travel health Flashcards
what are Pre-Travel Advice
Risks associated with travel:
Presence or increased incidence of diseases in other countries
Hazards of travel and travel related pursuits
Poor quality of local medical facilities
Risks increased by:
Area to be visited
Age of traveler
Pre-existing conditions of traveler
Length of time away
Patient Specific advice
Pregnant or breastfeeding, Contraception, Culture shock and mental health, Travelling with medicines.
Travellers: Pre-Travel Interview
Travel interview:
Who is going, where are they going, what are they doing, current medical histories, pregnant/bf.
What vaccinations have they had, have they used anti malarials before- if so was it ok? Planning pregnancy? Zika virus!
Children going?
what is travellers diarrhoea?
One of the most common health problems experienced during travel
Defined as 3 or more unformed stools in a 24 hour period. It is often accompanied by one of the following; fever, cramps, nausea, vomiting & urgency to pass stool. Bloody stools (Dysentery)
Mild – diarrhoea may be the only symptom and no disruption of normal activity.
On average can last 4-7 days, resolving without specific treatment
Moderate to Severe – Associated with additional symptoms and leads to interruption of normal activities.
Can be persistent or recurrent and cause systematic complications
Causes – Spread mainly through consumption of contaminated food/drink.
Bacteria - E.Coli Salmonella Virus - Norovirus Rotavirus Protozoa - Giardia
what is the prevention of travellers diarrhoea?
Water Hygiene
Bottled water – Carbonated
Purification – Boiling, filtration, chemical disinfection chlorine/silver
Avoid ingestion – Swimming pools
Food Hygiene
Cook it, Boil it, Peel it or leave it!
Avoid Shellfish, rare meat, cheese, ice cream, salad
Hand Hygiene
Washing
Alcohol gel
what is the Advice and treatment
The priority in treatment is preventing dehydration, especially in young children!
Oral rehydration solutions (Dioralyte®, Electrolade®)
Fluid and electrolyte replacement – sodium, potassium, citrate and/or bicarbonate, glucose or rice flour
Can be recommended even when referral to a doctor is considered necessary.
No contra-indications, but cautions in certain groups - Recommended for children and elderly
Adult 200ml after every loose motion, child 200ml, infant 1 – 1 ½ usual feed volume
Check brand dependent licence OTC
Adsorbents
Enterosgel®- 70% Polymethylsiloxane (medical device)
Anti-motility agents
Kaolin and morphine
Loperamide
Bismuth subsalicylate
Pepto Bismol®
Antibiotics (POMs available on private PGDs as standby medication)
Ciprofloxacin – AMR/ MHRA warning
Azithromycin
Rifaximin
Enkephalinase Inhibitors
Racecadotril (Hidrasec®) ESNM11/12 (POM)
Advice: dehydration
ORS: powders if not available
Level teaspoon of salt + 6 teaspoons of sugar with 1l water- so help achieve fluid replacement
ORS: needed even if being referred
Age groups: Dioralye regular and relief has different licensing check before giving
Rice and banana is ok- normal milk for children
Travellers Diarrhoea – RTS on returning from holiday
When to refer:
Association with severe vomiting and/or fever
Blood in the stools
More than 3 unformed stools in 24 hours with incapacitating symptoms
Babies less than 1 year with symptoms for more than 24 hours (under 3 months refer immediately)
Elderly/children under 3 who have diarrhoea for more than 48 hours if unwell or not drinking normally
More than 72 hours in older children and adults
More than 24 hours in diabetics
Other chronic serious conditions
Red flags:
Blood/mucus in stools
Incapacitating symptoms
Babies and children need to be referred due to dehydration
Sun Protection
Sunlight is electromagnetic radiation (infrared, visible, ultraviolet (UV))
UV light - invisible wavelengths, UV-A, B, C.
UV A and B responsible for skin ageing and cancer.
Acute damage - Sunburn
Photosensitive skin rashes
Aggravation of existing conditions such as Rosacea and Eczema
Chronic damage – Skin Cancer(Actinic keratoses, melanoma SCC, BCC)
Sun Protection – Safety Advice
Identify high risk group e.g. babies and children, fair skin, red or fair hair, history of skin cancer
Babies under 6 months of age should be kept out of direct strong sunlight
Infants and children should be well protected at all times
Seek shelter; avoid sun exposure between 11-3pm/10-4pm
Cover up using clothing such as wide brimmed hat and long sleeved tops, closed weaved fabrics
Sunglasses with wraparound lenses or wide arms with the CE Mark and European Standard EN 1836:2005.
Care in tropics and high altitude
Care when cloudy or windy
Care with water, snow, ice, light coloured sand
Effects of Sun Exposure
*Sunburn
inflammatory response to UV skin damage
hot, red and swollen, blistered skin
*Prickly heat (heat rash)
caused by blockage of sweat glands
prickling/ itching sensation
Red rash-small spots, mild swelling
Few days duration
*Heat exhaustion/heatstroke
tired/headache/vomiting/dizziness/
cramps in limbs and stomach
rapid heartbeat or breathing
dehydration/ thirst
confusion/pyrexia (38°+)
Sunburn - Treatment
Stay out of the Sun!
Drink plenty of fluids
Cool or lukewarm compress/ cool showers
Cooling lotions
Mild - mosituring or ‘after sun’ lotion
Calamine lotion or cream – use when required for itching/soreness
Paracetamol or Ibuprofen
Do not burst blisters
If severe (systemic symptoms, large area, children and babies, extensive blistering) - refer!
Prickly Heat - Treatment
Keep skin cool:
Wear loose cotton clothing
Use lightweight bedding
Take cool baths or showers
Drink plenty of fluid to avoid dehydration
To reduce itching:
Apply something cold, such as a damp cloth or ice pack (wrapped in a tea towel) for no more than 20 minutes
Tap or pat the rash instead of scratching it
OTC treatments
Calamine lotion
Antihistamine tablets (sedating antihistamines e.g. chlorphenamine better for itch relief/ to help sleep)
Hydrocortisone cream
Heat Exhaustion/Heat Stroke - Treatment
when to refer
Cool the person:
Move to a cool place
Lie down and raise feet
Drink plenty of water. Sports or rehydration drinks are OK
Cool the skin – spray or sponge with cool water/ fan/ cold packs around the armpits or neck/ cool shower
Refer to A and E if:
No improvement after cooling
Not sweating and hot
Temp above 40 degrees
Confused/seizure
Motion Sickness - WHAT
symptoms
non-pharmacological advice
Caused by repeated movements when travelling, the inner ear sends different signals to your brain from those your eyes are seeing.
Symptoms – Nausea and Vomiting
General malaise, Light headedness, Cold sweating, Yawning, increased Salivation, Pallor, Drowsiness, Headache and Fatigue.
Non-Pharmacological Advice:
Avoid heavy meals – spicy foods and alcohol
Breathe in fresh air – avoid pungent odours/fumes
Reduce motion – sit in the front of a car, middle of a boat or by the wing of an aircraft
Break up long journeys
Suck sweets to combat dry mouth caused by medication
Motion Sickness – Prevention/ Treatment
Formulation
Tablets – Dissolvable preparations available for children
Patches – Suitable for adults and children over 10
Acupressure bands – Drug free alternative but don’t work for everyone
Medication before travel
Antimuscarinic (Hyoscine)
Antihistamine (Cinnarizine, Cyclizine, Promethazine)
Considerations
Duration of journey vs duration of action of medication
Side-effects (drowsiness, dry mouth, blurred vision, urinary retention, constipation)
Avoid medication in patients with Glaucoma, Pregnancy, Breastfeeding, Prostatic hypertrophy
P med limitations e.g. Age
Hyoscine Hydrobromide Joy rides 150mcg®/Kwells 300mcg®/ Kwells Kids 150mcg®/ Scopoderm 1.5mg Patches®
Most effective drug for prevention
Short acting (4-6 hours)
Long acting (72 hour patch)
Pronounced Anti-muscarinic side effects
Tabs – Suitable for children from ¾ years depending on brand
Patches – Suitable from 10 years
Cinnarizine Stugeron 15mg®
Drowsiness
Duration for up to 8 hours
Children from 5 years
Promethazine Hydrochloride Phenergan® elixir 5mg/5mL or 10mg and 25mg tablets
Antimuscarinic and sedative properties
Children from 2 years
Duration 6-8 hours
Promethazine Teoclate Avomine®
Discontinued
Cyclizine (P med)
From 6 years (25mg up to tds, 1-2 hours before departure)
Meclozine Traveleeze® Sea Legs®
Discontinued
Altitude Sickness
types, symptoms and causes
Acute mountain sickness (AMS)
usually occurs above 2500-3000m
symptoms - headache, fatigue, loss of appetite, nausea, sleep disturbance, SOB
usually resolves after a few days at same altitude
Complications
High altitude pulmonary oedema (HAPO/HAPE)
symptoms -SOB, dry cough, progressing to productive with blood, pink or white frothy sputum, cyanosis.
High altitude cerebral oedema (HACO/HACE)
symptoms - lethargy, confusion, hallucinations, unsteady gait (ataxia), vomiting, loss of consciousness
Altitude Sickness - treatment
Treatment (symptomatic)
Headaches-paracetamol/ibuprofen
Nausea –antiemetics e.g. promethazine
Prophylaxis Acetazolamide (Diamox®) 125mg bd (POM and unlicensed use-Private Rx/ PGD)
Start 1-2 days before ascent and continue throughout
Side effects: nausea, tingling of fingers and around mouth, diuresis, flushing.
Diseases Contracted by Travellers: Routes of Transmission
Sexual/blood/body fluids: Hepatitis B and C, HIV
Water borne: Hepatitis A
Contaminated food/water borne: Cholera, Typhoid, Polio, Campylobacter, E. Coli
Soil /manure borne: Tetanus
Raw pork products: Hepatitis E
Droplet infection: Diptheria / Measles / Mumps / Rubella / Meningococcal Meningitis / Tuberculosis / Influenza/ COVID-19
Bites from infected animals: Rabies
Bites from insects
Diseases Contracted by Travellers: Spread by biting insects (vectors)
Protozoal:
malaria, trypanosomiasis, leishmaniasis
Viral:
Dengue fever, West Nile fever, yellow fever, Japanese encephalitis, chikungunya, Zika
Filarial (worms): onchocerciasis (river blindness), elephantiasis (Lymphatic filariasis)
Rickettsial: typhus
Bacterial: plague, Lyme disease
Maggot infestations: bot fly larvae
Diseases Contracted by Travellers: Spread by biting insects (vectors)
Malaria, Elephantiasis -anopheles Mosquito (active evening / night)
* check*
Bites – Prevention by Avoidance
Mosquitoes
Repellents applied to skin/clothes
Knockdown spray or plug-in insecticides to clear room of insects (not very effective)
Cover up including arms and legs
Sleep under insecticide–impregnated mosquito net
Wear light coloured clothing
Awareness that different mosquito species transmit different illnesses
Ticks
Treat socks with DEET or permethrin and tuck socks into trousers
Tsetse Fly
Use DEET repellent
Avoid the colour dark blue
Bites – Prevention by Repellents
Insect repellents interfere with chemical stimuli that attract mosquitoes
Removed by abrasion, sweating, washing
Apply frequently
Some is absorbed by the skin
Duration of action important
- DEET-containing (N, N-diethyl-m-toluamide) repellents most effective
(20-50% e.g. Jungle Formula Medium and Maximum®)
- Icaridin (Jungle Formula Outdoor and Camping/Kids®) ≥20% recommended
- Lemon eucalyptus oil (p-menthane 3,8-diol) (Mosi-guard®) –equivalent to 15% DEET
- Citronella oil-not recommended-short duration.
Bites – RTS
Treatment
Antihistamine tablets
- Sedating (Chlorphenamine Adults 4mg every 4-6 hours)
- Non-sedating (Loratadine, Cetirizine, Acrivastine)
Antihistamine cream (mepyramine 2% cream Anthisan)
- 2 or 3 times a day for up to 3 days
Ibuprofen or paracetamol for pain and swelling
Crotamiton cream 10% - adults and children over 3
Topical corticosteroid- Hydrocortisone 1% cream (over 10 years)
Advice
Try not to scratch – can introduce infection
Refer if infection suspected-pus /swollen glands, increasing redness, swelling and pain in and around the bite
ABCD of malaria
A Awareness of risk
B Bite prevention
C Chemoprophylaxis
D Diagnose promptly and treat without delay
what is malaria
chemoprophylaxis
Malaria causes highest mortality of insect-borne diseases
Plasmodium falciparum most serious-most cases seen in UK from travellers
Malaria-non-specific symptoms: fever, chills, headache, diarrhoea, cough
Areas of risk – take appropriate anti-malarial chemoprophylaxis- not 100% effective
Reduced during COVID but has increased again
Chemoprophylaxis
Proguanil 100mg tabs (Paludrine) (P)
Chloroquine phosphate 250mg tabs (Avloclor)(P)
Proguanil / Chloroquine (Paludrine/Avloclor Anti-malarial Travel Pack) (P)
Doxycycline 100mg caps (POM)
Mefloquine 250mg tabs (Lariam) (POM)
Atovaquone 250mg/proguanil 100mg tabs (Malarone (POM)/ generic (POM)/
Maloff Protect (P)) and paediatric tabs (62.5mg /25mg) (POM)
