Travel offers opportunities to meet a greater and more diverse range of diseases than at home – this fact can play on peoples’ minds especially when they get ill overseas. To help inform travellers, there are several authoritative sites which are updated daily by teams of experts with international networks. In my opinion, the best of these is www.fitfortravel.nhs.uk. It contains useful malaria maps and visitors to the site may be reassured that the authors have nothing to sell. Security briefs can be found at www.fco.gov.uk. The not-for-profit Blood Care Foundation (www.bloodcare.org.uk) also provides a worthwhile service.
American readers who seek up-to-the-minute travel health information may refer to their government site www.cdc.gov/travel although I feel that the content is – in places – unnecessarily scary.
Exotic or complex itineraries are best discussed face to face with a practitioner with expertise in travel health such as can be found at various travel clinics. Reassuring and accessible advice is to be found in The Essential Guide to Travel Health, Your Child Abroad and the specialist lavatorial guide How to Shit Around the World. There is also plenty of topical tropical information in the regular travel health features that I write for Wanderlust magazine. I have been writing for them since issue one and so far have concocted 179 double spread health features; some are available to read on their website here: Wanderlust magazine. Reading is good preparation for a healthy trip and better equips you to ask intelligent questions of your travel health advisor (and thus you may save money), and – if it comes to it – any doctor you consult abroad. There is a bit more information here Rip-off Britain interview.
Occasional travel health updates are posted below and I'd like to collect entertaining snippets to share. I welcome feedback, tips and stories from readers.
Travellers may either be blissfully unaware of the risks or, conversely fill their heads with what disasters might happen abroad. For most travellers though staying healthy is a matter of following a few easy rules.
1. Arrange good travel insurance. While a European Health Insurance Card (free to UK residents from EHIC) gives EU citizens access to basic state healthcare in most of Europe, cover is limited and obviously does not extend to the rest of the world. Falling ill without travel insurance could leave you owing thousands in medical charges while you recover and convalesce. Travel insurance should include at least £2 million-worth of medical / repatriation expenses, as well as a comforting 24-hour emergency assistance line.
2. Consult your GP surgery or travel clinic well before travelling. First, research your destination on www.fitfortravel.nhs.uk, and then have an informed conversation with your GP or practice nurse about immunisations and pills. Go early, ideally at least six weeks before a trip – many immunisations are courses of two or three jabs. Frequent travellers and people going to the tropics are commonly advised to have cover against diphtheria, tetanus, polio, hepatitis A and B, typhoid and yellow fever.
3. Take malaria precautions. Malaria is a potentially fatal mosquito-borne disease present in many tropical and sub-tropical countries. No vaccination is available for ordinary travellers, but three medicines offer good levels of protection as long as they are taken as prescribed. Since no antimalarial tablet is 100% effective, and mosquitoes also carry other diseases including dengue fever, zika and chikungunya, it is also important to avoid bites day and night. Wear long clothes, and use an effective insect repellent – 30-50% DEET is fine for most situations. For more on malaria, visit www.malariahotspots.co.uk.
4. Strategies to avoid mosquito bites will also keep ticks off and ticks also spread significant disease. See A Tick Bite for more on this.
5. Be sensible with food and drink. Contaminated food is more likely to make you ill than water. Ditch your five-fruit-&-veg-a-day habit, and only eat freshly cooked, piping hot food. Unless you know that tap water is safe to drink, boil it. Carry your own water bottle thereby avoiding adding to the huge global problem of disposing of 'mineral water' bottles. As the travellers’ mantra has it: if you can’t peel it, cook it or boil it – forget it.
6. Take a little travel health kit. Don’t assume you’ll be able to buy the medicine you need locally (although you often will). Counterfeit tablets are an increasing problem so bring any prescription medicines with you, plus painkillers, throat lozenges and a few rehydration sachets. If you intend to be a do-it-yourself doctor also pack a health guide.
7. If you do get ill, seek professional local advice. Pharmacists are often a good place to start for simple over-the-counter remedies and if it is anything more serious contact your insurance helpline.
8. Don’t ignore the obvious. The biggest threats to travellers are the same the world over: road accidents, unsafe sex and crime. Look after yourself, and the worst you’ll suffer is an upset stomach.
9. Pack the sunscreen. Malignant melanoma is on the rise and is caused by excessive sun exposure and sunburn. SPF 25 -30 is adequate but needs reapplying during the day. Replenish your sunscreen annually as it becomes less protective with shelf-age.
10. Flight socks need to fit properly. The pharmacist who supplies them should measure you – and ideally the socks should be put on when you are in the lying position, probably before you leave home, rather than at the airport. People taking hormones (e.g the combined contraceptive pill) are at increased risk of DVT.
11. Get fit for what you plan to do, especially if travelling with children. Tone those quads and you'll enjoy the trip far more, and keep up with the youngsters.
12. Flu risk? Travellers should always consider getting a flu jab before any long-haul trip. It probably helps fend off several kinds of respiratory infection.
Always roll your trousers up when using a pit latrine
– Sally Haiselden, who cycled solo from Khartoum to Cambridge
Never eat in a restaurant with laminated menus
– Pete McCarthy, McCarthy’s Bar
Wading in, as the hanging mist over the river began to lighten and lift… I swam a little way off, into an upstream eddy by the bank, and there, luckily, all alone I learned the most important lesson for tranquil conduct of life in the jungle: never, ever, shit in a whirlpool.
– Redmond O’Hanlon, Into the Heart of Borneo
By our bad habits we spoil our sacred river banks and furnish excellent breeding grounds for flies. A small spade is the means of salvation from a great nuisance. Leaving night-soil, cleaning the nose, or spitting on the road is a sin against God as well as humanity, and betrays a sad want of consideration for others. The man who does not cover his waste deserves a heavy penalty even if he lives in a forest.
– Mohandas K Gandhi
I sterilize all drinking water with tincture of iodine. This is extremely cheap, and it is also widely available (from pharmacists), although you need to check the strength. I use 5-10 drops per liter of the English variety, though rarely use more than 6-7 unless the water is particularly suspect. I let it stand for 20 minutes before drinking. Although the bottle says for external use only, it is safe if used in this way, and has kept me healthy on many extended trips where pure water is hard to find. A phial of iodine is much lighter than a water filter (backpackers must consider weight). One drawback is the horrible taste, which I counteract with powdered drink: added in small quantities, it just takes the taste of the iodine away without making the water too sweet.
– Phil Brabbs quoted in How to Shit Around the World
Do also check Jane's tweets @longdropdoc
Geography Worm, socks and sandals
Dr Hamat and colleagues described a case of cutaneous larva migrans aka geography worm due to the larval stage of a dog or cat hookworm after it's penetrated in tact skin. This caused a 12cm long itchy sinuous track on the foot of a Malaysian teacher. The lesion appeared to 'move' a little each day. The victim denied going barefoot but wore socks and sandals. The socks clearly did not isolate the victims feet from sand, indeed she noticed an accumulation of sand in her socks. The authors postulate that the socks may have allowed more prolonged contact with infected sand and thus facilitated acquisition of the parasite. It would seem then that wearing socks and sandals not only makes you look like a nerd but it also has health implications. Once diagnosed, these parasites are readily treated - by squirting liquid nitrogen at the head of the worm or anthelminetic tablets.
Transactions of the Roy. Soc. Trop. Med. Hyg. 104 pp 170-1
A 'new' antibiotic for travellers diarrhoea
Ciprofloxacin, an antibiotic often quoted as being useful against travellers diarrhoea, is largely ineffective these days. A better remedy is the non-absorbable antibiotic rifaximin (Xifaxanta aka Xifaxan) has been available on prescription in the UK since 2011, although it isn't well known even by pharmacists here. It has been in use for some years in Europe and the US and so the medicine is well understood by clinicians. It is useful in the treatment of simple travellers' diarrhoea; clinical trials comparing treated and untreated sufferers suggest that it reduces symptoms from around 60 hours to around 33 hours. It cannot be used for the more serious forms of gastroenteritis which cause fever and bloody diarrhoea; it is not licenced for anyone under the age of 18 years. The dose is one 200mg tablet three times a day for a total of just three days.
Several readers of Your Child Abroad: a travel health guide have emailed me to ask whether an updated edition is planned. The publisher (Bradt Guides) has launched an updated e-edition and a version for kindle readers but meanwhile be reassured that there have been surprisingly few significant developments in travel health since the second edition was launched. There is one gap: our book doesn't mention the possibility of immunisation against typhoid with a vaccine that is swallowed. Dosing instructions vary between Europe and North America but in the UK the course is three capsules that are taken over a week. These are useful in children over six years - as well as adults - and longer courses of capsules give immunity that probably lasts for 5 - 7 years. These capsules provide partial protection against typhoid but also against that increasing threat paratyphoid. This therefore is an advantage over the injectable typhoid vaccines. In the UK these capsules can be acquired by way of a prescription from your GP or from a travel clinic.
Counterfeit Rabies Vaccine
Counterfeit rabies vaccine entered the supply chain from the Philippines during 2013 and is likely to have spread to other countries in the region. It is more important than ever to consider pre-travel rabies immunisation.
Yellow Fever is a killer but the vaccine gives excellent protection. Research shows that the immunisation gives life-long protection to most people. Now we must wait for international health regulations to catch up so we won't need 10-yearly boosters to cross borders in Africa and the Americas.
Remember that some security checks require proof of travel to let you into the airport, even if you don't need anything more than your passport to check in.
Bats and Rabies (again)
In March 2013 Australian physicians reported the distressing news of the death of an eight-year-old boy in Queensland. The boy is thought to have been bitten or scratched by a bat three weeks before he died. This emphasises how important it is to seek medical treatment after any contact with bats anywhere in the world. This is the third known case of a bat-related death in Australia due to a virus very like rabies. Both Australia and the UK are said to be rabies-free. Even so, bats are dangerous in these 'rabies-free' regions.
Counterfeit Malaria Meds
A new survey looking at malaria medicines bought in S E Asia suggests one third are counterfeit and ineffective. Similar results have been found in sub-Saharan Africa. Travellers sometimes try to save money by buying prescriptions at their destination but it is important to be aware of the risks - it might be a false economy.
Driving in France
From 1st July 2012, all drivers on French roads must have a disposable breathalyser kit in the car so that they can test whether they are over the alcohol limit before driving away. It is intended that this will help cut the number of road accidents. Drivers found without a breathalyser in their vehicle could be fined €17. Tourists will not be exempt.
Malaria in Greece and Spain
The Hellenic Centre for Disease Control and Prevention reported six cases of malaria caught in Greece in August 2011 and cases seem to be occurring each summer since. Lakonia in the Peleponnese, a popular tourist area, is one of the districts where infection is a risk. This outbreak is due to Plasmodium vivax. The incubation period for this, relatively mild, form of malaria is usually 8-14 days although it can much longer, and up to as much as 10 months. Worryingly this follows and outbreak of malaria during the summer of 2010 in northern Spain so it is more important than ever to avoid bites even on trips to Europe. Malaria, of course, used to be a problem in SE England, East Anglia and Manhattan! Suitable mosquitoes still abound.
Iodine and drinking water
Since October 2009 there has been a European Union prohibition on the sale of iodine for use in purifying drinking water. This was not due to concerns about safety or effectiveness but simply because the profits on selling this cheap product would not cover the expense of registering for a product licence under the human biocide requirements.
One reader of The Essential Guide to Travel Health / Bugs Bites & Bowels told me how he'd suffered from dry peeling lips on a recent high altitude trek and wondered what the solution was. If you haven't packed lip balm for your mountain or desert trip it can be difficult to improvise although there is often scope for applying local grease like yak or camel butter. Also remember that dry cracked lips are an early sign of dehydration, and at altitude - especially when exercising hard - surprisingly large amounts of water are lost in sweat as well as from the lungs. Drinking more should help. Aim for at least three good volume urinations per 24 hours.
Most of us will be mindful of malaria when venturing into the tropics but there are some altogether nastier, more squirm-making hazards. In central and tropical south America there is the cunning bot-fly which hitch-hikes on mosquitoes and lays eggs that hatch into flesh maggots.
In tropical Africa there is a beast with a similarly unpleasant lifestyle. The tumbu fly or putsi is related to the blow-fly. The female lays her eggs on clothes that have been left out to dry on the ground or pegged to a line in the shade. As with the bot-fly, larvae hatch and penetrate the skin when they sense mammalian warmth. They then cause crops of boils which ‘hatch’ 15mm club-shaped grubs that fall out after about eight days.
With both species clumsy removal attempts can lead to infection and scarring to it is best to seek advice: often locals will be skilled in maggot evictions. Putsi is avoided by ensuring that laundry is dried to crispiness in the direct sun, or everything is ironed: including sheets, nappies and the elastic parts of underwear.
Keeping covered with long loose clothes (preferably impregnated or sprayed with permethrin) and applying DEET-based repellent to any exposed flesh reduces the risk of acquiring these nightmare hitch-hikers.
Preventable Rabies Death in Northern Ireland
It is distressing to report a further person died of rabies in the UK (December 2008). The victim had worked in close contact with animals including dogs in South Africa over the previous two years, and had not been protected with the highly effective vaccine. Immunisation before any bite or a course of injections after a bite would have saved this life. Anyone visiting or travelling in countries where rabies is endemic should be aware of the risk and either be protected through immunisation or should travel to a competent medical facility if bitten or scratched. Careful wound-care after any bite or scratch also helps reduce (but doesn't completely eliminate) the chance of infection with rabies, tetanus and other harmful microbes.
Always Beware of Bats
At the beginning of a two-week holiday in Kenya a small bat flew into the face of a woman. This happened at dusk in October at a camp site between Nairobi and Mombasa, while she was brushing her teeth. She tried to hit the animal away, but it made two scratches on the right side of her nose. The wounds, which bled, were washed with soap and cleaned with an alcohol solution. No other care was given to the woman. Local advice was that there was no rabies in bats in Kenya; the disease was thought only to be a problem spread by dog bites in the region: there had never been a death from rabies recorded in Kenya that was blamed on a bat.
The 34-year-old woman was admitted to hospital in Amsterdam 26 days after the brush with the bat. Her symptoms – difficulty with speech, walking and odd sensations of the skin of the face – pointed towards disease of the nervous system and rabies was suspected immediately by the Dutch doctors. All possible treatments were given to the woman but she died 23 days after becoming ill, in December 2007.
Wounds sustained from bats – even in England – carry a risk of rabies. Injections are required promptly after any contact with a bat where the skin is broken. Immunisation before travel gives great peace of mind.
Interesting research (in the 101st edition of the Transactions of the Royal Society of Tropical Medicine & Hygiene) reminds us that bednets are only protective if they are impregnated with a contact insecticide such as permethrin. Bednets bought in Britain are commercially impregnated – but that protective effect needs boosting periodically. A paper by Dr. J Etang et al in the Transactions reported research done in northern Cameroon where there is resistance to pyrethroids. These researchers stated that despite the local resistance to pyrethroids, permethrin-impregnated bednets gave good protection against acquiring malaria (compared to no protection from sleeping under untreated bednets). The protection was, though, only for the first three months after the net had been treated. Studies in West Africa have shown that unprotected people are bitten 200 times a night, and I take from this new research that travellers to West Africa should reproof their bednets every three months, rather than six-monthly as is usually recommended. This review was first published in the British Travel Health Association Journal vol X; page 62
Hepatitis E, the other common viral hepatitis, is often acquired by travellers. The disease is very like hepatitis A (infective hepatitis) and it is also acquired via the filth-to-mouth route. However hepatitis E can be much nastier, especially in pregnancy. A vaccine trial conducted in Nepal shows that the new hepatitis E vaccine based on hepatitis E capsid protein is 95.5% effective, and it has few side effects. Now it remains to be seen whether anyone will put up the money to develop this vaccine, which will be of most benefit to the poor living in regions lacking basic infrastructure. My review was first published in the British Travel Health Association Journal vol X and referred to a paper by Drs Khin Saw Aye Myint & Robert Gibbons in appeared in Transactions of the Royal Society of Tropical Medicine & Hygiene 102, pp 211-2.