TRAVEL HEALTH

MOTION SICKNESS

Definition

  • Motion sickness is a condition that occurs when the vestibular system sends conflicting messages to the brain from the senses, specifically the eyes and the vestibular system.

Causes

  • The vestibular system is responsible for providing the brain with a sense of balance and motion.

  • Travel-associated motion sickness occurs during travel, but motion sickness can occur without travel as well.

At-Risk Groups

  • More prevalent in:

    • Women

    • People affected by migraines

    • Children aged 3-12 years old

Symptoms

  • Symptoms begin with:

    • Nausea

    • Discomfort in the upper abdomen

    • General feeling of being unwell

  • More severe indicators include:

    • Pale skin

    • Cold sweat

    • Dizziness

    • Fainting

    • Increased salivation

    • Vomiting

  • Additional symptoms can be:

    • Rapid, shallow breathing

    • Headache

    • Drowsiness

    • Extreme tiredness

  • Referral indication: If symptoms persist after travel has ceased, consider labyrinthitis.

Treatment

  1. Medication

  2. Complementary therapies

  3. Self-care techniques

  • It is recommended to take medication before the journey begins to help prevent the onset of symptoms since motion sickness delays digestion.

Medication
Hyoscine

  • Mode of action: Blocks some nerve signals sent from the vestibular system, responsible for nausea and vomiting.

  • **Dosage: **

    • Hyoscine tablets: 1 tablet taken 20 minutes before the journey, may repeat every 6 hours if necessary.

    • Hyoscine patches: 1 patch every 3 days.

  • Common side effects:

    • Drowsiness

    • Blurred vision

    • Dry mouth

    • Constipation

  • Rare side effects:

    • Nausea, vomiting, mental confusion.

  • Cautions: Use with caution in children, elderly, those with epilepsy, kidney or liver issues, heart problems, and GORD.

Antihistamines

  • Function: Control nausea and vomiting associated with motion sickness.

  • Side effects: Drowsiness, headaches, pins & needles, dry mouth, blurred vision.

  • Dosage for specific drugs:

    • Promethazine (Phenergen®): 25mg (adults & children above 10); 5 mg (2-5 years) or 10 mg (5-10 years) once daily at night.

    • Cyclizine (Valoid®): 50mg (adults); 25mg (children) up to three times a day.

    • Cinnarizine (Stugeron®15): 2 x 15mg followed by 1 x 15mg (adults) or 1 x 15mg followed by half a tablet for children, taken 2 hours before the journey and then every 8 hours thereafter.

Complementary Therapies

  • Ginger: May prevent nausea and vomiting; available in supplements, biscuits, or tea from reputable sources.

    • Side effects: Diarrhea, heartburn.

  • Acupressure bands: Apply pressure to a point on the inside of the wrist between the two tendons running down the inner arm.

Self-Care Techniques
Do Recommendations:

  • Reduce motion when possible.

  • Focus on a fixed point straight ahead.

  • Breathe fresh air if possible.

  • Distract children by talking, listening to music, or singing.

  • Break up long journeys to allow for fresh air, hydration, or physical activity.

Do Not Recommendations:

  • Read, watch films, or use electronic devices while in motion.

  • Look at moving objects such as passing cars or rolling waves.

  • Consume heavy meals, spicy foods, or alcohol shortly before or during travel.

  • Close your eyes; rather, breathe slowly while focusing on your breathing.

  • Go on fairground rides if they induce unease.

DEEP VEIN THROMBOSIS (DVT)

Definition

  • DVT is the formation of a thrombus (blood clot) in a deep vein, primarily in the legs, which may partially or completely obstruct blood flow.

Causes

  • Travel-related cause: Prolonged inactivity during long journeys leads to blood collecting in the lower body, resulting in slow blood flow, which increases the likelihood of clot formation.

  • Risk factors include:

    • Personal or family history of DVT or pulmonary embolism

    • Certain medical conditions

    • Inactivity

    • Being overweight or obese

    • Oestrogen therapy (oral contraceptives or HRT)

    • Pregnancy

    • Inherited blood clotting disorders

    • Increasing age

    • Dehydration

    • Smoking

    • Varicose veins

Symptoms

  • Typical symptoms include:

    • Pain, swelling, and tenderness in the affected area.

    • Heavy aching in the region where the clot is located.

    • Warm skin in the area of the clot.

    • Redness of the skin.

  • Main complication: Pulmonary embolism can occur when a piece of the blood clot dislodges and blocks a vessel in the lungs, leading to:

    • Breathing difficulties

    • Chest pain

    • Collapsed lung

    • Heart failure.

Treatment
Anticoagulation

Parenteral:

  • Types include:

    • Heparin, dalteparin, enoxaparin, tinzaparin, fondaparinux.

    • Dosage: Dependent on patient weight.

    • Side effects: Skin rash, allergic reactions, bleeding, weakening of bones.

Oral:

  • Types include:

    • Warfarin; direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, rivaroxaban.

    • Administered after initial heparin treatment.

    • Regular blood tests required for determining warfarin dosage, while DOACs do not require routine monitoring.

Prevention
Do Recommendations:

  • Maintain a healthy weight.

  • Stay active by taking regular walks.

  • Drink plenty of fluids to avoid dehydration.

  • Wear loose, comfortable clothing.

  • Use graduated compression hosiery.

  • Perform simple leg exercises during long periods of sitting.

Do Not Recommendations:

  • Remain seated for extended periods; get up and move around every hour or so.

  • Cross your legs while sitting.

  • Use sleeping pills.

  • Consume excessive alcohol.

  • Smoke.

Graduated Compression Hosiery

  • Helps in preventing travel-related DVT in moderate to high-risk individuals.

  • Prevents calf pain and swelling, lowers the risk of ulcers post-DVT, and prevents post-thrombotic syndrome by applying pressure and preventing blood pooling in the calf.

Raising the Legs

  • Elevating legs relieves vein pressure and stops blood and fluid pooling in the calf, requiring the legs to be elevated above hip level to facilitate better blood return flow.

JET LAG

Definition

  • Jet lag refers to a feeling of tiredness and confusion following a long-haul flight, primarily caused by disruption of the circadian rhythm after crossing multiple time zones.

Causes

  • Disruption of circadian rhythm due to crossing several different time zones.

  • Decreased O2 levels due to lower air pressure in aircraft.

  • Symptoms are more pronounced when traveling east.

  • Additional contributing factors include:

    • Dehydration

    • Lack of sleep

    • Consumption of alcohol

    • Stress

    • Age over 60 years.

Severity

  • Severity correlates with:

    • Distance traveled

    • Number of time zones crossed

Symptoms

  • May include:

    • Sleep disturbances

    • Gastrointestinal issues: indigestion, constipation, diarrhea, nausea, loss of appetite

    • Cognitive issues: difficulty concentrating, disorientation

    • Mood disturbances: anxiety, irritability

    • Physical fatigue or lethargy.

Drug Treatment

  • Melatonin:

    • A hormone that signals to the body when to sleep, secreted in darkness. Its effectiveness for jet lag is not confirmed by NHS studies.

  • Sleeping tablets:

    • Recommended for short-term use only, not during flights, with concerns regarding addiction and side effects.

Non-Drug Advice
Before Travel:

  • Adjust sleep routine; ensure good rest; stay calm and relaxed; check in online.

During Flight:

  • Stay hydrated; limit caffeine; keep active; adjust watch to the new time zone; consume light meals; avoid alcohol.

Upon Arrival:

  • Try to avoid napping; sleep only if it's nighttime; establish a new routine; spend time outdoors to reset the body clock.

TRAVELLER'S DIARRHOEA

Definition

  • Defined as three or more loose stools within a 24-hour period along with at least one symptom of:

    • Nausea

    • Vomiting

    • Fever

    • Abdominal cramps

    • Faecal urgency

    • Presence of blood or mucus in stool.

  • Affects 20-60% of travelers worldwide.

Causes

  • Enteropathogens, including bacteria, viruses, and parasites, primarily contracted through contaminated food and water.

  • Most cases are self-limiting, resolving in 3-5 days.

Treatment
Primary Treatment: Rehydration

  • Drink plenty of fluids, utilize oral rehydration solutions to prevent dehydration, replenishing water, salts, glucose, and minerals.

  • Dosage:

    • Adults: 1-2 sachets after each loose stool.

    • Children (> 2 years): 1 sachet per loose stool.

    • Babies: 1-1.5 times normal fluid intake in 24 hours.

Secondary Treatment: Medicines

  • Loperamide:

    • An antimotility agent to slow down peristalsis for improved reabsorption of water and electrolytes from gut contents, resulting in firmer stools.

    • Dosage: 4mg initially, followed by 2mg after each loose stool for up to five days, maximum 16mg daily.

  • Analgesics: for fever and discomfort.

  • Antibiotics: for bacterial causes (e.g., ciprofloxacin, metronidazole).

  • Referral: If symptoms are severe, include blood in stool, fever with chills, marked abdominal pain, or symptoms lasting longer than 7 days.

Prevention
Hygiene Measures:

  • Wash hands thoroughly after using the bathroom and before eating/preparing food.

  • Carry sanitizing gel or wipes; disinfect toilets regularly.

  • Avoid sharing personal items like towels and utensils and use clean dishes and utensils.

Food & Drink Advice:

  • Exercise caution with food hygiene when using street vendors; avoid unpasteurized dairy products.

  • Only consume freshly prepared, well-cooked meat, and avoid leftovers or food that has been exposed to air.

  • Peel and consume fruits immediately before eating; choose safe drinks like sealed bottled water, bottled fizzy drinks, hot tea/coffee, freshly boiled milk, and avoid ice made from local water.

Water Purification:

  • Drink only purified water, applicable to making ice or brushing teeth.

    1. Boiling: Kills bacteria and viruses instantly.

    2. Chemical purification: Works with chlorine compounds, effectiveness varies.

    3. Filtration: Removing particulate matter, but should supplement other methods; no system is entirely effective against all contaminants.

SUN PROTECTION

Sunburn
Definition

  • Sunburn is damage to the skin resulting from overexposure to ultraviolet (UV) light.

Symptoms

  • Primary Symptoms:

    • Red, sore skin (erythema)

    • Warm to touch

    • Tenderness

    • Skin may flake or peel

  • Severe Symptoms:

    • Blisters

    • Swelling

    • Chills

    • Fever

    • Malaise

  • Heat Exhaustion Symptoms:

    • Dizziness

    • Headaches

    • Nausea.

Types of UV Rays

  • UVA: Responsible for skin tanning and ageing.

  • UVB: Absorbed by the epidermis and responsible for sunburn.

  • UVC: Filtered out by the ozone layer.

  • Other sources of UV light include tanning beds and phototherapy lamps.

  • Long-term Effects of UV Overexposure:

    • Premature skin ageing

    • Solar keratoses

    • Increased infection risks

    • Photokeratitis

    • Skin cancer.

At-Risk Groups

  • Individuals with:

    • Fair skin that burns easily

    • A history of multiple sunburns in childhood

    • Personal/family history of skin cancer

    • Moles or existing skin lesions

    • Immunosuppressive conditions.

Prevention Strategies

  • Best practice: Avoid strong sunlight, especially around water, snow, and sand.

  • Sunscreens:

    • Physical: Deflect or block UVA and UVB, may leave a white residue.

    • Chemical: Absorb UVA and UVB.

  • Sunscreen Star Ratings:

    • Up to 5 stars on UK sunscreens indicating the level of UVA protection, with higher ratings indicating better protection.

  • SPF (Sun Protection Factor):

    • Measure of UVB protection,

    • Scale from 2 to 50+, higher means more protection.

  • Application Recommendations:

    • Generously apply and reapply regularly, especially after sweating or swimming.

    • Use on high-risk areas (nose, ears, lips).

Self-Care for Sunburn
Do Recommendations:

  • Move out of the sun immediately.

  • Cool skin with a cool shower, bath, or damp towel.

  • Drink plenty of water to prevent dehydration.

  • Use aftersun products to soothe skin.

Do Not Recommendations:

  • Use petroleum jelly on burned skin.

  • Apply ice directly to burns.

  • Scratch or pick at peeling skin.

  • Wear tight clothing on burned skin.

  • Ignore severe blistering or swelling; seek medical assistance as required.

SKIN CANCER

Definition

  • Skin cancer is a serious condition arising from damage due to UV rays.

Risk Factors

  • Increased risk if:

    • Skin burns easily

    • History of sunburns as a child

    • Family history of skin cancer

    • Presence of abnormal moles or lesions

    • Immunosuppressive conditions.

Prevention Strategies

  • Avoid overexposure to the sun, protect skin through clothing and sunscreen, and regular checks for abnormalities in the skin.

    • Referral to dermatologist for concerning skin changes:

    • Small lumps:

      • Waxing, smooth, or bleeding tendencies.

    • Red flat spots:

      • Scaly and crusty.

    • Painless growing lumps:

      • Slow in growth.

    • Changes in moles:

      • Irregular in shape or color; over 7mm in diameter, inflamed, or itchy.

PRICKLY HEAT

Definition

  • Prickly heat, known as miliaria rubra, is a rash of small raised spots causing mild swelling, itching, and a stinging sensation.

Risk Factors

  • More likely to affect:

    • Overweight/obese individuals

    • Babies and children

    • Hot climate exposures

    • Situations involving immobility and excessive clothing.

Causes

  • Results from excessive sweating:

    • Dead skin cells and bacteria block sweat glands.

    • Trapped sweat creates pockets under the skin, leading to stinging sensations.

Treatment

  • Prevent with cooling measures:

    • Avoid excessive heat, wear loose cotton clothing, and keep skin cool.

    • Antihistamine or hydrocortisone cream can relieve symptoms.

INSECT BITES & STINGS

Types

  • Various bites: ant bites, bed bug bites, bee stings, chigger bites, flea bites, mosquito bites, spider bites, and tick bites.

Symptoms

  • General symptoms include:

    • Redness, swelling, and itchiness.

    • Infected bites can produce blisters, pus, tenderness, and flu-like symptoms.

    • Severe reactions can lead to anaphylaxis, characterized by:

    • Wheezing, difficulty breathing, and gastrointestinal upset.

Complications

  • Can lead to:

    1. Infections requiring antibiotics (impetigo, cellulitis, etc.).

    2. Lyme disease with severe complications (meningitis, encephalitis).

    3. West Nile virus and malaria.

Treatment

  • Basic care: wash the area, apply cold compress, avoid scratching.

    • Painkillers and topical anesthetics may help.

    • Severe cases might require antibiotics or steroids.

Anaphylaxis

  • Recognized as a medical emergency requiring immediate care, including:

    • Calling for an ambulance, administering adrenaline, hospital treatments, fluid drips, and resuscitation efforts.

Prevention Strategies

  • Wear light-colored clothing, utilize insect repellent, cover exposed areas, and avoid strong perfumes.

  • Camp away from water sources, secure food, and close windows/doors appropriately.

Insect Repellents

  • Effective in preventing bites but not killing insects. Ensuring formulations contain DEET or other protective agents is key. Application should cover all exposed skin and be reapplied regularly, especially after swimming or sweating.

MALARIA

Definition

  • Malaria is a febrile illness resulting from the infection of red blood cells by the parasite Plasmodium, transmitted through the bite of infected female Anopheles mosquitoes. The five species include:

    1. Plasmodium falciparum

    2. Plasmodium vivax

    3. Plasmodium ovale

    4. Plasmodium malariae

    5. Plasmodium knowlesi

Cycle of Infection

  • Cycle starts when a mosquito bites an infected person, transferring sporozoites that travel to the liver, reproduce, and reinvade red blood cells, where they multiply until the cells burst.

Symptoms

  • Symptoms generally emerge 10-15 days after a mosquito bite:

    • Fever, chills, malaise, myalgia, headaches, vomiting, and gastrointestinal changes. Severe cases can present with seizures, renal impairment, and possibly lead to cerebral malaria.

Risk Factors

  1. Environmental variables: temperature, altitude, and seasonality.

  2. Rural vs. urban settings.

  3. Type of accommodations and activities.

  4. Duration of stay.

Prevention - ABCD Strategy

  1. Awareness: Assess risk based on travel destination and seek health advice.

  2. Bite Prevention: Wear protective clothing, use insect repellent, and sleep under properly treated nets.

  3. Chemoprophylaxis: Employ medications to reduce malaria risk by up to 90% as a supplemental measure.

  4. Diagnosis: Seek medical care for any febrile or flu-like symptoms post exposure.

Chemoprophylaxis Doses

  • Recommended regimens include:

    • Atovaquone and Proguanil (Malarone®): 1 adult tablet daily; paediatric doses are weight-based.

    • Chloroquine: Once weekly; dosing adjusted for children based on weight.

    • Mefloquine: Weekly dosing adapted for specific weight categories.

    • Doxycycline: Daily dosing as prescribed.

Treatment

  • Anti-malarial medications are used for treatment depending on:

    • Type of malaria

    • Severity of symptoms

    • Previous use of prophylactics

    • Unique cases for pregnant individuals

  • Emergency treatment may be necessary if no access to comprehensive medical care is available.

TRAVEL VACCINATIONS

Considerations for Travelers

  • Important factors include:

    • Destination(s)

    • Travel dates

    • Duration of stay

    • Age and health status

    • Activities planned (aid work, medical settings, or animal contact).

Common Vaccinations (NHS)

  • Necessary vaccinations may include:

    • Combined diphtheria, polio, and tetanus booster.

    • Typhoid and hepatitis A (combined options also available).

    • Cholera.

Private Vaccinations

  • Possible additional vaccines include:

    • Hepatitis B (individual).

    • Japanese encephalitis and tick-borne encephalitis.

    • Meningococcal meningitis and rabies.

    • Tuberculosis (TB) and yellow fever.

Booking Vaccinations

  • Vaccinations should be scheduled well in advance of travel along with obtaining an International Certificate of Vaccination, which can be acquired through GPs or travel clinics.

Additional Advice

  • Assess guidelines for those with special conditions (e.g., pregnancy, HIV, chemotherapy).

GENERAL MEDICINES & KITS

First Aid Items

  • Essential items for first aid kits include:

    • Adhesive tape

    • Antiseptic wound cleanser

    • Bandages and scissors

    • Insect repellents and treatment for bites

    • Antihistamines, oral rehydration sachets, analgesics, and thermometers.

Additional Items

  • Regular medications and specific needs like anti-diarrhoeal medicines, anti-malarials, mosquito nets, and water purification tablets should be included alongside dental and personal hygiene items.

ROLE OF THE PHARMACIST

  • Tasks include:

    • Promote effective health measures for travelers.

    • Discuss issues in travel medicine and provide drug-related advice.

    • Administer vaccines and manage travel-related medications under Patient Group Directions (PGD).

    • Guide patients to other useful information sources.

REFERENCES

  • Various resources such as the government travel advice website, the HPA web, and NHS conditions for health travel guidance are noted for additional support.