is permitted during pregnancy. Yellow fever vaccine is considered safe after the 6th month. As a general rule pregnancy and travel to third world countries do not mix and pregnant women should be advised not to travel to these countries. Avoid travel if possible in Zika-affected areas.

Tetanus immunisation is important as protection is passed on to the child during early infancy. Immunoglobulin can be safely given as prevention against hepatitis.

The antimalarial drugs chloroquine, quinine and proguanil (with 5 mgm folic acid) may be given to pregnant women but all others mentioned in TABLE 14.2 are contraindicated.

Although children, including infants, are good travellers and adapt well, their resistance, especially to heat and infections, is lower. A child can suffer from acute dehydration very rapidly.⁹ Air travel is not recommended for infants of less than 7 days or premature infants.

The change in atmospheric pressure on landing can cause distressing ear pain, so taking a bottle during descent is recommended.

In tropical areas it is important to keep children well hydrated and they should wear loose cotton clothing. A good guide to the health of children is the amount and colour of their urine. If it is scanty and concentrated they are not getting sufficient fluid.

Most vaccines (diphtheria, tetanus, poliomyelitis, BCG) can safely be given in the first few weeks of life. Measles is common overseas and it is worthwhile considering it even under 12 months. Yellow fever vaccine should not be given under 12 months, hence the importance of protection against mosquito bites. Malaria prophylaxis is important. Chloroquine, proguanil and quinine may be given safely to infants. However, as a rule young children should be discouraged from travel.

Air travel is safe and comfortable, but jet lag and air sickness are problems that face many travellers.

Jet lag

This is the uncomfortable aftermath of a long flight in which the person feels exhausted and disoriented, and has poor concentration, insomnia and anxiety. The problem on arrival is poor concentration and judgment during the daytime.

Other symptoms that may occur include anorexia, weakness, headache, blurred vision and dizziness.

Jet lag is a feature of flying long distances east–west or west–east through several time zones, causing the person's routine daily rhythm of activity and sleep to get out of phase. The worst cases appear to be in those travelling eastbound from England to Australia. It can occur with travel in any direction, but the north–south flights are not so bothersome.

Factors influencing jet lag

Personal factors. These include age, state of health, tolerance to change, preparation for the long trip and, very importantly, the emotional and mental state.

General factors. Noise, vibration, air humidity and sitting still for long periods can influence jet lag.

Specific factors. Duration of the flight, time of departure, and changes in climate and culture at the destination affect the severity of jet lag. The problem is aggravated by:

• stress of the pretrip planning

• last-minute rushing and anxiety

• lack of sleep during the trip

• overeating and excessive alcohol during the flight

• smoking

How to minimise the problem (advice to patients)

Before the flight

• Allow plenty of time for planning.

• Plan a stopover if possible.

• If possible, arrange the itinerary so that you are flying into the night.

• Ensure a good sleep the night before flying.

• Ensure a relaxed trip to the airport.

• Take along earplugs if noise (75–100 decibels) is bothersome.

During the flight

• Fluids. Avoid alcohol and coffee. Drink plenty of non-alcoholic drinks such as orange juice and mineral water.

• Food. Eat only when hungry and even skip a meal or two. Eat the lighter, more digestible parts of your meals and avoid fatty foods and rich carbohydrate foods.

• Dress. Wear loose clothes (e.g. long skirts, comfortable jeans, light jumpers) and avoid restrictive clothing. Wear comfortable (not tight) shoes and take them off during the flight.

• Sleep. Try to sleep on longer sections of the flight (give the movies a miss). Close the blinds, wear special eye masks and ask for a pillow. Sedatives such as temazepam (Euhypnos or Normison) or antihistamines can help sleep.

• Activity. Try to take regular walks around the aircraft and exercise at airport stops. Keep feet up when resting, and exercise by flexing the major muscles of the legs. Avoid resting the calves of legs against the seat for long periods. Rest without napping during daylight sectors.

• Special body care. Continually wet the face and eyes.

A wetting agent such as hypromellose 0.5% eye drops can help those with a tendency to sore eyes.

At the destination

Take a nap for 1–2 hours if possible.

Wander around until you are tired and go to bed at the usual time. It is good to have a full day's convalescence and avoid big decision making soon after arrival. Allow about 3 days for adjustment after the London to Australia flight.

Role of melatonin¹⁰

The importance of melatonin, a hormone secreted by the pineal gland, is somewhat controversial. However, a major review of trials by the Cochrane Library pointed to its efficacy for alleviating jet lag. Oral medication in a 2–5 mg dose close to the desired or usual bedtime decreased jet lag. One possible explanation is that it has a low-grade hypnotic effect.

Who is fit to fly?

Patients with these problems should avoid flying^9,11 or be assessed for fitness:

• upper airways congested by infection, including influenza, e.g. within 6 weeks of severe acute respiratory illness

• acute gastroenteritis

• severe respiratory disease (COPD, chronic bronchitis, pneumothorax)

• recent thoracic surgery

• cystic fibrosis

• pulmonary tuberculosis (people should not fly until rendered non-infective)

• past history of respiratory problems while flying (dyspnoea, chest pain, confusion)

• unstable heart failure

• severe anaemia (below 7.5 g/dL)

• pregnancy beyond 200 days (28 weeks) (up to 36 weeks if necessary)

• previous violent or unpredictable behaviour

• within 7 days of a myocardial infarction

• within 3 days of a cerebrovascular accident

• within 5–10 days of major surgery

• brain tumour or recent skull fracture

• recent eye surgery

• severe or poorly controlled hypertension

• poorly controlled epilepsy

Special precautions are required by travellers with the following problems:

• Colostomy. Patients should wear a large colostomy bag and take extra bags.

• Varicose veins. Such patients should wear supportive stockings and exercise frequently.

• Plaster casts. Those with broken limbs in plaster should be careful of swelling.

• Pacemakers. Those with pacemakers may have a problem with X-rays at some overseas airports. Mention it to security officials before passing through security equipment.

• Epilepsy. Medication should be increased on the day of travel.

• Diabetics. Diabetics should discuss their therapy and control with their doctor. They should carry sweets.

Prevention of DVT

There is a risk of DVT in any person flying on long international flights. Risk factors include: increasing age, clotting tendency, i.e. thrombophilia, past history of DVT, family history of DVT, smoking, obesity, varicose veins, dehydration, significant illness, recent major surgery and oestrogen therapy (see CHAPTER 131).

Prevention is by:

• keeping hydrated—drink ample fluids but avoid alcohol and caffeine drinks

• in-flight exercises, such as foot pumps, ankle circles, knee lifts

• compression stockings (class 18–20)

• medication for those at risk, e.g. thrombophilia, Clexane 80 mg SC 12 to 24 hourly (if no contraindication and normal renal function) use one dose for travel to South-East Asia and two doses for travel to Europe

Almost everyone is sick when sailing on rough seas. However, some people, especially children, suffer sickness from the effect of motion on a boat, in a car or in a plane. The larger the boat, plane or car, the less the likelihood of sickness; travel by train rarely causes sickness. Nearly all children grow out of the tendency to have travel sickness, but many adults remain ‘bad’ sailors.

The problem is caused by sensitivity of the semicircular canals of the inner ear. They are affected by the movement and vibration of travel. Some people have sensitive inner ear canals and are prone to sickness, especially on certain types of journeys (e.g. winding roads through hills) and in certain vehicles.

The main symptoms of travel sickness are nausea, vomiting, dizziness, weakness and lethargy. Early signs are pallor and drowsiness, and sudden silence from an active, talkative child.

Medication for travel sickness

Many medicines are available for travel sickness. They include hyoscine, various antihistamines and other phenothiazine derivatives, all of which can cause drowsiness; although a problem for drivers, this sedative effect may be helpful for children or for those travelling long distances by plane.

Phenothiazine derivatives that provide appropriate anti-labyrinthine activity include prochlorperazine (Stemetil), promethazine hydrochloride (Phenergan) and promethazine theoclate (Avomine).

Combination antihistamine and hyoscine preparations for travel sickness include Travacalm and Benacine.

Hyoscine comes in tablet form, either alone or in combination and in the popular adhesive patches.

Recommended medications

Car travel: adult passengers and children

• dimenhydrinate (Dramamine)

  or

  promethazine theoclate (Avomine)

  or

  hyoscine (Kwells)

These preventive oral preparations should ideally be taken 30–60 minutes before the trip and can be repeated 4–6 hourly during the trip (maximum 4 tablets in 24 hours).

• hyoscine dermal discs (Scop)

If available, one of these adhesive patches should be applied to dry, unbroken, hairless skin behind the ear, 5–6 hours before travel and left on for 3 days. Wash the hands thoroughly after applying and removing the disc—be careful of accidental finger-to-eye contact.

Sea travel

Sea travel generally poses no special problems apart from motion sickness and the possibility of injuries in the aged. The larger the ship, the less likely the problem. Those prone to sea sickness are advised to take anti-emetics 60 minutes before sailing and for the first 2 days at sea until they obtain their ‘sea legs’. However, the use of hyoscine transdermal delivery systems is recommended for convenience.

Experienced seamen's ‘tricks’:

• always keep looking to the horizon

• plug one ear with cotton wool or Blu-Tack

• drink ginger drinks, e.g. ‘dry ginger’, ginger beer

• chew gum

Severe sea sickness

The standard treatment is promethazine (Phenergan) 25 mg IM injection. If injections are not possible, prochlorperazine (Stemetil) suppositories can be used.

The aged

Generally the elderly travel well but should take safeguards to avoid falls. The chief surgeon on P&O's flagship recommends that elderly people should bring the following:

• a letter from their doctor stating diagnosis and medication

• a spare set of spectacles

• a spare set of dentures

• a walking stick (if appropriate)

High altitudes pose special problems for people who live at low altitude, especially if they have heart and lung disease. The severity depends on altitude, the speed of ascent, the temperature and level of activity. The high altitudes of Africa (Kilimanjaro, Kenya), India, Nepal (Himalayas), the Rockies of Canada and the US, and the Andes of South America provide such problems. It is usually safe to trek under 2500 m altitude but rapid ascent beyond this commonly precipitates altitude sickness. Serious altitude sickness occurs at 3500–5800 m.

Forms

1. Acute mountain sickness (mild to severe)

2. High-altitude pulmonary oedema

3. High-altitude cerebral oedema

Clinical features

• Usually within 8–24 hours of exposure

• Frontal headache (worse in morning and when supine)

• Malaise, fatigue, anorexia, nausea, insomnia

More severe: fluid retention (peripheral or facial oedema), dyspnoea, vomiting, dry cough, dizziness

Serious: marked dyspnoea, neurological symptoms and signs

Prevention

• Careful acclimatisation with gradual ascent¹¹

• Spend 2–3 days at intermediate altitudes

• Ascent rate less than 300 m per day above 3000 m (that is, try not to sleep at an altitude 300 m higher than that of the previous day)

• Ample fluid intake (more water than usual)

• Avoid alcohol

• Acetazolamide (Diamox) 250 mg 8 hourly the day before ascent; continue 3–6 days (deaths from mountain sickness have still occurred while on this drug)

Treatment

• Immediate (urgent and rapid) descent to below 2000 m

• Oxygen

• Dexamethasone (e.g. 4 mg, 6 hourly)

If a person intends to travel for a long time the following represents a comprehensive medical kit. It should not be regarded as an alternative to seeking appropriate medical help if it is available. Typical examples of general items are included in brackets.

Materials

• Alcohol swabs

• Bandaids and Elastoplast dressing strip

• Bandages (2 cotton gauze, 2 crepe × 10 cm)

• Pocket torch

• Steristrips or ‘butterfly strips’ (to patch small cuts)

• Sterile gauze and cotton wool

• Sterile gloves

• Thermometer

• Scissors and tweezers

• Safety pins

• Water purification tablets or iodine solution

Topical items

• Antifungal cream

• Chlorhexidine/cetrimide antiseptic cream (Savlon)

• Condoms

• Corticosteroid cream (e.g. hydrocortisone)

• Insect repellent containing diethyl-m-toluamide (DEET, Muskol, Repellem or Rid)

• Insecticide spray

• Mosquito net repellent solution: permethrin (Ambush—ICI)

• Nasal spray or drops

• Stingose spray (for bites and stings)

• Strepsils

• UV antisunburn cream (factor 30+)

Medication checklist

The medications below marked with * usually require a prescription.

• Antibiotics*

  • – amoxycillin + clavulanate forte

  • – norfloxacin 400 mg (6 tablets for 3 days)

  • – azithromycin (for children)

• Antacid tablets—for heartburn or indigestion

• Antimalarials*—where appropriate (including malaria emergency self-treatment)

• Diamox tablets* for acute mountain sickness

• Fasigyn* 2 g or Flagyl* 2.4 g—for amoebiasis or giardiasis

• Laxative (Senokot)

• Imodium* or Lomotil*—for diarrhoea

• Motion sickness tablets (Avomine, Kwells or Phenergan)

• Paracetamol tablets—for fever or pain

• Sleeping tablets* (temazepam, promethazine)

• Rehydration mixture (Gastrolyte)

• Throat lozenges

• EpiPen—if history of anaphylaxis

Hand-out sheets from Murtagh's Patient Education 7th edition:

• Travel: air travel

• Travel: guide for travellers

• Travel sickness

World Health Organization, International travel and health: <www.who.int/ith/en>

Travel Doctor-TMVC: <www.traveldoctor.com.au>

Smartraveller (country-specific information provided by the Australian Government): <http://smartraveller.gov.au>

Centers for Disease Control and Prevention: <www.cdc.gov/travel>