I have returned from Bali all bikini-tanned, buffet-fed, spa-pampered and utterly relaxed. It was a fantastic weekend, the highlight of which was the beautiful wedding of a gorgeous friend and the outrageously fun after-party. But back to reality now and so here is, as promised, my approach to the pre-travel consultation. This is just the tip of the iceberg as travel advice can get quite complicated but I find that this covers most of the common travel scenarios. A huge thank you to Dr Sean Stevens, my former supervisor, whose excellent travel med tutorial forms the basis of this presentation.
1: The history
Travel medicine advice needs to be specifically tailored to the patients individual health and travel situation, so you need to know:
- Where are they going? And be specific … not just which country but which city / town / area.
- How long are they spending in each place?
- What kind of activities will they be doing?
- Are they up to date with vaccines and have they had any previous travel vaccines?
- General medical history and current medications.
This is the bit that most patients care about. Often times they just want to know if they need any particular jabs before they go overseas, not realising that this is only a small part of a thorough travel medicine consultation. The go-to reference for travel information in general is the Centers for Disease Control and Prevention, which you can search by country at http://wwwnc.cdc.gov/travel/destinations/list. But, in general:
- Hep A and typhoid are recommended for anyone travelling to developing countries, tropical countries or anywhere where water born infections are common. They come in a combined vaccine. A second Hep A booster ideally at 6-12 months (but up to 3 years) after the first one will confer life-long immunity. Typhoid will have to be boosted every 3 years if ongoing or repeat exposure.
- Hep B is not routinely recommended, but is a good idea for those potentially at risk of exposure to blood borne viruses, eg through sexual contact, tattoos & piercings, injuries requiring blood transfusion or occupational (eg health care workers). The 3-dose course is given at 0, 1 and 6 months. It is also available in a combined vaccine with Hep A.
- Rabies vaccination is recommended in certain countries in those at risk of animal bites, for instance those going hiking in rural areas or those working with animals. The vaccination course is given in 3 doses at 0,7 and 21-28 days. Note: If the patient is bitten or scratched by an animal in a rabies-prone area, they need to seek immediate medical attention to access post-exposure prophylaxis / immunoglobulin.
- Japanese Encephalitis is uncommon but the vaccine is recommended for travel to rural areas in certain Asian countries, depending on the time of year. A booster is given 28 days after the first dose.
- Yellow Fever vaccine is compulsory for those travelling from endemic countries (Subsaharan Africa and Central and South America) to other sub-tropical countries. It needs to be given at a registered yellow fever vaccination clinic.
- Cholera vaccination is not routinely recommended as the risk to travellers is low. It can be given as two oral doses 1-6 weeks apart, for some travellers to endemic or epidemic areas eg disaster relief workers.
- Routine vaccinations such as MMR, DTP, Polio and annual influenza should be boosted if the vaccination is not up-to-date.
More detailed vaccine information including dosing, precautions, contraindications etc can be found in the Australian Immunisation Handbook at http://www.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10part4
3: Advice about prevention of infectious diseases
Once you have up-dated any relevant vaccines, it’s important to provide the patient with specific advice around the prevention of the vast majority of infectious diseases which are NOT covered by vaccines.
- Viral infections: eg URTI, flu-like illneses are the most common travellers infection, particularly on public transport and in crowded areas. Advise patients to be attentive to hand hygeine and take hand sanitizing gel.
- STIs: The second most common type of infection acquired in 18-35 year old travellers. Advise patients to take condoms from Australia (some overseas products are unreliable).
- Food and water borne illnesses: In developing / tropical countries; don’t drink tap water and avoid ice. Don’t eat food which has been washed in tap water (eg salads). Drink bottled water and only eat food & drink which has been peeled, boiled or cooked. Use bottled water also for brushing your teeth.
- Mosquito-borne infections: eg dengue and malaria. Prevent mosquito bites by wearing long sleeved, light coloured clothing, sleeping behind insect screens/nets or in air conditioned accommodation and avoid outdoor activities at dusk and dawn (but note that dengue carrying mosquitos can be active at any time of day). Use a DEET-based insect repellant (eg RID, Bushman, tropical strength Aerogard). Check the Malaria status of the destination country at http://www.cdc.gov/malaria/travelers/country_table/a.html and discuss the need for malaria prophylaxis with patients. This is my “cheat-sheet” summary table for malaria prophylaxis:
Dose and duration
|Hydroxychloroquine (Plaquenil)||ii weekly (400mg = 310mg hydroxychloroquine base)
From 1/52 prior to 4/52 post travel
|-Weekly dosing||-Can’t be used in chloroquine or mefloquine resistant areas
-May exacerbate psoriasis
-Have to take for 4 weeks on return
|Atovaquone+proguanil tablets 250/100mg
|One daily with fatty food, from 1 day prior to 7 days after travel||-Shorter duration of treatment
-paediatric dosing available
-Ok for last minute
-Avoid in renal failure
-Avoid in pregnancy
|Doxycycline 100mg||One daily,
1 day prior to 4 weeks after travel
-Ok for last minute
-Avoid in pregnancy
-Risk of gastric upset or thrush
|Mefloquine 250mg||Once weekly, 2-3 weeks before until 4 weeks after travel||-weekly dosing
-Ok for pregnancy
|-Avoid in psychiatric disorders, seizures or cardiac conduction anomalies
-long duration required
Each destination will have its own unique risks which should be discussed, eg: for Bali specific risks include: rabies from monkeys in the Monkey Forest, HIV from tattoos and methanol poisoning from alcoholic drinks.
4: Advice about non-infectious travel problems
- DVT: A risk on long-haul flights, particularly those with additional risk factors eg pregnancy, thrombophilias, family history, OCP/HRT. Patients should maintain hydration, do calf / ankle exercises periodically throughout the flight and consider the use of prophylactic clexane in high risk groups.
- Jetlag: Can be reduced by having an overnight stop to break-up a long haul flight, flying at night if possible, sleeping/waking at the appropriate time for the destination time zone as early as possible (even before departure, ideally). Melatonin or temazepam can be used for up to 3 nights after arrival to help adjust to the new time zone. Be very careful of personal safety and security if using sedatives on flights, particularly if travelling alone.
- Altitude sickness: Can be reduced by “climbing high, sleeping low” and walking rather than flying to altitudes of 3000m. Prophylactic acetazolamide 125-250mg bd can be used – start 1-2 days prior to travel and continue for 3 days after the highest altitude is reached. Take a trial dose before departure to ensure there is no allergy.
5: Paperwork & Documentation
- Comprehensive travel insurance is recommended. Note: Pregnant patients should be advised that in the event of the infant being born overseas, he/she will not be covered by the mother’s travel insurance and if neonatal care is required it could be extremely expensive.
- Provide a medication list and health summary.
- Encourage registration with smarttraveller.gov.au
6. Medical kit
In addition to a sufficient supply of their usual medications, patients should consider taking some medical supplies with them. The contents of the medical kit should be tailored to the destination but could include:
- Simple analgesia
- Antihistamine (for bites, allergies)
- Cold and flu tablets
- Motion sickness tablets (hyoscine, ginger)
- Multivitamins if diet may be lacking in essentials
- ORS eg gastrolyte
- Regular meds (in original container)
- Antiseptic solution / ointments
- Bandaids / dressings
- Medical tape
- Crepe bandage, gauze swab, steristrips
- Insect repellent
- Sting relief (Eg stingose)
- Eye lubricant drops
- Ear plugs
- Medical equipment (eg insulin needles)
- Condoms / contraception
- Water purifying tablets
- Mosquito bed net
See also my previous blog post about the overseas medical kit for doctors.
Resources & References:
Australian Immunisation Handbook: http://www.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10part4
Center for Disease Control and Prevention: http://wwwnc.cdc.gov/travel/
Royal Children’s Hospital fact sheet on mosquito repellants for kids: http://www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=7755
Please feel free to correct any of my inaccuracies or add in your own experiences below in the comments!