Pre-travel

Those travelling to developing countries or contemplating travelling with significant pre-existing medical problems, should be encouraged to consult a health professional at least 4-8 weeks before travel, earlier where long-term travel/work overseas is anticipated. Most travel vaccine courses can be given over 4 weeks so travellers should plan for this accordingly. Last minute consultations, although less flexible, can also provide benefits.

Patients can access up-to-date travel advice via a number of 'phone or internet services. However, face-to-face consultation with a health professional can enable risk and advice to be individualised and the best package of preventative measures to be put in place. As this is likely to be multifaceted, a checklist approach or computer template ensures systematic attention to detail. In the UK, pre-travel consultations are often nurse-led and, either in primary care or at private travel clinics.

Risk assessment

Individual risk of travel is related to:

• Mode of transport - risks of overland, sea or air travel differ.
• Destination determines the likely standard of accommodation, hygiene, sanitation, access to medical care and water quality. It also influences the risk of exposure to certain infectious diseases, which may be emergent, endemic or epidemic in a particular location at a particular time. Different locations within a country may be very different in terms of risk, eg urban versus rural. Also consider any stop-overs contemplated.
• Duration of visit - risk increases with length of stay in general.
• Purpose of travel - tourists are more likely to stay in better quality accommodation than aid or emergency relief workers or those visiting friends and relatives in developing countries.
• Behaviour and lifestyle of traveller - riskier activities increase the chances of mishap.
• Pre-existing medical conditions - doctors may be consulted to assess an individual's fitness to travel. Ideally the patient should be as stable as possible, with arrangements made in advance to reduce/eliminate foreseeable difficulties.^[3]

Special travellers

Pre-existing conditions

• See separate article Flying with Medical Conditions for information about assessing fitness to fly.
• Always inform companies providing medical travel insurance of any pre-existing medical conditions when the policy is obtained.
• Carry a medical letter with details of the condition and any treatment (ideally a list of any drug therapy with generic names and dosages).
• Carry sufficient medication to cover the entire duration of the trip and any possible delays.
• Carry medication in hand luggage for the journey, or divided between that of the traveller and a companion. Note that there may be fluid restrictions in hand luggage on some flights. Spare medication should be kept in separate luggage in case of loss or theft.
• Keep a list of routine prescriptions (generic names and doses). Be aware that some countries restrict drugs, even where prescription. All medications should be carried in pharmacy-labelled bottles.
• Treatment for certain conditions, eg insulin-treated diabetes mellitus, will require adjustment over travel periods.
• Immunosuppressed patients should not receive live vaccines.

Pregnant women

• No pregnancy can be assumed to be risk-free and travel may hamper access to healthcare, records and good communication in the event of complications.
• Some infectious diseases, such as malaria and hepatitis E, are more serious in pregnant women.
• All pregnant women travelling to malarial zones should take chemoprophylaxis and avoid being bitten by mosquitoes:^[4]
  • Chloroquine and proguanil (usually combined) are suitable for areas at lower risk of chloroquine resistance. A supplement of folic acid 5 mg daily should be taken with proguanil.
  • Mefloquine is suitable for women in their second or third trimesters.
  • Doxycycline is contra-indicated in pregnancy.
  • Atovaquone-proguanil (Malarone®) is not recommended due to a lack of safety data.
  • Seek specialist advice if a woman is in her first trimester (or intends to become pregnant whilst travelling) and chloroquine-proguanil provides inadequate protection.
• Immunisations are generally avoided in pregnancy, although inactivated vaccines may be used if the risk of disease exceeds the potential risk to the fetus.^[5]
• The best window of opportunity for flying in pregnancy is usually suggested as 18 to 24 weeks. Most airlines will allow pregnant women to fly up to 36 weeks, with a doctor's note beyond 28 weeks.
• Check that there is no exemption of cover for pregnancy in the medical travel insurance.

Children

Children have always travelled with adults, but increasingly more families are travelling to more exotic destinations for leisure purposes. Frequently, guidance has had to be extrapolated from adult research.^[6]

• Routine infant immunisations may be brought forward if children are travelling to high-risk countries for prolonged periods and may have close contact with the indigenous population. Consult product information as to the lower age limit for travel vaccines and the varying ages at which the paediatric dose changes to the adult dose.^[5]
• For malarial chemoprophylaxis:^[4]
  • A combination of chloroquine and proguanil is suitable in some areas with low or absent Plasmodium resistance to chloroquine.
  • Mefloquine or Malarone® (atovaquone-proguanil) may be suitable in areas with a high risk of chloroquine-resistance Plasmodium falciparum but Mefloquine should not be used in children weighing less than 5 kg and Malarone® in those weighing less than 11 kg.
  • Doxycycline is contra-indicated in children aged under 12 years.
  • Compliance with antimalarial drugs is likely to be more difficult in children.
• Young children and babies are more susceptible to dehydration with diarrhoeal illness. Recommend that oral rehydration salts should be accessible.
• Fever in a child should prompt medical attention.
• Children should be protected from sunburn and excessive UV exposure.

Immunisation^[7]

• Check current vaccination status. Patients should have a hand-held record of their own vaccinations since they may receive these from a number of different centres.
• Follow up-to-date guidelines:
  • Ensure routine immunisations are up to date, eg tetanus and diphtheria boosters.
  • Consider if any immunisations are required, eg yellow fever in tropical Americas and Africa, quadrivalent meningitis vaccination prior to Hajj pilgrimage in Saudi Arabia. Travellers to these countries, with contra-indications, should carry exemption documentation.
  • Recommended immunisations are based upon the risk of exposure during the traveller's planned itinerary and their current immune status, eg hepatitis A, typhoid, rabies, Japanese B encephalitis.
• Ensure there is no history of adverse events to previous immunisation, or other contra-indication.
• Recommended intervals between doses and vaccines should be followed to allow optimal antibody production prior to travel. At least 10 days (ideally 3 weeks) should separate all travel vaccinations so that any adverse reaction can be correctly attributed; however, in practice, many vaccines are often given simultaneously due to time constraints without ill effect or loss of efficacy. Live vaccines should be administered at least three weeks apart or on the same day. Oral typhoid and polio vaccines are usually separated (by at least two weeks) due to the risk of possible interference in the gut.
• Since most travel vaccination falls outside of NHS provision, cost is a consideration to many travellers.

Malaria prevention

See separate article on Malaria Prophylaxis.

Counselling and education

Travellers should receive information as to how to stay healthy, or if they become ill, how to self-medicate (if appropriate) and how/when to seek medical help.

Travellers' diarrhoea

See separate article on Travellers' Diarrhoea.
General precautions:^[2][5]

• Standard handwashing (after toilet, before eating or handling food)
• Avoid tap water, ice and bottled water if the seal is not intact for drinking or brushing teeth. Drink boiled or sterilised water, carbonated water and soft drinks, packaged and pasteurised fruit juices.
• Avoid buffets and salads.
• Avoid thin-skinned fruits, eg raspberries, and peel thick-skinned fruits oneself.
• Avoid shellfish, particularly raw.
• Avoid food containing uncooked eggs.
• Eat freshly cooked, piping hot food. Avoid food which has been kept warm or may have been exposed to flies.

Sexual health

• An individual's sexual risk-taking may increase with travel, increasing their risk of contracting HIV, hepatitis B or other sexually transmitted infections. Inhibitions are further reduced by alcohol and drug taking.
• In a Dutch study, 4.7% individuals who were seen in a pre-travel clinic had casual sexual contact whilst abroad, usually not anticipated prior to travel and frequently without protection (condoms, hepatitis B immunisation).^[8]
• Advise travellers to follow safe practices. Condoms purchased abroad may be of less good quality than those used at home and the integrity of condoms may decline in hot, humid conditions over time.
• Sex tourism is hazardous but is also illegal where children are involved, and individuals may be pursued internationally for these crimes now.
• Risks of contraception failure, eg following diarrhoeal illness with the combined oral contraceptive pill, unwanted pregnancy, sexually transmitted infections and rape, may be discussed. Availability of emergency contraception and post-exposure HIV prophylaxis should be considered.

Sun protection

80% of skin cancers are thought to be preventable. Excessive sun exposure, and sunburn in children, are a major risk factor for later skin cancer. Skin protection in children and adolescents is crucial. Sun-induced damage is cumulative over a lifetime.
To avoid sun damage:

• Keep out over the midday sun (from 11.00 am to 3 pm).
• Stay in the shade.
• Dress to screen from the sun - including wearing T-shirts, long-sleeved shirts and hats.
• Use a broad spectrum, high-factor sunscreen and replenish it according to instructions.

Activity

Specific advice may be required depending on the type of trip or activity proposed whilst abroad; for example, regarding climbing or trekking at high altitude - see separate article High Altitude Illness, or scuba diving - see separate article Diving Accidents.

Insurance

Travel insurance varies considerably: travellers should be advised to investigate different providers, to ensure that they have adequate medical insurance to cover emergency repatriation, and ideally the maximum amount of coverage for potential medical, surgical and dental costs.

Illness on return

• Screening of asymptomatic tropical travellers is not routine. However, some may request it, and approximately 1 in 4 will have an abnormality detected on screening. Appropriate tests will vary: stool MC&S, FBC (eosinophilia may require further investigation), malaria films, schistosome enzyme-linked immunosorbent assay (ELISA) and stool/terminal urine microscopy.
• However, all those who do return with symptoms should be advised in advance to seek medical attention:
  • Malaria urgently needs to be excluded in individuals with febrile illness who have visited malaria-endemic areas. Imported Plasmodium falciparum malaria usually presents within the first three months of return, but this can be delayed for up to one year, and relapsing forms of malaria may present even later.
  • See separate article Diagnosing The Tropical Traveller.

Information sources

Infectious disease epidemiology, drug resistance patterns and political situations change rapidly. It is essential that those intending to travel have access to up-to-date advice. Sources include:

• EMIS customers may wish to use the regularly updated travel advice in the EMIS/UCL Hospital for Tropical Diseases' travel database on the Travel section homepage. Within EMIS, a selection of pages exists on advice for travellers.
• If in doubt, the NaTHNaC Health Professionals Advice Line can be contacted on 0845 602 6712 (calls cannot be taken from the general public), or advice found on the web.^[9]
• Another source of information is The Department of Health Booklet 'Health Information for Overseas Travel 2001' - 'The Yellow Book'.^[5] It is also available online, but requires registration.
  It provides comprehensive information on travel-related issues.
• Patients should be advised to consult the Foreign & Commonwealth Office's 'Travelling & Living Overseas' website page, for up-to-date advice on safety issues in particular countries.^[10]