Travel Advice: Keeping Healthy When Abroad

Air Travel

To reduce the risk of Deep Vein Thrombosis it is sensible on any long haul flight to:

Be comfortable in your seat.
Exercise your legs, feet and toes while sitting every half an hour or so and take short walks whenever feasible. Upper body and breathing exercises can further improve circulation.
Drink plenty of water and be sensible about alcohol intake which in excess leads to dehydration.

Drinking Water

Diseases can be caught from drinking contaminated water (or swimming in it). Unless you KNOW the water supply is safe where you are staying, only use:

Boiled water.
Bottled water or canned drinks (and drink them from the original container).
Water treated by a sterilising agent (you can buy water purification tablets from a pharmacy).

This advice applies to ice cubes in drinks and water for cleaning your teeth.

Food Safety

Contaminated food is the most common source of many diseases abroad. You can help prevent it by following these guidelines:

Only eat well cooked fresh food
Avoid leftovers and reheated foods
Ensure meat is thoroughly cooked
Eat cooked vegetables, avoid salads
Only eat fruit you can peel
Never drink unpasteurised milk
Avoid ice-cream and shellfish
Avoid buying food from street vendor's stalls unless it is thoroughly cooked in front of you
Alcohol! If you drink to excess, alcohol could lead you to become carefree and ignore these precautions

Hygiene

Many diseases are transmitted by what is known as the 'faecal-oral' route. To help prevent this, always wash your hands with soap and clean water after going to the toilet, before eating and before handling food.

Diarrhoea and Vomiting

This is the most common illness that you will be exposed to abroad and there is no vaccine against it! Travellers' diarrhoea is caused by eating or drinking food and liquids contaminated by bacteria, viruses or parasites. Risk of illness is higher in some countries than others:

High risk areas include North Africa, sub-Saharan Africa, the Indian Subcontinent, South East Asia, South America, Mexico and the Middle East.
Medium risk areas include the northern Mediterranean, Canary Islands and the Caribbean Islands.
Low risk areas include North America, Western Europe and Australia.

You can certainly help prevent travellers' diarrhoea in the way you behave - make sure you follow the food, water and personal hygiene guidelines already given. Travellers' diarrhoea is 4 or more loose stools in a 24 hour period often accompanied by stomach pain, cramps and vomiting. It usually lasts 2 to 4 days and whilst it is not a life threatening illness, it can disrupt your trip for several days.

The main danger if the illness is dehydration, and this if very severe can kill if it is not treated. Treatment is therefore re-hydration. In severe cases and particularly in young children and the elderly, commercially prepared re-hydration solution is extremely useful. This can be bought in tablet or sachet form at a chemist shop e.g. DIORALYTE; or ELECTROLADE. (Dioralyte Relief is a new formula containing rice powder which also helps to relieve the diarrhoea, particularly useful in children). Prepare according to instructions. Anti Diarrhoeal Tablets can be used for short term relief for adults (eg for a bus or train journey or flight) but should never be used in children under 4 years of age, and only on prescription for children aged 4 to 12 years. Commonly used tablets are IMODIUM and LOMOTIL. None of these tablets should ever be used if the person has a temperature or blood in the stool. Do seek medical help if the affected person has:

A temperature
Blood in the diarrhoea
Diarrhoea for more than 48 hours (or 24 hours in children)
Becomes confused

In very special circumstances, antibiotics are used for diarrhoea, but this decision should only be made by a doctor (a woman taking the oral contraceptive pill may not have full contraceptive protection if she has had diarrhoea and vomiting. Extra precautions must be used - refer to your 'pill' information leaflet. If using condoms, use products with the British Kite Mark).

Sun Sense

Sunburn and heat-stroke cause serious problems in travellers. Both are preventable - to avoid, use the following precautionary guidelines:

Increase sun exposure gradually, 20 minutes limit initially.
Use sun blocks of adequate Sun Protection Factor strength (SPF 15 minimum). Reapply often and always after swimming and washing. Read manufacturer's instructions.
Wear protective clothing - sun hats etc.
Avoid going out between 11am - 3pm, when the sun's rays are strongest.
Take special care of CHILDREN and those with pale skin/red hair.
Drink extra fluids in a hot climate.
Be aware that alcohol can make you dehydrated.

Why factor 15?

The reason experts recommend factor 15, is that this represents the best balance between protection and price. You will get over 90 per cent protection from UVB rays with SPF 15. But no sunscreen, no matter how high the factor, can offer 100 per cent protection.

Factor 15 sunscreen offers about 93% protection
Factor 30 sunscreen offers about 96% protection
Factor 60 sunscreen offers about 98% protection

When Buying sunscreen:

Choose one with an SPF of 15 or above - this will give you over 90% protection.
Make sure it is labelled 'broad spectrum' - to protect against UVA and UVB.
Choose water resistant - it is less likely to wash or be sweated off.
Check the 'use by' date - most sunscreens have a shelf life of 2-3 years.
You don't have to pay for expensive brands. All types are tested and the cheaper brands are just as effective if used properly - just remember factor 15+.

Tips for using sunscreen properly:

Try to apply it 15-30 minutes before going out in the sun.
Apply to clean, dry skin and rub in only lightly.
Use generous amounts.
Re-apply once outside to ensure even coverage.
Then re-apply every 2 hours or more frequently if washed, rubbed or sweated off.
Put on before make-up, moisturiser, insect repellant, and so on.
Never use it to spend longer in the sun - this will put you at risk of sun damage that could lead to skin cancer.
In hotter climates and hotter days in the UK avoid direct sun exposure between 11am and 3pm.
Take special care of children and those with pale skin / red hair.
Use SPF 60 on any areas of recent scarring / skin damage.
You can get severe sunburn in the UK.
Do not store sunscreens in very hot places as extreme heat can ruin their protective chemicals.

Personal Safety

Leading causes of death in travellers are due to drowning and traffic accidents. You can help prevent them by following these precautionary guidelines:

Avoid alcohol and food 1 hour before swimming.
Never dive into water where the depth is uncertain.
Only swim in safe water, check currents, sharks, jellyfish etc.
Avoid alcohol when driving, especially at night.
Avoid hiring motorcycles and mopeds.
If hiring a car, rent a large one if possible, ensure the tyres, brakes and seat belts are in good condition.
Use reliable taxi firms.
Know where emergency facilities are.

Sexual Health

Remember that unprotected sex can result in anything from Chlamydia to HIV. The Sun newspaper reported in July 2005 that a Syphilis outbreak in Manchester was quickly replicated in Amsterdam, Dublin, and Paris as a result of people jetting from place to place and having unprotected sex - everyone going on holiday should take condoms, don't leave it to chance, it's not worth the risk

Psychological Support

Medical Students - On your elective you may have many new and sometimes distressing experiences including helplessness and frustration witnessing preventable deaths. You may experience significant culture shock and have difficulty adjusting on your return to the UK. It is important to prepare for this and also to ask for help from peers, colleagues, counselling services or doctor if needed.

First Aid Kit

If you are travelling to remote areas where access to medical care is limited we strongly advise you to carry a medical kit appropriate to the nature of your trip.

Parasites and Other Diseases

Parasitic diseases are common in the local population in many travel destinations and although you should not worry, it is advisable to be aware of some of these diseases and how they can be avoided.

Dengue Fever

Prevalence: Common in many parts of the tropics

Dengue fever is caused by one of four virus serotypes which are spread by Aedes species of mosquito. These mosquitoes bite during the day. The epidemics of dengue fever are often seasonal, during or just after rainy seasons. Check the NATHNAC link for current outbreaks.

Symptoms come on very suddenly, with fever, severe headache, and muscle and joint pains, with a rash typically developing after 3-5 days. Nausea, vomiting and diarrhoea are also common. The acute phase usually lasts a week, and although serious complications are uncommon, post-viral fatigue syndrome is common, so take it easy for a few weeks if you can. Rarely, dengue fever can develop into a more serious form, called dengue haemorrhagic fever, which in turn can lead to dengue shock syndrome, which can be fatal. The haemorrhagic form occurs more commonly in subsequent attacks with a different serotype of dengue virus.

Treatment is symptomatic: keep your fluid intake up (not alcohol!) so that you don’t dehydrate, and pain should be relieved with paracetamol, not aspirin or ibuprofen. Hospital care is indicated in severe illness or if complications occur.

Diagnosis is usually made clinically. Self-diagnosis of dengue in a malarious area could be very dangerous – All illnesses with fever should be considered to be malaria until proven otherwise. In places with good medical facilities a blood test can be done at 8 days after the onset of fever to confirm the diagnosis. It can be useful if you are a long-term or recurrent traveller to know if you have had dengue as subsequent episodes should be monitored more closely for complications.

Prevention, as with all insect-borne diseases, is by using insect repellent (containing DEET), covering up with clothing where possible and sleeping/resting under a mosquito net impregnated with permethrin.

African Trypanosomiasis (sleeping sickness)

Prevalence: Patchy distribution in sub-Saharan Africa

African trypanosomiasis is a potentially lethal disease caused by a microscopic parasite spread by tsetse flies. These flies are large, brown and give a painful bite, often resulting in a boil on the skin if the fly is carrying the parasite. In different parts of Africa the flies favour either shady riverside habitats or the bases of tree trunks in the savannah regions. An important feature of the disease is swollen glands, especially on the neck, accompanied by fever, headaches and joint pain. Use insect repellent (50% DEET) and wear long, loose clothing to prevent being bitten by tsetse flies.

South American Trypanosomiasis (Chagas' disease)

Prevalence: Mexico, Central and South America

South American trypanosomiasis is transmitted by ‘kissing bugs’ that feed by sucking blood when you are asleep, often from your face. Parasites are passed out of the bug not in saliva but in faeces, and you become infected if you scratch the bite and rub the faeces into the wound. The bite is surprisingly painless even though the bug may feed for more than 10 minutes. The bugs typically live in the cracks of mud huts or in thatched roofs, but they also live behind furniture and pictures on the wall. The disease is serious in that, if undiagnosed or untreated in the acute phase (the first few weeks), damage to the heart and digestive system is irreversible and can lead to health problems in the future. It is strongly advised that you do not sleep in rural dwellings in Latin America without an insecticide-treated bed net, and make sure you tuck it under your mattress!

Leishmaniasis

Prevalence: Patchy distribution worldwide

The most serious is visceral leishmaniasis, which can be lethal if untreated. Symptoms include fever, anaemia, weight loss, and enlarged liver and spleen.
Less serious is mucocutaneous leishmaniasis, only present in Central and South America, which causes a skin ulcer and spreads to disfigure the nose and throat.
Least serious is cutaneous leishmaniasis which causes self-healing ulcers, often leaving a scar.

Sandflies bite from dusk throughout the night and insect repellent should be used. If you are going to a known endemic area, consider buying a sandfly net, which is a finer mesh than a mosquito net and will keep out sandflies. Make sure it is insecticide-impregnated every 6 months with permethrin. If you develop a skin ulcer that persists, or the symptoms of visceral leishmaniasis, seek medical attention.

Onchocerciasis (river blindness)

Prevalence: Patchy distribution in equatorial Africa and equatorial Latin America

Onchocerciasis is a chronic disease caused by small parasitic worms which are transmitted by the bite of black flies which live near rivers. The worms take up residence in your skin, producing itchy skin and nodules. They also show a preference for the eye but blindness only occurs after many years of infection. If you are concerned see a doctor on your return.

Lumphatic Filariasis

Prevalence: South-East Asia, India, Equatorial Africa, some parts of Latin America

Lymphatic filariasis is a parasitic infection which initially causes fever and inflammation of the skin. When chronic the disease affects the lymphatic system which results in swelling, usually of the legs. It occurs mainly in the least developed countries of the world and usually travellers are not at high risk. The parasitic worms are spread by mosquitoes which bite at night, so use a good insect repellent containing DEET and an insecticide-treated mosquito net.

Plague

Prevalence: Isolated foci in Africa, Asia and Latin America

Plague is fortunately rare. It is spread through the bite of infected rodent fleas. Don’t lose any sleep about this but use insect repellent (containing DEET) if you are staying in very rough, rural housing. If you develop a large, red, painful boil in your groin or armpit, see a doctor soon.

Leptospirosis

Prevalence: Worldwide distribution

Leptospirosis is a bacterial disease spread through animal urine, usually from the rat. It can be lethal but unless you will be working in sewers you will probably be at low risk of the disease. However, if you are working in rural areas or shanty towns, especially in the rainy season, don’t mess about in the flood water and cover any cuts and grazes with waterproof dressings.

Soil-Medicated Parasitic Worms

Prevalence: Very common in the tropics

Be aware of washing your hands before you eat and don’t go barefoot as some worms will penetrate your skin. See your GP if you have any intestinal symptoms that continue on your return to the UK, and let them know where you have travelled to.

Cutaneous Larva Migrans

Prevalence: Southeast Asia, Latin America, and the Caribbean basin

Cutaneous larva migrans is a characteristic itchy creeping skin eruption, usually of the foot. It is due most commonly to a dog or pig hookworm, passed in faeces. The worm can enter your skin when walking barefoot in sand or dirt in the tropics. Treatment is by medication (even though this is a self-limiting disease with the larva dying and the lesions resolving - but this can take from 4 weeks to 1 year).

Myiasis

Prevalence:

A rather unpleasant boil with a little surprise in store. The Bot fly lays an egg under the skin and the larva feasts on your subcutaneous tissues. A reactive boil forms but the larva has formidable hooks which allow it to prevent efforts to removal by squeezing it out. The technique for removal is to coat the area in a thick layer of Vaseline and wait for it to come up for air, whereupon it can be grabbed!

Rift Valley Fever

Prevalence: Kenya, Tanzania and Somalia

Rift Valley Fever is a viral disease primarily affecting domestic animals including cattle, sheep and goats. It can be transmitted to humans via mosquito bites or through contact with body fluids (including milk) and meat of infected animals. The majority of cases experience a brief flu-like illness but the disease can progress and become fatal. Avoid insect bites using insect repellent (containing DEET), long, loose clothing and consider buying a bed-net impregnated with insecticide. Boil fresh milk, cook meat thoroughly and avoid direct contact with raw meat.

Chikungunya Virus

Prevalence: India, Sri Lanka, Indian Ocean Islands, Africa

Chikungunya Virus, like Dengue Fever, is spread by day-biting Aedes mosquitoes. The illness presents as rapid onset on joint pains, muscle pain, high fever, conjunctivitis and rash. Avoid mosquito bites by using DEET insect repellent, long, loose clothing and consider buying a bed-net impregnated with insecticide.

Schistosomiasis (Bilharzia)

Prevalence: Africa (90% of cases), some parts of Latin America and South-East Asia

Schistosomiasis is a disease caused by blood flukes acquired when wading or swimming in infested fresh water lakes and streams. When you are in the water, microscopic parasites burrow through your skin and migrate through your body until they come to their final destination in the veins of the bowel or bladder. Light infections may pass unnoticed but more severe infections may cause blood in the urine or faeces, together with other symptoms. Avoid swimming in freshwater lakes or rivers, or if you do, request a blood test 12 weeks after returning from your trip. In addition It is wise never to go barefoot, but to wear protective footwear when out, even on the beach. Other diseases and parasites can be caught from sand and soil, particularly wet soil.

Leishmaniasis embraces a range of diseases caused by different types of microscopic parasites and they occur in many countries of the world. All are spread by sandflies, which are smaller than mosquitoes and are quite hairy.

When You Return

Have you been travelling to tropical or sub-tropical countries over the summer? If so we strongly advise you to make an appointment with a practice nurse to arrange for a screening stool culture and a full blood count. This is to check that you haven't picked up any diseases or travelling companions. If you have been travelling and have returned feeling unwell, especially with an unexplained fever or prolonged diarrhoea you should make an appointment with a doctor.

If you have been to Africa, South America or some parts of the Caribbean, and have been swimming in fresh water lakes and steams, you will need screening for Schistosomiasis. Make an appointment with a practice nurse 12 weeks after after your return.

Maintain a high degree of suspicion of Malaria if you develop any flu-like illness (characterised by fever, headache, joint aches etc).

Travel occasionally brings some negative experiences. Please seek support for any unresolved issues from whomever you feel most comfortable with: friends / family / doctor or counselling services.