TRAVEL MEDICINE

Medical insurance Don’t travel without adequate insurance Don’t travel without adequate insurance Make sure it covers repatriation Make sure it covers repatriation In Europe have E 111 as well In Europe have E 111 as well In 2 nd /3 rd world countries have IV kit In 2 nd /3 rd world countries have IV kit Take your own medicines Take your own medicines

Death’s abroad 69% CVSMI etc 69% CVSMI etc 21%Accidents 21%Accidents 4%Infectious diseases 4%Infectious diseases

Behaviour Drink more Drink more Take more risks Take more risks Unfamiliar surroundings Unfamiliar surroundings Less supervision of children Less supervision of children

Immunisation Risks balanced against incidence of disease Risks balanced against incidence of disease Risk of japanese encephalitis 1 in 1x10 6 th Risk of japanese encephalitis 1 in 1x10 6 th Risk of anaphylaxis due to vaccine 1 in 40,000 Risk of anaphylaxis due to vaccine 1 in 40,000 Risk of vaccine greater than risk of disease Risk of vaccine greater than risk of disease

Immunisation Arrange immunisation 8 weeks before travel Arrange immunisation 8 weeks before travel Up to date advice available from special web site Up to date advice available from special web site

Advice Drink bottled water Drink bottled water Avoid ice in drinks Avoid ice in drinks Peel or wash fruit and veg Peel or wash fruit and veg Clean teeth with bottled water Clean teeth with bottled water Be careful where you eat Be careful where you eat Avoid ice cream Avoid ice cream

Sun Cover up with tightly woven cotton clothes Cover up with tightly woven cotton clothes Wear hat with large brim Wear hat with large brim Sit in shade Sit in shade Stay out of sun either side of noon Stay out of sun either side of noon Use high spf and uva protection creams Use high spf and uva protection creams Apply thickly before going out Apply thickly before going out Reapply after swimming Reapply after swimming

Dehydration Drink fluids ++++ Drink fluids ++++ Carry water round Carry water round Add salt to food Add salt to food

Malaria 3,500 new cases per year 3,500 new cases per year 10 deaths 10 deaths

Malaria 50% cases in visiting friends and relatives 50% cases in visiting friends and relatives 19% visitors to UK 19% visitors to UK 16% tourists 16% tourists 11% immigrants 11% immigrants 5% expats 5% expats

Diagnosis Must think of it Must think of it Has the pt malaria Has the pt malaria Falciparum or one of the others Falciparum or one of the others From a chloroquine resistant area From a chloroquine resistant area Mild Moderate or severe Mild Moderate or severe

History Travel upto a year Travel upto a year Fever with rigors Fever with rigors Flu like illness Flu like illness Jaundice Jaundice Diarrhoea Diarrhoea

Malaria Signs Signs Fever Fever Splenomegally Splenomegally Investigations Investigations Blood films Blood films 95% thrombocytopaenia 95% thrombocytopaenia +_ anaemia +_ anaemia Wbc normal Wbc normal

Prevention Bprevent Bites Bprevent Bites CCompliance with medication CCompliance with medication AAwareness of risk AAwareness of risk DDiagnose early DDiagnose early

Risk Place Place Activity Activity Travel Travel Length of stay Length of stay Effectiveness of prophylaxis Effectiveness of prophylaxis

Countries Africa=Falciparum West Africa v high risk of catching low drug resistance = few deaths East Africa lower risk of catching high drug resistance = large no of deaths India Pakistan Thailand = Vivax

Prevention Mosquito nets Mosquito nets repair holes repair holes Tuck into mattress Tuck into mattress Impregnated with pyrethroid Impregnated with pyrethroid

Prevention Clothing after dark Clothing after dark Long trousers Long trousers Long sleeved shirts/blouses Long sleeved shirts/blouses Tuck trousers into socks Tuck trousers into socks

Prevention Use appropriate insect repellent Use appropriate insect repellent Close windows if lights on after dusk Close windows if lights on after dusk Use knock down spray or coils Use knock down spray or coils

Prevention Chemoprophylaxsis Chemoprophylaxsis Use most effective for country Use most effective for country Start 1 week before travelling Start 1 week before travelling Continue for 4 weeks after return Continue for 4 weeks after return Away from medical help carry quinine Away from medical help carry quinine

Resistance East Africa East Africa Mefloquine90% protection Mefloquine90% protection Proguanil/chloroquine70% protective Proguanil/chloroquine70% protective

ME vs PC Similar nos serious advers effects Similar nos serious advers effects Similar nos discontinue Similar nos discontinue ME better compliance ME better compliance ME 3x no of neuropsychiatric effects ME 3x no of neuropsychiatric effects Doxycycline main adverse effect photosensitisation Doxycycline main adverse effect photosensitisation Malarone licensed for 28 days only Malarone licensed for 28 days only

Remember Risk proportional to length of stay Risk proportional to length of stay The longer the stay the greater the need to take prophlaxsis The longer the stay the greater the need to take prophlaxsis Adverse effects occur early on Adverse effects occur early on

Travellers diarrhoea Tunisia70% Tunisia70% Kenya50% Kenya50% Egypt50% Egypt50% Spain 7% Spain 7%

Infectious agents Rota virus Rota virus E coli E coli Campylobacter Campylobacter Salmonella shigella chloera Salmonella shigella chloera Giardia lamblia Giardia lamblia Cryptosporidium Cryptosporidium 50% no cause found 50% no cause found

Avoidance Wash fruit and veg Wash fruit and veg Drink bottled water Drink bottled water No ice cubes in drinks No ice cubes in drinks Clean teeth with bottled water Clean teeth with bottled water No ice cream No ice cream Be wary of where you eat Be wary of where you eat Hand washing Hand washing

Treatment Fluids only Fluids only Rehydration salts Rehydration salts Antibiotics rarely neededciprofloxacin Antibiotics rarely neededciprofloxacin

Persisting diarrhoea Stool culture Stool culture Giardia Giardia Metronidazole Metronidazole tinidazole tinidazole

Imported infectious diseases Malaria2000 Malaria2000 Hep A1000 Hep A1000 Typhoid200 Typhoid200 Chloeraa few Chloeraa few

Imported fever - causes Malaria42% Malaria42% Non- specific viral25% Non- specific viral25% Viral dengue6% Viral dengue6% Viral Hep A3% Viral Hep A3%

Investigation of fever Thick and thin blood films Thick and thin blood films FBClow platelets – malaria dengue FBClow platelets – malaria dengue Dipstick urine Dipstick urine Blood cultures – typhoid Blood cultures – typhoid CXR CXR Serology – toxoplasma hep A Serology – toxoplasma hep A