Travel Consult

Notes from Travel update by Dr. Peter Hopkins 2023

Basics

  • Where going?

  • Where staying? Accommodation

  • When? Duration

  • Why? Purpose of visit

  • With whom?

History

  • Past medical history of relevance

  • Past vaccinations

  • Past travel

  • Current medications and allergies

  • Regulation 49

  • Print health summary to take

COVID

  • Requirements vary

  • Need AIR proof for some countries

  • May need hard copy

  • Check if travel insurance covers COVID

  • Masks, RAT, hand sanitiser if needed

  • Take antivirals (cost = $1k)

What goes wrong

  • Gastroenteritis

    URTI

  • ACcidents

  • Malaria

  • Hep A

  • Worms

  • Mixture of different conditions

Gastro

  • If you can’t cook it, boil it, peel it then forget it

  • From contaminated water

  • Preference bottled water, check the seal

  • Water filters

  • Decontamination tablets better than nothing

  • Beware of ice which is frozen tap water

  • Fresh salads likely contact with water or soil

  • Reheated meat a risk

  • Managmenet

    • Hydration

    • Avoid alcohol and dairy

    • Phenergen for nausea

    • Loperamide to slow diarrhoea

    • Noroxin or Axithromycin if fevers or passing blood

Hep A

  • Food and water

  • Very common

  • Vaccine close to 100% cover

  • Booster 6 to 12 months later = lifelong

  • Okay if delayed for up to 3 to 4 years

  • Kids under 5 do not become ill with it, but can still bring home and spread easily

  • Can give vaccine from 12 months

Typhoid

  • Relatively uncommon

  • Bacteria

  • Food and water

  • Would recommend if traveling rough, rural, camping

  • Single injection for 3 years, about 70-75% effective

  • 4 capsule over 1 week = 5 years

  • 3 capsules over 1 week = 12 months

  • Cheaper if health fund

Cholera

  • Dukoral covers Cholera and Enterotoxic E. coli

  • 2 doses orally 1 to 4 weekly apart

  • Keep refrigerated

  • No food for 1 hour before taking

  • Lasts 2 years

  • Booster is a single dose

  • Risk is low for traveller’s unless outbreak

  • Cochrane review not supportive

Malaria

  • Mosquito

  • Night time dusk to dawn mosquito

  • IF day trips to jungle then night time in hotel, lower risk

  • 5 types of malaria

  • If the mosquito doesn’t bite you, you can get malaria

  • Many low risk e.g. Bangkok, Bali, Thailand, Nairobi, Harare, Lima, Iguassu falls

  • High risk - Lombok, Chitwan national park, North of Chang Mai

  • Airconditioned accommodation usually protective

  • Mosquito nets, preferably treated with Permethrin

  • Busman repellant 6-8 hours, 80% DEET

Malaria Meds

Chloroquine

  • Cheap

  • Effective against P. Vivaz and ovale

  • Poor against P. Falciparum

  • Maybe use in Central America

  • Nausea

  • Corneal deposits if using > 12 months

Doxy

  • Cheap

  • Most commonly used

  • Good against Falciparum

  • 1 daily

  • 2 days before

  • 4 weeks after

  • Always with food

  • Do not lie down 1 hour post

  • Rarely rash

  • Occasionally vaginal thrush

Mefloquine / Lariam

  • Good for Africa, SA, Asia

  • Expensive

  • 1 weekly

  • 1 week before, and 2 weeks after risk area

  • Nausea, vivid dreams

  • CI if depression

  • Uncommonly causes psychosis, epilepsy

  • Can’t take if diving or flying an airplane

Malarone

  • Effective

  • Gold standard

  • 1 daily with food

  • 1 day before and 1 week after

  • $30-60 for 12 tablets

  • GI symptoms

Symptoms

  • 8 days to occur

  • May take weeks or months

  • Can be fever and diarrhoea only

  • If travel to risk area and fever = malaria until disproven

Meningococcal

  • Bacteria

  • Subsaharan Africa and on Haj to Mecca

  • Single injection = 3 years

  • Doesn't cover all types

Polio

  • Viral

  • Food and water

  • Afghanistan and Pakistan risk area

  • 10-year cover by booster

Rabies

  • Viral

  • Animal bites

  • Dogs, monkeys, bats

  • 3 injections over 1 month

  • $300

  • Even if vaccinated and bitten, needs 2 x injections post

  • If not vaccinated, needs IGG within a week, then 4 x vaccinations of rabies vaccine

  • Bali high risk

Measles

  • Low threshold for giving to most traveler’s

  • MMR free

  • Live vaccine = can’t give with Yellow Fever (needs 1 month)

Yellow Fever

  • Virus

  • Central Africa and South America

  • 1 injection is good for life

  • Some countries won’t allow entry without evidence of vaccination

  • Only in registered practices

  • Not on prescription

  • Need proof with stamped vaccination book

  • Live virus

  • Possible severe reaction 7 to 10 days after

  • Use with care in those over 65 and HIV

Dengue

  • Virus

  • Mosquito

  • In Australia, North of Townsville

  • Can be lethal with further attacks (more than 1)

  • No vaccine here

Zika

  • Virus

  • Mosquito

  • Spread by sex

  • Virus may exist in sperm for 3-6 months

  • Spreads mother to fetus

  • Symptoms mild - rash, fever, joint pain, red eyes for a week

  • Bloods - Zika IgM and IgG

  • Risk areas - South America, Caribean, New Caledonia, PNG, Tonga, SE Asia, India, USA

Japanese Encephalitis

  • Virus

  • Mosquito

  • Hosts pigs, humans, wild birds

  • Japan, Korea, Phillipines, China, Malaysia, Singapore

  • Vaccinate if > 1 month if staying in rice paddy areas or piggeries

  • 33 cases in Australia

  • Jespect - 2 vaccines 1 month apart $360 for over 18 years

  • Imojec 1 vaccine $250 for over 1 year old

Hep B

  • Virus

  • Sex or blood contact

  • 3 vaccinates over 6 months or accelerated at 0, 1, and 4 weeks with booster

  • Memory cells matter, antibodies don’t

Altitude Sickness

  • >2400m

  • SOB, headache, nausea, LOC

  • Acetazolamine (Diamox) acidifes blood to speed up acclimatisation

  • 250mg 1/2 BD started 24 hours before exposure

Influenza

  • Crucial for cruises due to risk of epidemic

Tetanus

  • Bacterial in soil

  • Booster 10 years

Diptheria

  • Bacteria

  • Cough

  • Booster 10 years

  • Endemic Eastern Europe and Russia

Pertussis

  • Recommended pregnant women and contact with newborns

  • Some cases locally

HIV

  • Sex

  • Virus

  • Safe sex

  • No vaccines

Medical kit

  • Panadol

  • Phenergan for nausea + motion sickness, 10mg tablets

  • Loperamide for diarrhoea

  • Azithromycin for severe diarrhoea, 1g stat

  • Cephalexin (Skin chest, urine)

  • 2 sterile needles and syringes if developing countries

  • Betadine

  • Bandaids

  • Sunscreen

  • Insect repellant

    • Bushman

    • 6 to 8 hours

    • Cream not spray

    • Plain, not with sunscreen

    • Sparingly on clothes

    • Destroys plastic

    • Not for infants

Example - Consult 1

28yo, Bali 2 weeks for honeymoon, in a resort

  • Hepatitis A

  • Typhoid - if good accommodation risk is low

  • Boostrix - if due

  • Flu

  • MMr - if under 60 + no 2 doses

  • Rabies - Monkeys/dogs in Bali, cost/benefit

    • No IgG, if bitten needs to go to Singapore or Darwin

    • Travel Insurance

  • No Malaria in Bali but some in Lombok

  • Traveller’s diarrhoea

    • Beware salad, cold meat, water, ice, cold seafood

  • Accidents

  • Travel Insurance

  • Dengue fever - insect repellant

  • Sunscreen

  • Animal bites - see a doctor or head home

Example - Consult 2

35yo x 2, kids x 5yo + 6yo, 3 weeks Nepal, 1-week mountain trek Katmandu, 2 day trip Chitwan National Park

  • Hep A

  • Typhoid

  • Boosrix if due

  • Flu

  • Malaria in Chitwan

    • Doxy for parents

    • Malarone Jr for children

    • Insect protection

  • Travelers diarrhoea

  • Mountain sickness

  • Insurance

Example - Consult 3

35yo, 6 months in Uganda for aid work, living in villages

  • Hep A

  • Typhoid

  • Yellow fever

  • MMR

  • Influenza

  • Boostrix +/- Polio depending if Polio still in Africa

  • ? rabies

  • ? dukoral

  • Insect protection

  • Mosquito nets with Permethrin

  • Antimalarials

    • Doxy +/- Chlorquine or Larium

  • Diarrhoea

  • Insurance

  • Bare feet and still water re: worms, schistosomiasis

Example - Consult 4

24yo, Thailand, Bangkok, Vietnam, ho chi mink, Phuket, 3 star hotels, 4 weeks trip

  • Hep A

  • Typhoid

  • MMR

  • Flu

  • ? rabies

  • ? Japanese encephalitis, probably not long enough

  • Insect repellant

  • Malaria - probably not unless

    • ? 3-day elephant ride out of Chang Mai

    • ? Hill tribes in Vietnam eg Sapa or Mekong Delta

  • Dengue risk

Example - Consult 5

41yo, Peru, Inca trail, asthmatic

  • Hep A

  • Typhoid

  • ? Yellow fever depending if going Amazon

  • High attitude = no mosquito

    • Can write a waiver letter

  • Traveller’s diarrhoea

  • Antimalarials if Amzon

  • Diamox for altitude sickness

  • Asthma doesn’t increase risk

Example - Consult 6

50yo, South Africa, Victoria Falls, Zambia or Zimbabwe hotel 2 nights, Kruger National Park

  • Victoria Falls safe for Yellow Fever

  • Low-risk Malaria in Kruger but can take

  • Doxy, Mefloquine

Websites

References: