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Travel advice and Travel Vaccinations

BEFORE YOU LEAVE

INSURANCE

Make sure you have full medical insurance covering all activities you are likely to take part in, and make sure it is a repatriation policy. The biggest risks to travellers abroad are theft and road accidents. Make copies of your travel insurance documents, take one with you and leave a copy with a contact in the UK.  If you can, scan them and e-mail them back to yourself.  Do the same with your passport and tickets etc. Keep a copy of your travel insurance company telephone number and your insurance document number with you at all times.

If you are a UK resident, you can obtain a European Health Insurance Card, this entitles you to medical treatment that becomes necessary, at reduced cost or sometimes free, when temporarily visiting a European Union (EU) country, Iceland, Liechtenstein, Norway or Switzerland.

LOCAL KNOWLEDGE

Look up information, medical and otherwise on the area you will be travelling to and draw up a list of items you need to take (including medical kit). Be aware of the medical conditions you are likely to encounter and read up on them.

IMMUNISATIONS

Make sure you plan these well in advance, please make your first travel clinic appointment at least 8 weeks before you leave Leicester.

See the vaccine preventable diseases section for more detail about immunisations you may require.

You may wish to contact MASTA (Medical Advisory Services for Travellers Abroad). For £3.99 you can obtain a personal travel schedule for every country on your trip, which will advise you about: recommended vaccinations, up to date alerts and warnings for each country including any disease outbreaks, and tailored travel advice for your trip. Bringing this report to your first travel consultation here will save a lot of time.

PERSONAL HEALTH

Make sure you have adequate supplies of any regular or intermittent medications you take. Have a full dental check up a couple of months before you go.

FIRST AID KIT

Put together a medical kit appropriate to the nature of your trip. See our medical kit page.

MEDICAL INDEMNITY

Medical Students need to contact MPS or MDU and arrange an elective study indemnity policy.

Cuts & lacerations

First Aid

  1. Press on the wound to stop bleeding.

  2. Clean the wound no matter how small it is, rinse it well with tap water. Cleaning will reduce the chance of infection. It is not recommended to rinse with antiseptic solutions (e.g. Dettol, TCP) as they may damage skin tissue and delay healing.

  3. After cleaning, cover the wound with a sterile, non-sticky dressing.

Do I need to see a nurse or doctor?

Many people deal with minor cuts by themselves. The following gives a guide as to when to consider getting medical help:

  1. If the bleeding is heavy or does not stop quickly.

  2. If the wound is large, deep, or dirty, or abrasions caused by gravel. There is a risk of infection, and also a risk of permanent 'tattooing' of the skin from gravel, dirt, grit, etc, which remains in a wound.

  3. If you suspect the cut has damaged deeper tissues such as nerves, tendons, or joints.

  4. If the wound is caused by penetrating glass, metal, etc. It may need to be carefully examined, and may need an X-ray to check that there is nothing left inside.

  5. If the wound is gaping open it should be closed with stitches, glue, or sticky tape. Even small gaping wounds on the face are best dealt with by a doctor to keep scarring to a minimum.

You should have a tetanus booster if you are not up to date with your immunisations. Antibiotics are not needed in most cases. However, a course of antibiotics may be advised in some situations where there is a high risk of a wound infection developing. These include: wounds to the feet (especially if you have poor circulation to the feet), large wounds inside the mouth, contaminated wounds (with soil, manure, or faeces), deep puncture wounds, or if your resistance to infection is low (e.g. if you are on chemotherapy; have no working spleen; have diabetes; have alcohol dependence; have HIV/AIDS, etc).

As the cut heals

The most common complication after a cut is an infection of the wound. See a doctor or nurse if the skin surrounding a wound becomes more tender, painful, swollen, red, or inflamed over the next few days. In some cases, as the wound heals, the colour in the skin darkens around the scar ('hyperpigmentation'). This may be prevented if you use high factor sun screen regularly for 6-12 months on healing wounds that are exposed to sunshine.

DVT ( Air travel Related)

Limited research suggests that immobilisation on journeys lasting more than five hours may increase the risk of DVT (deep vein trombosis) and pulmonary embolism (PE).

The vast majority of air passengers do not need clinical intervention but all should do regular flexion/extension exercises of the lower limbs, deep breathing exercises, and walk around the cabin when safe, to help reduce risk.

Passengers should also drink plenty of water, avoiding excess coffee and alcohol.

Those at increased risk include: anyone with a history of DVT or PE, those who have experienced recent hospitalisation for major surgery especially hip or knee replacement, those with congestive heart failure, paralysis of the lower limbs or malignancy and those who have suffered stroke.

Clinical advice may be sought about the advisability of travelling, suitable exercise, and the suitability of compression stockings or anticoagulants.

Pregnant women or those who have recently delivered, and women on the contraceptive pill or HRT may also be at increased risk.

HIV and post-exposure prophylaxis

This information is written specifically for 4th year medical students on electives overseas, regarding HIV risk and post-exposure prophylaxis.

Prevention

  • The most effective approach is not to put yourself at risk at all

  • Use good infection control procedures at all times

  • Wear gloves if you are likely to be contaminated with body fluids (take gloves with you)

  • Think about what you will do in the event of an injury before it happens

Prevalence

According to the World Health Organisation, the numbers of adults and children estimated to be living with HIV at the end of 2005: 40 million.

 Epidemiology of HIV world-wide - local seroprevalence

  • Highest in sub Saharan Africa

  • Highest in Central, East, South East and South Africa

  • Up to 20% of the population HIV infected (Botswana 36%)

  • Far East - Thailand (2%) and Cambodia(4%), Caribbean (1-5%).

  • Increasing in India, Eastern Europe and Russia

Risk after exposure

  • Risk of acquiring HIV infection following occupational exposure to HIV infected blood is low

  • Average risk for HIV transmission after percutaneous exposure to HIV infected blood in health care settings is approx 1 per 300

  • After mucocutaneous exposure,

  • No risk of transmission where intact skin is exposed to HIV infected blood

Calculating HIV seroconversion risk after needlestick/sharps injury

  • Known HIV positive - risk is 1 in 300

  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 3 (i.e. 30%) - risk is 300 x 3 = 1 in 900

  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 10 (i.e. 10%) - risk is 300 x10 = 1 in 3,000

  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 100 (i.e. 1%) - risk is 300 x 100 = 1 in 30,000

Occupational exposure

Four factors associated with an increased risk of occupationally acquired HIV infection:

  • Deep injury

  • Visible blood on the device which caused the injury

  • Injury with a needle from artery or vein

  • Terminal HIV illness in source patient

Almost all reported cases of HIV seroconversion have occurred after injuries with hollow bore needles.

Body fluids and materials which may pose a risk of HIV transmission

  • Amniotic fluid

  • Cerebrospinal fluid

  • Human breast milk

  • Pericardial fluid

  • Peritoneal fluid

  • Pleural fluid

  • Saliva in association with dentistry

  • Synovial fluid

  • Unfixed human tissues and organs

  • Vaginal secretions

  • Semen

  • Any other fluid if visibly bloodstained

  • Fluid from burns or skin lesions

Post-exposure risk assessment [1] Immediate action

  • Wound or non-intact skin to be washed liberally with soap and water without scrubbing

  • Antiseptics should not be used as no evidence of efficacy and effect on local defences unknown

  • Free bleeding encouraged

  • Exposed mucous membranes irrigated with water and remove contact lenses

Risk Assessment of Occupational Exposure

Ideally this should not be done by the injured Health care Worker. Assessment of the injury involves:

  • Nature of the injury - was there significant contamination?

  • The risk the patient has HIV (do they have Hep C, Hep B)

  • Known HIV positive

  • Person of unknown HIV serostatus

Risk Assessment [2] Circumstances of exposure

Assess if exposure was significant.

  • Percutaneous injury (needles, instruments, bites which break skin)

  • Exposure of broken skin (abrasions, cuts)

  • Exposure of mucous membranes (including the eye and mouth)

Risk Assessment [3] The Source Patient

If of unknown HIV serostatus a designated doctor should approach the source patient and ask for informed agreement to HIV testing (this should not be the exposed worker).

Current guidelines for UK Health care workers seconded overseas - HIV post-exposure prophylaxis

Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS, UK Department of Health, February 2004 (currently under revision) http://www.dh.gov.uk/assetRoot/04/08/36/40/04083640.pdf

Post-exposure prophylaxis

PEP should ideally be started within 1 hour of the injury. Current EAGA recommendations for UK Health care workers seconded overseas:

  • In areas where no anti-HIV treatment is available for patients: 2 drug combination (Zidovudine 250mg and Lamivudine 150mg bd (Combivir 1 tablet BD) for 28 days). BUT anti-HIV treatment is being rolled out to the local population in many developing countries (parts of Uganda, Malawi, Botswana etc). In these areas anti-HIV treatments are likely to be readily available to staff who have significant occupational injuries (ask your supervisor!)

  • Where drug resistant HIV likely to be present in local population: 3 drug combination recommended for exposures to ‘treatment experienced’ HIV population (Zidovudine 250mg + Lamivudine 150mg BD (Combivir 1 tablet BD) + Nelfinavir 1250mg BD for 28 days).

Costs

Combivir 1 BD- 7 days = £72.88, 28 days = £291.65 (recommend 7 day pack)

Combivir 1 BD + Nelfinavir 1250mg BD- 7 days = £148.48, 28 days =£896.33 (recommend 7 day pack).

Questions that you need to answer

  • Will any work during my elective put me at significant risk of contamination with blood borne viruses? If the answer is no, you do not need to consider PEP.

  • What is the prevalence of HIV in the local/hospital population? If high, is the local population being treated with anti-HIV treatments?

  • What is the local process for handling significant exposures/contamination injuries?

  • Are anti-retrovirals locally available within the hospital/health care centre where you are working? If so, which ones, how quickly can they be accessed and cost?

  • Who will manage/advise you in the event of a contamination injury? Contact your local supervisor (although you often don’t get a response!)

  • Consider insurance to cover repatriation in event of significant injury requiring PEP.

Source: Dr Eric Monteiro, Clinical Director, Department of Genitourinary Medicine

Image source: With permission SOS Children's Villages - the world's largest orphan charity.

Insects, Malaria and Altitude

INSECT BITES Mosquitoes, certain types of flies, ticks and bugs can transmit many different diseases. e.g. malaria, dengue fever, yellow fever. Some bite at night, but some during daytime. The main way to avoid illness is to avoid being bitten, where possible:

  • If your room is not air conditioned, but screened, close shutters early evening and spray room with knockdown insecticide spray. In malarious regions, if camping, or sleeping in unprotected accommodation, always sleep under a mosquito net (impregnated with permethrin). Avoid camping near areas of stagnant water, these are common breeding areas for mosquitoes etc.

  • Electric insecticide vaporisers are very effective as long as there are no power failures! Electric buzzers, garlic and vitamin B are not effective.

  • Cover up skin as much as possible if going out at night, (mosquitoes that transmit malaria bite from dusk until dawn). Wear light coloured clothes, long sleeves, trousers or long skirts.

  • Use insect repellents on exposed skin. (Choose those containing DEET or eucalyptus oil base. A content of approximately 35% DEET is recommended for tropical destinations.) Clothes can be sprayed with repellents too. Impregnated wrist and ankle bands are also available. Check suitability for children on the individual products.

  • Report any unexplained illness with symptoms such as fever, headache, malaise, muscle aches and fatigue.

MALARIA

Malaria is probably the most common and most serious disease you will be exposed to when travelling.  Malaria is caused by a microscopic parasite transmitted by female mosquitoes when they take a blood meal at your expense.  There are four species of malaria parasite, of which Plasmodium falciparum is the most dangerous and can lead to cerebral malaria and death.

Malaria usually starts as a fever and you will feel very unwell.  Other symptoms may include diarrhoea, headache or a cough.  In a malarious area, all illnesses with fever should be considered to be malaria until proved otherwise.  Seek medical help as soon as you can if you become ill.

Check carefully the areas you plan to travel to and take anti-malarial tablets (prophylaxis) if advised by the travel-health nurse or doctor.  Some tablets can be bought over the counter in a chemist but others are only available on prescription.  Do not take over-the-counter tablets if prescription-only prophylaxis has been advised.

You can get malaria even when taking prophylaxis, but this happens more commonly in individuals who forget to take one or more tablets.  It is essential that you take the tablets you are prescribed regularly and on time and for the whole of the recommended time after leaving a malarious area (sometimes for 4 weeks after).

Mosquitoes that transmit malaria bite mainly at night, but this can be any time from dusk onwards and even just after dawn.  Use insect repellent containing at least 35% DEET, wear long, loose clothing when possible and consider taking a mosquito net impregnated with permethrin to sleep and rest under.  These can be bought in outdoor/camping shops which stock a full range of products.  Do not rely on insect repellent and mosquito nets alone if you have been advised to take prophylaxis as well; all forms of protection are important.

  • Take adequate supplies of the antimalarial agent suited to your area of travel and remember to take it. People die every year from malaria in the UK.

  • Even with the best prophylaxis you may still catch malaria so have a high index of suspicion.

  • Report any unexplained illness with symptoms such as fever, headache, malaise, muscle aches and fatigue.

  • Malaria can occur up to two years after being bitten by an infected mosquito.

  • If you become unwell with fever up to a year after returning from a malarious area, see your GP and tell them you have travelled abroad.

TRAVELLERS TO HIGH ALTITUDE

Acute altitude sickness occurs when an individual who is accustomed to low altitudes rapidly climbs to high altitude (above 8,000 feet). Clinical features of mild altitude sickness are:

  • Headache

  • Loss of appetite

  • Nausea

  • Fatigue

  • Dizziness

  • Insomnia

  • Extremity oedema

  • Dyspnoea

  • Palpitations 

The treatment for acute altitude sickness ranges from rest and analgesia, to oxygen therapy and descent.

Extreme altitude sickness can be fatal. It is advised that climbers should acclimatise if climbing to high altitude:

  • If above 10,000 feet, no more than 1000 feet should be climbed per 24 hour period.

  • If a climber develops symptoms of mild altitude sickness then he/she should rest for 24 hours at that altitude.

  • If a climber has more severe symptoms then he/she must descend to the last altitude at which they felt well. This should occur whether or not they are using medication prescribed to help cope with high altitude.

The following preventative measures should be utilised:

  • Slow ascent e.g. once over 8000ft (2500m) avoid sleeping more than1000ft (300m) higher than previous day

  • Keep warm

  • Keep well hydrated and avoid alcohol

  • High carbohydrate diet

  • Modest exercise on acclimatising days

Travel Vaccinationsglobal air travel

If you require any vaccinations relating to foreign travel you need to make an appointment with the practice nurse to discuss your travel arrangements. This will include which countries and areas within countries that you are visiting to determine what vaccinations are required.

There is further information about countries and vaccinations required on the links below

Europe Europe & Russia

North America North America

Central America Central America

South America South America

Caribbean Caribbean

Africa Africa

Middle East Middle East

Central Asia Central Asia

East Asia East Asia

Australasia Australasia and Pacific

It is important to make this initial appointment as early as possible - at least 6 weeks before you travel - as a second appointment will be required with the practice nurse to actually receive the vaccinations. These vaccines have to be ordered as they are not a stock vaccine. Your second appointment needs to be at least 2 weeks before you travel to allow the vaccines to work.

Some travel vaccines are ordered on a private prescription and these incur a charge over and above the normal prescription charge. This is because not all travel vaccinations are included in the services provided by the NHS.


Travelling in Europe

If you are travelling to Europe a very useful booklet has been published with advice and guidance to help you get the most out of your holiday. To visit please click:- http://ec.europa.eu/publications/booklets/eu_glance/86/en.pdf (this is a large document and may take a minute or two to view)

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