Key points:
- Take a good history:
> Information about the traveller
- Age
- Medical history
- Medications
- Allergies
- Vaccination history
- Previous travel
> Information about the itinerary and activities
- Reason for travel
- Style of travel
- Duration of stay
- Exact destinations
- Season/s
- Accommodation
- Exposures
- Specific activities
- Budget
- Potential issues for pre-travel consultation:
- Aircraft travel issues (e.g. reduce oxygen pressure, humidity)
- lack of fitness to travel
- DVT risks
- Motion sickness
- Jetlag
- Altitiude illness
- Heat/cold/sun exposure
- Water safety/accidents/injuries
- Animals bites
- Insect bites
- Carrying medicines
- Accessing medical care
- Drugs and alcohol
Communicable risks - no vaccines
- Traveller's diarrhoea from causes other than enterotoxigenic E.Coli
- Dengue fever
- HIV infection
- Amoebiasis
- Giardiasis
- Helminthic infestations
- Sexually transmitted infections
Communicable risks - vaccine preventable
- Traveller's diarrhoea due to enterotoxigenic E. Coli
- Hepatitis A and B
- Typhoid
- Yellow fever
- Cholera
- Diptheria/tetanus/pertussis
- Measles/mumps/rubells
Altitude sickness can occur at any altitude above 2100 metres and sometimes less, depending on the rate of ascent and individual susceptibility. Acetazolamide 125mg twice per day for 5 days starting just before flying would be appropriate. Acetazolamide is contraindicated in people with severe sulphur sensitivity, but can be tested in those with a vague history of possible sulphonamide allergy in childhood. Common adverse effects of acetazolamide include premolar tingling, flushing and frequent urination
3 Rs provide a systematic approach to the consideration of the travel vaccination and help guide the priorities.
Fitness to fly refers to whether a person is physically and mentally fit enough to undergo a trip in a pressurised jet aircraft, and usually relates to the problem of sitting confined in a depressurised and lower oxygen environment for several hours.
Malaria is an infection caused by the protozoa plasmodium, transmitted by the bite of female Anopheles mosquitoes. Foremost in prevention is avoiding exposure to theses mosquitoes. Strategies include:
- minimising exposing to the mosquito between dusk and dawn. Anopheles mosquito is a night feeder
- wearing protective clothing including long sleeves and trousers, ideally pretreated with permethrin 9 ac common insecticide)
- wearing light coloured clothing - this is associated with reduced risk of mosquito bite
- use of 20% or greater concentration DEET insect repellents on exposed skin
- sleeping in screened or air-conditioned rooms under mosquito nets
- using 'knockdown sprays' (sprays which create a specific rough surface) on the internal walls of accommodation.
The decision on whether to prescribe chemoprohphylaxis is made after detailed discussion of the risks and benefits, and the realistic risk of developing malaria.
"VFR"stands for visiting friends and relatives, it describes citizens and permanent residents who were born overseas (and their children) who live in Australia and are travelling to their country of origin for any purpose.
Pregnancy and travelling:
- requires planning
- best time is second trimester
- history of pregnancy complications such as pre-eclampsia, diabetes and miscarriage should be a contraindication to travelling.
- need a letter from obstetrician to outline the progress of pregnancy and other requirement.
Malaria in pregnancy tends to be more frequent and severe, and the risk of complications such maternal death, abortion and stillbirth are significant.
Oral cholear vaccine reduces the risk of traveller's diarrhoea, as it has also some activity against the toxin which is implicated in traveller's diarrhoea but will not prevent traveller's''s diarrheoa or replace the need for self treatment.
Malarial protection in children
- advice the same as adults
- medications essentially the same (please click here to view the list and dose of the mediations)
Bacteria are condsidered the predominant cause ( 80-90% overall), with enterotoxigenic E.coli being the most common, followed by campylobacter jejune, shigella, salmonella and other strains of E.coli. Viral causes are thought to account for 5-10 % of cases, including norovirus and rotaviurs. Protozoal causes, such those of the guard genus, are slower to present, but may cause about 10 % of disease in long term travellers.
The adage, ' cook it, peel it, or forget it' is good for travellers to remember but the evidence suggests most people will faiths within 48 hours.
Oral cholera vaccine (Dukoral) which includes recombinant cholera B toxin subunit provides some cross protection against enterotoxigenic E. Coli. Two doses of the vaccine provide protection against enterotoxigenic E. Coli at 60-80% and the protective effect lasts for about 3 months. Overall, the risk reduction against traveller's diarrhoea is about 20%.
Traveller's medical kit for traveller's diarrhoea:
- anti nausea medication
- loperimide (except in bloody diarrhoea)
- azithromycin
- oral rehydration sachet
- Tinidazole may be useful for longer travel where giardia becomes more likely
There are two golden rules in the management of a febrile returned traveller:
- an unwell febrile returned traveller needs hospital admission under an infectious diseases unit
- always consider malaria as a differential diagnosis in a febrile returned traveller where any possibility of malaria exists
Dengue fever aka "breakbone fever"
- biphasic (saddleback) fever pattern may or may not be found d
- rash is often, but not always present. Rash often becomes confluent, sparing normal islands of normal skin, and blanches under pressure. On resolution, the skin may desquamate.
- There is often some elevation of liver transaminases and mild hyponatraemia in the acute phase of the illness.
- often associated with leucopenia, thrombocytopaenia and low platelet counts.
