travel

Health Advice for the Returning Traveller; When to see the GP?

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It’s the time of year again when all our backpacking students return from the four corners of the world. Some will be arriving for the first time in Bristol, as international students of course, and many of you will have been traipsing through the jungles/ beaches and villages of the world’s most remote places, possibly even to Coca-cola free zones!

Unfortunately, even if you did everything right, had every last jab, and took all your malaria pills, you may still be at risk of post-travelling illness, so here is a quick summary of what to watch for and what to act on;

  • Tell the nurse/ doctor exactly where you have been, and dates
  • Tell them if you worked in ‘at risk’ environments, eg in a hospital/ clinic
  • Most illnesses will be common conditions like pneumonia/ fungal skin rashes
  • Be honest about malaria tablet history and compliance
  • Report any treatment tried or taken overseas
  • Fever is a common symptom requiring medical attention in returning travellers, especially if it is accompanied by; rash/ jaundice/ breathing difficulties/ bruising/ persistent vomiting/ altered conscious level or paralysis (the latter are extremely rare with only 0.3% of unwell travellers ever requiring hospital admission).
  • Malaria commonly presents with fever, chills, sweats, headaches, muscle pains, nausea and vomiting.
  • Jaundice (yellowing of the skin, and whites of the eyes) can indicate Hepatitis, most commonly type A, from infected food and water.
  • Arbovirus infections (Dengue, West Nile and Chikungunya fevers) are the main cause of viral fevers in returning travellers, and tend to have short incubation periods, typically less than two weeks .ie you will show symptoms within 2 weeks of being infected.
  • Diarrhoea is extremely common in travellers, and those who develop three or more loose stools in an eight-hour period, especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools, may benefit from antibiotics.
  • Prolonged, severe diarrhoea with blood should be reviewed by a GP.
  • Skin rashes are very common, and should be reviewed by your GP if not settling, or if associated with fever.
  • The vast majority of travellers’ infections have a short incubation period, meaning that symptoms will start within 10 days or less from infection. The notable exceptions are schistosomiasis (bilharzia)/ malaria/ TB/yellow fever, and Q fever.

 

 

Therefore, if you continue to feel unwell despite being home, and eating and drinking normally for you, then please come and see one of the GPs. You may also find it useful to look at the following;

 

http://www.nathnac.org/travel/index.htm

 

 

 

World Health Day 7th April 2014: safer travel for all Bristol students

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World Health Day is celebrated on 7 April every year to mark the anniversary of the founding of the World Health Organization in 1948. Each year a theme is selected that highlights a priority area of public health. In past years themes as diverse as road safety, climate change and high blood pressure have been chosen. The topic for 2014 is vector-borne diseases, which could be of great personal relevance to a large number of students who make international journeys whilst they are studying at the University of Bristol.

Vectors are organisms that transmit pathogens and parasites from one infected person (or animal) to another. Vector-borne diseases are illnesses caused by these pathogens and parasites. Vector-borne diseases account for a massive 17% of the estimated global burden of all infectious diseases.

The most well known and deadly vector-borne disease is of course Malaria but the world’s fastest growing vector-borne disease is Dengue with a 30-fold increase in disease incidence over the last 50 years. Others you may have heard of are Yellow Fever and Schistosomiasis. Vector borne diseases are most commonly found in tropical areas and places where access to safe drinking-water and sanitation systems is problematic. However, globalization of trade and travel and environmental challenges such as climate change and urbanization are having an impact on transmission of vector-borne diseases, and causing their appearance in countries where they were previously unknown.

 

So World Health Day 2014 has a particular relevance for people on the move, which includes many UoB students. Large numbers of you will travel to countries where vector borne diseases pose a threat. This includes some of our International Students who return home during the course of their degree. Many of the risks of global travel can be minimized by precautions taken before, during and after travel. Whether you are a student planning an exciting trip during one of the university holidays, or whether you are an International Student intending on going home during your degree, it is important that travellers to developing countries consult a travel medicine clinic well in advance of the intended journey. We run travel clinics at Students’ Health service, which are open to our International Students too.

 

Road Traffic Accidents Kill More People in the World than Malaria!

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Got your attention?! It definitely got mine reading this- perhaps unbelievable? But true. According to the World Health Organisation (WHO), road traffic accidents (RTAs) kill more people around the world than malaria, and are the leading cause of death for young people aged 5 to 29 – especially in developing countries. Each year WHO estimates that worldwide 1.3 million people are killed on roads and up to 50 million people are injured in RTAs, globally.

Many of the students I see each year in our Travel Clinics travel to SE Asia, Thailand being a very popular destination and usual first port of call for most. Thailand has been classed as one of the deadliest holiday destinations for Britons. This is a direct result of fatal motorbike accidents.

The Foreign and Commonwealth Office (FCO) statistics show that between 1st April 2012 and 31st March 2013, there were 870,164 visitors to Thailand. During this time there were 389 deaths and 285 hospitalisations, this number has increased by 31% (a third) and was linked to RTAs.

Thailand is the 4th country in the world in which Britons are most likely to require consular assistance (behind Spain, USA and France).

I know when I was backpacking in my early 20’s around Thailand, I was not made aware of these dangers in my pre travel clinic appointment, and I was totally ignorant/unaware of these risks. So there I was happily zipping around on a scooter- in my shorts, flip-flops and vest, no helmet on- I can’t actually remember if I had any insurance to ride one! I had a few near misses, but fortunately I was lucky- nothing serious.

Like me, often tourists to hot destinations ride scooters with no helmet while wearing shorts, a vest top and flip-flops. Think aboutwhat might happen  if you fell off your scooter- the risk of major injury and need for hospitalisation is significant. Also many backpackers, being broke, forgo travel insurance as well.

In March 2013, the Foreign Office launched a road safety campaign for driving abroad. The focus is very much on Thailand:

‘After deaths from natural causes, road traffic deaths are the most common cause of death for British nationals in Thailand and cause a high number of hospitalisations. The majority of RTAs involve motorcycles and scooters, although serious accidents also occur with other vehicles. For instance, in the past year a number of British nationals were involved in accidents whilst travelling by overnight coach.’

Mark Kent, Her Majesty’s Ambassador to the Kingdom of Thailand, said:

“British nationals using the roads in Thailand should bear in mind that road laws and driving customs here are different from those in the UK and road conditions, driving standards and road traffic regulations can vary.”

So if you are planning on motorcycling around Thailand, as many backpackers do, what safety measures can you exercise?

*Make sure you can ride one safely first! Many people have their first try on a scooter whilst abroad and may not be familiar with the controls and how to ride one.

*Make yourself aware of the laws and driving customs in the Country

*Wear a helmet: Thai law states that safety helmets must be worn- this is widely ignored in Thailand.

*Ensure you have comprehensive, adequate travel insurance- due to financial pressures you may skip on travel insurance in a bid to save money- this may have significant repercussions in the event of any accident/injury.

*Check the small print of the lease agreement and don’t hand over your passport as a guarantee against returning a motorcycle or scooter. Unscrupulous owners have been known to hold on to passports against claimed damage to the motorcycle or scooter.

*Bear in mind, many of the motorcycles and scooters that are available for hire in beach resorts are unregistered and cannot legally be driven on a public road. This could invalidate any travel insurance policy should you wish to make a claim.

Finally… Do not drink and drive

 

Sources:

 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212707/British_Behaviour_Abroad_report_2012-13.pdf.

 

https://www.gov.uk/government/news/foreign-office-launches-road-safety-campaign-for-driving-abroad.

 

https://www.gov.uk/foreign-travel-advice/thailand/safety-and-security.

 

 

 

Rabies – Cost vs. Protection/Risk

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Blah Blah Blah…. “For India you are recommended to have your free NHS Hepatitis A and Typhoid”…. Cool that’s what my other friends have all decided to have as they’re free… Blah Blah Blah…. “Food and water precautions”…..I’m starving, wonder what to have for dinner tonight… Blah Blah Blah… “You are up to date with your tetanus, diphtheria and polio”… Great one less injection!… Blah Blah Blah… “Rabies is high risk”…. Blah Blah Blah… “£150 for the primary course of 3 immunisations”… Blimey that’s expensive don’t think I’ll have those injections…  Blah Blah Blah… “In the event of a scratch or a bite, you would then only require 2 post exposure injections”…Blah Blah Blah… “In stead of 5 injections over 30 days and immunoglobulin”… Blah Blah Blah… “Malaria”…Oh looks like its brightened up outside, hopefully won’t get wet walking home…  Blah Blah Blah.

 

People do tend to ‘zone out’ during their travel clinic appointments especially when prices of vaccines are discussed or indeed have a lack of awareness of risks at their destinations.

Travel can be very expensive, flights, accommodation, activities, food, drink whilst away, equipment, clothes, travel insurance… etc…

Travel vaccinations tend to be low down on the list of priorities but are in fact very cost effective – the majority are effective for a few years, so if you are planning long haul trips in the future they are a good investment, and obviously they could also prevent you from becoming seriously unwell, disrupting your trip or having to spend a fortune on medical treatment whilst away.

Many travellers we see in our travel clinics are planning on visiting ‘high risk’ destinations for rabies.

 

Rabies is a serious, fatal infection transmitted through a scratch, bite or lick of broken skin/mucous membrane of an infected mammal- these include bats, dogs etc…

There is a pre travel/exposure vaccination course that consists of 3 injections on day 0, 7, 21 or 28. By completing this course you will be considered ‘fully immunised’ and as an infrequent traveller to a high risk destination will only then need to consider a booster at 10 years if you are travelling again to a high risk area, so it is good value for money. (This advice will alter for those travellers at continuous or frequent risk – the nurse will advise these travellers accordingly).

Guidance for considering immunising ‘infrequent travellers to high risk destinations’ includes:

  • Those travellers who may not be able to promptly (<24 hours) access a major medical centre for advice and safe, reliable post exposure rabies vaccine and immunoglobulin (if these products are available).
  • Those travelling for more than 1 month.
  • Those doing higher risk activities e.g. cyclists/runners
  • Those working or living in remote areas.
  • Children, who may lack awareness of the need to avoid animals or to report an animal bite.

 

You will always need post exposure treatment in the event of any suspected rabies contact, and what you receive post exposure will depend on what you have received pre exposure

.

Post Exposure Treatment:

 

High Risk Unimmunised/incompletely immunised Individual i.e. has not received 3 pre travel/exposure rabies injections Fully Immunised Individuali.e. has received 3 pre travel/exposure rabies injections
  Five doses (each 1ml ampoule of 2.5 IU) rabies vaccine on days 0, 3, 7, 14 and 30, plus HRIG (within 7 days of starting the course of vaccine) Two doses (each 1ml ampoule of 2.5 IU) rabies vaccine on days 0 and 3 – 7

 

 

Points to emphasise are that there is a worldwide lack of rabies post exposure immunoglobulin (HRIG), so you may have great difficulty accessing this at your destination, and even if post exposure rabies vaccines and immunoglobulin are available at your destination, they may not be safe or reliable. Immunoglobulin is a blood product and may also carry the risk for blood borne viruses e.g. HIV, Syphilis, Hepatitis B and Hepatitis C.

 

So if you are travelling to a high risk destination for rabies it is always worth considering a pre-exposure course of vaccine, as it is cost effective- booster not considered for another 10 yrs, and negates the need of ‘risky’/ ‘unavailable’ immunoglobulin at your destination if you have no immunity/pre travel injections.

Ultimately the advice is just to stay away from any animals!

 

Further reading/information on rabies and what to do immediately after any contact/emergency 1st aid:

http://www.who.int/rabies/rabnet/en.

http://www.nathnac.org/travel/factsheets/rabies1.htm.

 

A Quick Dip

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“Jump in”…

“Come on In” I hear them shout… The water looks cool and inviting, the surface twinkling under the sun. I’m hot and sweaty and in desperate need to feel cold water on my skin. I hear them all splashing in the water, laughing calling me in to join them… Beads of sweat have formed on my forehead, I wipe them away- my T-shirt has stuck to my back where I was carrying my daypack.

I do so want to run in, or at least take my sandals off and feel the coolness on my hot feet-  but something in my head tells me no… Why? I retrace my thoughts and vaguely remember something the nurse said in the travel clinic something about snails and freshwater…? and that Lake Malawi was high risk… ?

I can’t see anything in the water- I’m getting hotter and everyone is now in the water- calling me in to join them… What harm can it do?

 I take off my sandals and join in the fun- such a relief from the heat of the sun….

 I think nothing more of it… and 4 months later I am back in Bristol uploading my travel photos onto facebook. I find a selection of leaflets amongst my travel documents that I must have collected from the nurse in the travel clinic- one of them mentions something called ‘Schistosomiasis’ (Bilharzia).

Ahhhh this is the disease that I recalled at Lake Malawi- but I feel totally ok, not unwell at all- so I don’t think I have to worry about this. I start reading the information and it states:

‘The majority of people who contract Schistosomiasis have no symptoms’!

Oh!

But fortunately I can have a screening test 12 weeks after possible exposure which I can have done at my GP practice.

I ring up Students’ Health Service and book a nurse appointment.

Better to check after my quick dip…

 

Schistosomiasis is one of the most widespread of all parasitic infections of humans. It is the most common parasite transmitted through contact, by either swimming or wading in fresh water in parts of Africa, for example Lake Malawi. South America and the Middle and Far East are also affected.

Initial contact with cercariae can cause an itchy rash, known as “swimmers itch.” Once infection has been established, clinical manifestations/ symptoms can occur within 2-3 weeks of exposure, but many infections cause no symptoms.

 

Advice for Travellers

Avoid skin contact with fresh water in endemic areas e.g. ponds, lakes and rivers. Swim only in protected swimming pools or safe sea water. Avoid drinking infected water. Wear protective footwear when walking in soil, especially if it is damp or water logged. Those who have been knowingly exposed can be screened after return but if there are no symptoms this should be delayed for 12 weeks after the last possible exposure so as to allow the time for the development of antibodies.

 

Sources:

Students’ Health Service ‘Travel Guidelines’ patient information leaflet- available at the practice

http://www.nathnac.org/travel/factsheets/schistosomiasis.htm.

 

Taking Risks

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“I’m lying here with a drip in my arm on a hospital bed, gazing out of the window, watching a couple of local children playing with a tin can, wishing I was out there in the sun… Thank goodness I had taken out good travel insurance as I was advised; otherwise this ‘cheap’ backpacking trip would have cost me and my family a fortune in hospital costs…

Being admitted to hospital in India was not on our travel plans.

I feel so sorry for my friends who have cut their holiday short to stay and look after me and update my worried parents on my progress…

 How did I end up here you may ask? Well now, that’s a good question…

Between the many visits to the bathroom to either vomit or have profuse diarrhoea- been probed, prodded or injected with goodness knows what-  I have been lying here asking myself that very question over the last few hours…

 I remember what the nurse told me in the travel clinic about water and food precautions- but how many times did I take risks??

 Was it those delicious tomatoes that I bought from a street seller but which I didn’t bother to wash… that local ice cream that was sooo refreshing… those prawns that looked so fresh… that salad… that meat that was not cooked quite so thoroughly… the buffet we treated ourselves to- how long had it been kept warm for… those ice cubes in my drink… or indeed running out of bottled water and brushing my teeth with tap water?

I have also been eating with my hands a lot and not washed them as much as I should have, and it didn’t help that I’d forgotten to pack some alcohol gel…

I wish I’d been more vigilant with precautions as I was advised,and not taken any risks…”

 

Any one of these risks could result in severe travellers diarrhoea due to transmission of a bacteria/parasites/virus/cysts.

For advice on prevention please read from the list of sources below.

 

Remember that Traveller’s Diarrhoea is the most common illness you will be exposed to and the main danger is dehydration, which, if very severe, can be fatal if untreated.

Treatment is therefore rehydration– ensuring you drink plenty of clean water, particularly salty soups and fruit juices with bland bulky foods- bread, pasta, rice and potatoes. You will also need to replace some of the lost salts by taking an oral rehydration sachet e.g. Dioralyte. Anti diarrhoea tablets should be used sparingly and only when truly necessary e.g. a long distance bus/train journey.

Contact medical help if the person has:

♦ A temperature

♦ Vomiting and unable to keep fluids down

♦ Blood or mucus in the diarrhoea

♦Persistent diarrhoea

♦ Become confused

♦Any pre existing medical conditions e.g. diabetes

 

Sources:

Students’ Health Service ‘Travel Guidelines’ patient information leaflet- available at the practice

http://www.nathnac.org/travel/misc/travellers_food.htm.

http://www.fitfortravel.nhs.uk/home.aspx.

It only takes ONE bite!

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“Off to Tanzania- leave in a couple of days! Sooo excited- mustn’t forget my yellow fever certificate- what was it the nurse said- Oh yes to photocopy it, keep this separate and put the original in my passport- good advice. I’ve been planning this trip for months- teaching English to children and construction work in a remote village. Not sure what to expect as staying with a local family- what will their home be like? What will I eat? How hard will the work be? Will they have internet close by??

Must start taking my malaria tablets… and remember to take them everyday.

 What an amazing country- full of colours, sights and smells… Love it! My host family are so welcoming and generous, I’ve settled in well- if a little homesick to start with- and enjoying the teaching. The children are sooo adorable. I have made a couple of friends here who are also doing charity work- one in particular Sarah who is staying with the same family as me.

We are sharing the same room which is rather basic but home to us now and it’s good to have the company- Luckily my little travel sewing kit came in useful as managed to tear a hole in my mosquito net on the first night!

Its such a different world here- so lovely eating dinner every evening outside under the stars- Although there are lots of mosquitoes so have been spraying myself with DEET and wearing my long shirt and trousers as the nurse in the travel clinic advised- mentioned this to Sarah, but she doesn’t seem that bothered with this- wearing vest tops and shorts- as says ‘she doesn’t usually get bitten’ and is taking her antimalarial tablets like me everyday anyway.

 We have now moved on to helping build another room for the school. Sarah hasn’t been well since waking up this morning- feeling a bit ‘fluey’ muscle aches and a headache- she reckons its too much sun as we spend a lot of our time outside now, she’s going home to bed- I’ll check on her at lunchtime…

 Sarah isn’t at all well – she now has a very high fever I’m really worried about her… I spoke to one of the charity organisers and they have sent her straight to hospital with suspected malaria. I cannot believe it! She only has a few mosquito bites- I know she didn’t cover up or use insect repellents, but she took her antimalarial tablets just as I did everyday.”

 

 

♦ Between 1990 – 2009, every year approximately 1,800 British travellers returned home with malaria.

♦ The UK is one of the biggest importers of malaria in Europe.

♦ The most severe form of malaria (plasmodium falciparum) accounted for 79% of cases amongst British travellers in 2009.

♦ Malaria is a preventable infection but can be fatal if left untreated – an average of nine people die each year from malaria in the UK.

♦ Malaria is transmitted by an infected mosquito. It only takes one bite from an infected mosquito to contract malaria.

 

Remember that antimalarial tablets reduce your risk of malaria significantly, but they are not 100% effective.

ABCD of malaria prevention:

Be Aware of the risk

Bite prevention

Compliance with Chemoprophylaxis

Recognising symptoms and prompt Diagnosis

 

Sources:

Students’ Health Service ‘Malaria Advice’ patient information leaflet- available at the practice

https://www.malariahotspots.co.uk/index.html.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tickets… Passport… Sunscreen?!

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The holiday is in sight, the packing almost done. Some sun, sea and sand beckon… but wait a minute, that golden all-over tan…will achieving it be the most dangerous thing you do on holiday?

 Here at Students’ Health Service we have just diagnosed a malignant melanoma (skin cancer in a mole) in a student in his early twenties. It’s unusual, but not that rare. And numbers nationally are increasing, especially in men.

Two new cases of melanoma are diagnosed in the 15-34 year age group every day in the UK, that’s 900 new cases a year. A total of 12 000 in all age groups.

 Women are more at risk than men, and other risk factors include; a relative with a malignant melanoma, fair skin, red/ fair hair and pale eyes, having more than 100 moles on your whole body, severe sunburn in childhood, or an outdoor job.

 The main cause of melanoma is excessive sun exposure, and sunburn, even in theUK, can cause problems if repeated over the years.

 So if you notice a change in a mole such as darkening patches, or irregular edges, or a brand new mole growing, then we would like to see you to check it.

If you also notice bleeding/ crusting or a reddish edge then these need checking if they don’t settle back to completely normal within 2 weeks.

 So back to packing that bag; what can you do to protect yourself from sun damage and skin cancer?

 Simple measures like wearing a hat, and sunglasses with UV protection.

Always using sunscreen of SPF 15 or higher, with UVA protection too.

Keeping in the shade where possible.

Taking care not to burn and to avoid being in the sun between 11am and 3pm, with extra care nearer the equator and at high altitude.

 

These basic steps will significantly reduce your risk, not just of sunburn and melanoma but also of other non melanoma skin cancers too.

 

If you are ever worried about a mole, then please come and see any of the doctors, and you could also checkout www.sunsmart.org.uk

 

Have a great holiday!