Understanding

Travel & Holiday Health

Dr Gil Lea & Bernadette Carroll

IMPORTANT NOTICE

This information is intended not as a substitute for personal medical advice but as a supplement to that advice for the patient who wishes to understand more about his or her condition.

Before taking any form of treatment YOU SHOULD ALWAYS CONSULT YOUR MEDICAL PRACTITIONER.

In particular (without limit) you should note that advances in medical science occur rapidly and some of the information about drugs and treatment may very soon be out of date.

About the Authors

Dr Gil Lea

Has been instrumental in setting up the National Travel Health Network and Centre to advise medical professionals. She is co-editor of Health Information for Overseas Travel, the standard handbook for GP’s and practice nurses. She has 20 years experience of advising travellers and runs the Trailfinders’ Travel Clinic in London.

Bernadette Carroll

Is a research nurse at the Hospital for Tropical Diseases, London, where she has been involved in developing a course in travel medicine, research and teaching. She has many years of practical experience of travel health issues that arise in a major travel clinic.

Introduction

Over 70 million holiday and business trips are taken abroad each year by people from the UK, and it’s inevitable that some travellers will become ill or have accidents while they’re away. Some of these people will need immediate medical attention, while others can wait until they get home before seeing a doctor. A few will feel well when they first get home, and start to feel ill only some time later.

Most of the illness and accidents that affect travellers are preventable, at least to some extent. The aim of this book is to explain the potential hazards and offer you some practical advice on how you can keep these risks to a minimum. Some advance planning and commonsense precautions while you’re away can make all the difference between a successful holiday or business trip and a medical nightmare.

Planning ahead

Choosing the right holiday

For anyone planning a package holiday, the range of options on offer is almost mind-boggling. It’s as easy to get to distant tropical destinations as it is to the Mediterranean and, although some brochures supply information about possible health hazards, others still provide virtually none. The organisers of activity or adventure holidays usually give some guidance as to the level of physical fitness required, but, even if you’re considering a relaxing beach holiday or a sight-seeing tour, it’s worth giving some thought to the possible stresses involved.

Some of them aren’t obvious until you think about them. For example, if you’re flying directly into airports at high altitude – such as those in the Andes in Peru, Ecuador or Bolivia – you need to check that the itinerary allows you time to acclimatise to high altitude before much physical activity or further ascent is necessary.

Even without altitude problems, very busy itineraries may result in the holiday being far from restful, particularly for elderly or less fit people. Sometimes travel companies are tempted to cram too much into a relatively short time to attract clients who want to see the maximum in a limited holiday period. Once committed to the itinerary, travellers who find it too arduous may be unable to make last-minute alterations.

If you’re pregnant or travelling with young children, you need to think extra carefully about any possible health risks, especially malaria. The disease is more dangerous in pregnancy and high-risk malarial areas are unsuitable destinations during pregnancy.

Some anti-malaria tablets and immunisations against other diseases may not be suitable so make proper enquiries before you book. It’s a good idea to check with your GP if you’re in any doubt whether the holiday may complicate any existing health problems, and you could also take the opportunity to top up your supplies of any medication you need to take regularly.

Tropical climates are a major attraction when it comes to beach holidays, but bear in mind that high humidity may be uncomfortable, even when you’re planning to be thoroughly lazy. It’s worth checking out the likely hours of sunshine and humidity as well as the temperature and rainfall before finally settling on your destination. It is also worth checking on the National Travel Health Network and Centre (Nathnac) website – www.nathnac.org/ds/map_world.aspx – for any major disease outbreaks. In these days of increased security warnings against terrorism, it is sensible to check the advice on political stability and safety given by the Foreign and Commonwealth Office (see ‘Useful information’). Even for the many destinations where there are no travel restrictions, it is sensible to be aware of any personal safety issues in the country to be visited. If you have any reason to be concerned, it’s useful to know that you can get advice on political stability and traveller safety from the Foreign and Commonwealth Office, which has been running its ‘Know Before You Go’ campaign (see ‘Useful information’).

Travel insurance

As well as covering you for any medical expenses abroad, travel insurance normally includes theft or loss of your baggage as well, and you would be foolish to risk going away without it. Unfortunately, it can be expensive so if you’re on a tight budget it’s tempting to economise and rely instead on the reciprocal health-care arrangements between the UK and the European Union and some other countries. Although these are useful, they cannot replace proper travel medical insurance.

First, less than a third of countries worldwide have any type of agreement with the UK. Second, even those that do make no provision for getting a patient home in an emergency, nor do they provide any help towards an escort travelling or repatriation of a body should someone die overseas. Nevertheless, even given these limitations, the agreements can sometimes be useful. Details of arrangements with individual countries are given in the free booklet Health Advice for Travellers (T7.1), available from the Department of Health (see ‘Useful information’). It contains information on how to obtain a European Health Insurance Card (EHIC), which has replaced the E111 form. The card should be taken away with you. The quickest way to get an EHIC is online from: www.dh.gov.uk/travellers. Alternatively an application form can be obtained from the post office or by calling 0845 606 2030.

Virtually all tour operators offer travel insurance policies that you buy at the time of booking, and many travel agencies offer a similar service. Before agreeing to either, make sure that you read the small print carefully. Some policies specifically exclude ‘dangerous activities’ such as motorcycling, scuba diving or parasailing. Extra premiums may be required for winter sports. There may be exclusions for pregnancy, age and accidents involving alcohol and drugs. Nearly all insurance policies exclude pre-existing medical conditions. You will need to inform them of any such condition and request them to confirm in writing whether they have agreed. This situation can otherwise lead to disputes. Another circumstance that is usually excluded is any claim arising from an act of war or terrorism. Currently, a very small number of companies will cover these issues, so it is worth shopping around. You should also read the section on repatriation arrangements and check the amount of cover that you’re buying. You need to be sure that it’s adequate for your destination, bearing in mind that medical costs in countries such as the USA are extremely high.

In most cases the insurance company will provide a 24-hour assistance telephone number to be contacted before any major medical decisions are made. Ask for and keep all receipts for any medical treatment or medicines obtained abroad in case you need to make a claim when you get home.

All about immunisations

The words ‘vaccination’ and ‘immunisation’ have come to be used almost interchangeably, although vaccination originally only referred to the smallpox vaccination. The term ‘vaccination’ is used by the World Health Organization (WHO) to describe the other internationally required certificates of vaccination against yellow fever and, in the past, cholera.

Immunisation is a more modern term and covers the production of immunity (or protection from infection) in two ways. In ‘active’ immunisation, the body believes that the viruses or bacteria in a vaccine are an attack from a real disease and after about a week the body ‘actively’ produces its defence antibodies, which will then be ready for an encounter with that disease. In ‘passive’ immunisation, the antibody (part of the body’s defence system against infection) itself is injected (for example, gamma-globulin used in the past against hepatitis A) and the body ‘passively’ receives some instant protection. This ‘borrowed’ protection lasts less time than protection built by the body itself.

These days there are very few immunisations that are compulsory. In other words international certificates of immunisation are required only to enter a small number of countries when you’re travelling direct from the UK. These are some of the countries within the potential yellow fever disease zones across Africa from west to east and also the north part of South America.

A yellow fever vaccination certificate is required from all travellers for entry to some of these countries, even straight from the UK. For others, the certificate is not required for entry on a direct flight, only if your journey is via another country within the yellow fever zone. Otherwise, there are no other international certificates required by the International Health Regulations. At one time, smallpox and cholera certificates were necessary to cross most borders beyond Europe, but the eradication of smallpox, and the fact that immunisation against cholera does not stop the international spread of the disease, have resulted in them no longer being required.

One other mandatory requirement does exist, in excess of the International Health Regulations. Proof of immunisation against meningococcal meningitis has been required for all those going on the pilgrimage to Mecca in Saudi Arabia since 1988. This regulation was introduced following an outbreak of the disease, exacerbated by the huge influx of people from many corners of the world.

Apart from these mandatory requirements, other immunisations may be advisable but are not compulsory. Frequently these optional immunisations are important for your own protection but attempts to find out what you need may end in confusion.

Some foreign embassies and tourist offices in this country, who are anxious to encourage visitors, may well tell you that you don’t need any immunisations.

This is literally true in that no certificates are required to enter the country for travellers coming from the UK. It does not necessarily mean that you don’t need to consider getting yourself protected against certain health risks before you go.

Where to get advice

Increasingly, responsible tour operators are putting a few lines on health precautions in their brochures or booking forms and some travel agents will provide a little advice. However, you

shouldn’t expect them to tell you precisely which malaria tablets and optional immunisations you should have, although they will warn you about mandatory certificate requirements.

Once you’ve decided which country you’re visiting, you should consult your GP or a specialist travel clinic for travel health advice. In fact, an even better option is to make preliminary enquiries before you finally make up your mind about your destination as the answers may influence your decision.

A useful booklet worth consulting before you book is Health Advice for Travellers (T7.1) produced by the Department of Health. You can get a free copy on request (see ‘Useful information’). It contains advice on health topics as well as information on how to obtain the European Health Insurance Card (see earlier).

Arranging your immunisations

Travellers often worry that they may have left it too late to obtain full protection. In fact, while it is ideal to start in plenty of time, especially for long overland trips, some useful protection may be worthwhile even a day or two before departure if necessary.

For a major journey including rural areas it is wise to start about 6 to 8 weeks before you travel so that immunisations against diseases such as rabies and Japanese encephalitis can be spaced over a month and be completed at least 10 to 14 days before you leave. The interval allows time for the vaccine to become effective and for any reaction to have settled. Yellow fever immunisation takes 10 days to become fully effective and for the certificate to become valid.

For most package holidays to the Mediterranean or to the main resorts in the Far East, taking your immunisations about two or three weeks before your trip will suffice. Although the vaccine for hepatitis A takes at least two weeks to become maximally effective, it is believed to provide some useful protection even a few days before travel. This is because the incubation period of the disease is three to six weeks, which allows the vaccine protection to be building up, and so taking the vaccine late is better than omitting it completely. A second dose 6 to 12 months later prolongs the protection for at least 20 years and prevents the late immunisation situation arising again – very useful for the growing number of last minute bookings. If necessary you can have it right up to your departure date. As hepatitis A is the most common disease in travellers for which an immunisation exists (apart from influenza!), it is worth considering even at this late stage if you’re going anywhere with poor food and water hygiene conditions.

Middle-aged and older people and anyone else who did not receive childhood immunisations should allow 10 weeks, where possible, before travelling for their first course of immunisations. For repeated trips, this will not apply.

Side effects

Everyone seems to have heard scare stories about bad reactions – either the pain of the injection or the after-effects appear to get magnified with the telling. Of course older people, particularly men who served in the armed forces some years ago, do remember times when the needles became blunt with re-use and the vaccines caused more reaction. The old TAB (typhoid and paratyphoid A and B) jab, sometimes combined with cholera, was famous for causing the recipient to feel very ill for a day or two, sometimes with a temperature and generalised aches and pains.

The new vaccines are more purified, often containing just the required part of the organism, and this results in fewer reactions. In fact nowadays it is uncommon to suffer much, usually just a tender area on the arm and only occasionally a little tiredness or mild under-the-weather feeling.

The actual injection is done with a sharp, fine needle and this reduces the discomfort a great deal. People are often surprised to learn that they have received several immunisations when they only really felt one. In time, more vaccines are likely to be swallowed in liquid or capsule form.

Even gamma-globulin, which was the injection people liked least (probably because it was given into the buttock), was not nearly as bad as the stories would have you believe. Even so, most people are greatly relieved to hear that none of the travel vaccines currently available is given into the buttocks.

Some people – mostly young men – are prone to fainting after injections. This is very rarely anything to do with what was actually in the injection, but more a reaction to the fact of being injected. As people become more used to having immunisations as an adult, and find that they are not as terrible as they feared, they gradually overcome the tendency to faint.

If you know that you’re one of the fainting sort, you can help yourself (and the doctor) by ensuring that you have eaten something before you attend for immunisations. It also helps to lie down while the immunisations are being done and for a little while afterwards. This will usually stop you fainting and help to build up your confidence.

In recent years some rare but serious side effects have been reported after yellow fever vaccine. Although this is one of the most effective vaccines ever made and provides almost 100 per cent protection against a horrific disease, it is now necessary for an individual risk assessment to be carried out for anyone travelling to the areas of Africa or South America where the disease could exist (see ‘Yellow fever vaccine’).

Egg allergy

Before you have any immunisations, you may be surprised to be asked whether you are allergic to egg. The reason is that some vaccines (including yellow fever, tick-borne encephalitis, flu and some makes of hepatitis A and rabies vaccines) can contain minute quantities of egg. This might mean that you couldn’t have the vaccines if you have a true egg allergy, but, if you don’t eat them simply because you don’t like them or they give you indigestion, you can still go ahead.

You should discuss any allergies (including penicillin) with the doctor but they are rarely a problem in practice. Urticaria or other allergies such as an allergy to bee and wasp stings may mean that you shouldn’t have the Japanese encephalitis vaccine.

Nevertheless, in the unlikely event that you do experience a severe or possibly allergic reaction after any immunisation, you should tell the doctor before you have any further ones.

Vaccines that you may need: the basics

Tetanus

Everyone should have had a basic course of vaccine against tetanus. Travelling is an opportunity to check. This is particularly important for older people who may have missed out on a childhood course. A booster will be recommended for those travelling to developing

areas who received a basic course over 10 years ago. It is also important for those travelling to remote areas or camping, when medical treatment may not be available. Tetanus is caught by bacterial spores from soil or dirt getting into a wound – even a fairly minor one.

Nowadays, tetanus vaccine is always combined with diphtheria and polio vaccine.

Diphtheria

This vaccine is routinely given to babies, to children when they start school and to school leavers. However, adults born before 1940 may have never been immunised and they should be protected. Travel is an opportunity to boost diphtheria protection for those who have not taken it in the last 10 years. It is not available alone but is combined with tetanus and polio.

Polio

Protection is generally advised for travel outside northern and Western Europe, North America, Australia and New Zealand. Cases of polio have been falling worldwide and the WHO had hoped for polio eradication by the end of 2005. However, outbreaks in Nigeria and Indonesia, with spread to other countries, have dashed these hopes. The disease has almost gone from large areas of the globe and the vaccine will be gradually recommended for fewer areas throughout the world. Polio, or more correctly poliomyelitis, was once known as infantile paralysis. However, it can affect adults who are not immunised (usually those who were born before 1958).

Travellers are still advised to take polio vaccine boosters for travel to Africa, the Indian subcontinent and any areas where cases persist. In practice, as polio vaccine is now usually given combined with tetanus and diphtheria vaccines, a booster of this will usually be taken for travel to most developing areas, especially if it is over 10 years since protection was last taken. The oral vaccine, given as drops on the tongue or on a sugar lump, is no longer available because the extremely rare paralysis caused by the vaccine can be avoided by the newer vaccine.

The three vaccines above are included in the routine childhood immunisation programme which reminds us that one of the ways some diseases are kept at bay is by the great majority of people being immunised in childhood. In countries where immunisation programmes do not reach everyone, the risk may be higher. Any travellers who have not completed their courses should enquire about doing so.

Tuberculosis (TB)

BCG immunisation against TB has been dropped from the routine schedule for teenagers. Babies considered to be at high risk are still given the vaccine. The Department of Health has changed the advice for travellers so that vaccine is now only recommended for those under 16 going to live or visit for 3 months at least in a high-risk area. Where vaccine is still recommended for those over six years, a skin test must be carried out and re-examined three days later before the vaccine is given Those vaccinated in the past usually have a BCG scar on the upper outer part of the arm.

Extras for certain areas

The general recommendations for each geographical area do not vary very much and the main guidelines can be given here. However, it’s important to get up-to-the-minute advice on the country you’re going to before you leave because there may have been alterations to the international yellow fever regulations published annually by the WHO, new vaccines may have become available or there may have been recent disease outbreaks.

Yellow fever

Yellow fever immunisation is needed only for travel to or through a yellow fever endemic zone (see maps). A certificate may be required (check with a yellow fever centre) and this becomes valid after 10 days and lasts 10 years. A certificate should be provided when the immunisation is performed. Even if a certificate is not required, currently the WHO recommends immunisation for all travel to countries where there is risk of yellow fever, particularly if you’ll be travelling outside the main cities. This is because yellow fever is a serious and untreatable disease. Unfortunately, global surveillance after immunisation has identified rare, very serious reactions to the vaccine, so far only in first-time vaccines and particularly older people. This means that ideally no one should take the vaccine unless he or she is at risk of yellow fever disease. The itinerary needs to be checked to see whether the traveller is at risk and whether a certificate will be required to enter the country or countries to be visited. A medical exemption may be preferable to vaccination in certain cases, especially in those over 60; however, it is impossible to guarantee the acceptance of such an exemption. This situation means that travellers should check whether yellow fever vaccine is advised before booking their trip.

Some, but not all, GP practices are yellow fever immunisation centres, but if not they can supply you with the address of one in your area. There are specialist travel clinics in most main cities that can also provide this immunisation (plus the others if required).

Areas of Africa where yellow fever may be a risk

These guidelines change from time to time, so be sure to check the current situation before making plans

Areas of South America where yellow fever may be a risk

These guidelines change from time to time, so be sure to check the current situation before making plans

Cholera and travellers’ diarrhoea

This disease is still common in areas where hygiene is poor, but the traditional injected immunisation against it is not very effective and is never given these days. There are no remaining official requirements for an international certificate and any unofficial demands should be met by obtaining a medical certificate of exemption. Such demands for cholera certificates become more uncommon each year and, it is hoped, will soon cease altogether. Most travellers are at very little risk from cholera. A new vaccine combining cholera with ETEC (enterotoxigenic Escherichia coli), one of the most common forms of travellers’ diarrhoea, became available here in 2004. The vaccine has been used in Scandinavia and Canada, where it is considered to provide some protection against cholera for two years in adults and against ETEC for three months.

The vaccine is not used in children under two years of age. It is taken as a drink. Two doses are needed pre-travel, at least one week apart for adults and three doses for children aged two to six. In the UK it has been licensed only for use against cholera. However, the idea of a vaccine to prevent travellers’ diarrhoea is very attractive. It must be remembered that ETEC is not the cause in all cases and the vaccine claims only partial efficacy. Therefore, only a low proportion will be prevented. This may be enough to attract those whose holiday has been spoilt by previous unpleasant episodes. The cholera component may be useful for the handful of travellers who may be at high enough risk, probably not holidaymakers, but health-care workers going to outbreak areas and refugee camps.

Typhoid

This immunisation may be given to those who are travelling to areas where the standards of food and water hygiene are poor. This includes many countries of the tropical and developing world, but if you’ll be staying only in first-class hotels for a short time (for example, in established resorts in the Caribbean) you may be at very little risk. Being careful about what you eat and drink and your personal hygiene will help to protect you, not only against typhoid, but against all food- and water-borne diseases including travellers’ diarrhoea and hepatitis A. Discuss this with your doctor or travel clinic.

Hepatitis A and B

Many people are confused about the types of hepatitis, which now stretch along the alphabet from A to G. They are all transmitted like either hepatitis A or hepatitis B. Hepatitis A is passed through infected food and water and hepatitis B is transmitted in similar fashion to HIV through sexual contact or blood and non-sterile medical equipment. Hepatitis C is transmitted in a similar way to hepatitis B.

There are vaccines against only hepatitis A and B. As hepatitis A is transmitted through food and water, protection is recommended for most of the same areas as typhoid. However, hepatitis A is more common than typhoid.

Hepatitis B is transmitted as HIV is, and so individual behaviour is an important factor. For those who are likely to have sexual contact (heterosexual or homosexual) overseas or who are at extra risk of requiring medical treatment in developing areas, there is a vaccine available. It is not given for most holidays, but usually for longer travel such as backpacking or postings abroad. You can carry condoms from the UK where appropriate, and needle and syringe kits. There is also a combined vaccine available that gives protection against both hepatitis A and hepatitis B infections.

Non-routine immunisations

If the type of trip that you’re taking may pose unusual health risks, or you’re going away fo long period or to somewhere very much off the beaten track, other immunisations should discussed with your doctor. These are not usually given for package holidays - those bas in main centres and lasting less than four weeks - although they may be advisable in exceptional circumstances.

Rabies

The risk of rabies is discussed later in the book, and immunisation before departure may advised if you will be out of reach of medical help or on a long trip through developing are usually causes very little reaction. You must, however, still seek medical help after a bite o scratch from an animal. This may give the impression that the immunisation is not worthw but it should mean that treatment after a bite works more quickly and effectively.

Tick-borne encephalitis (TBE)

This vaccine should be considered for walking or camping holidays in wooded areas, or the surrounding countryside, in parts of Europe, especially central and Eastern Europe, including areas of the former Soviet Union. The risk is more acute in spring and early summer.

Many people going on such holidays do not discover that there may be a risk until they arrive. If you think that you may need it, you can ask your travel clinic or family doctor to obtain the vaccine for you.

It is relatively expensive and ideally you should allow at least four weeks before travel. The areas of the Czech Republic, Slovakia, Austria, Hungary, Poland, Germany and Scandinavia affected are quite well mapped, but there is little information about which parts of the former Soviet Union are involved. There are also very small risk areas in other European countries.

The disease is transmitted by ticks attaching to people when brushing the undergrowth, so you can discourage them by tucking your trousers into your socks, using insect repellent on your skin and insecticide on your clothes, and checking yourself frequently to remove ticks with tweezers.

Meningitis

There are several different types, including that prevented by the Hib (Haemophilus influenzae type b) vaccine and the conjugate meningococcal type C vaccine, given to young people routinely. The meningitis vaccine given for travel needs to contain type A, so vaccine containing both A and other strains is usually used.

Strain A is rare in the UK, but has caused outbreaks in certain areas of the world, and vaccine is recommended for longer travel, especially if you’re staying or working with local people or backpacking. Large outbreaks occur in the ‘meningitis belt’ of Africa. The belt stretches from Senegal in the west to Ethiopia in the east, and now extends down the eastern side to Zambia. Package holidays to The Gambia and Kenya are usually considered low risk and immunisation is not routinely given unless an outbreak is reported. Check with your travel clinic before travel.

Proof of immunisation with meningitis vaccine is required for Muslims travelling on the pilgrimage to Mecca in Saudi Arabia (Haj or Umra). No other country requires proof of meningitis immunisation.

Pilgrims on the Haj are required to take the A, C, W, Y vaccine because cases of W meningitis occurred in pilgrims on the Haj of 2000 and 2001. As W meningitis is starting to be reported from Africa, the A, C, W, Y vaccine has replaced the A and C vaccine.

Japanese encephalitis

This is unlikely to be advised for short package holidays, but it is nowadays needed more often because of the increase in overland trips. It is unlicensed for routine use in the UK. Generally the vaccine is used only for travellers who will spend at least a month staying in rural areas in the endemic zone.

This stretches from parts of India, across south-east Asia to China. There are very few cases in Japan these days. It is spread by mosquitoes, which breed in rice fields and bite farm animals, especially pigs, so being out in areas that combine these risk factors (especially after dusk when most of these mosquitoes bite) may make the vaccine worthwhile.

Although your GP can obtain it for you, many family doctors have little experience with it and so may suggest that you get it from a specialist travel clinic. Ideally, you should start the course eight weeks before departure so that three doses can be given over a month, allowing time for it to become effective. However, when time is short, two doses a week apart should provide some protection. On rare occasions, this vaccine has caused allergic reactions so you’d be wise, if you can, to take the last dose at least 10 to 14 days before travelling. A new vaccine is expected late in 2008 or in 2009. It is hoped that the vaccine will have a UK

(European licence) and will cause fewer allergic reactions so that you can take it closer to your travel date.

Influenza

This is often overlooked as a travel vaccine but those who are in the high-risk groups at home should also be immunised before travel, especially if there will be a group of people travelling together. Outbreaks on cruise ships illustrate the point about group travel. These outbreaks may occur at any time of the year.

Special precautions

Anyone who has had their spleen removed may need extra immunisations, and there are special considerations regarding immunisation for pregnant women. Some vaccines may not be advisable for those with any serious or chronic disease and in anyone during an infection. Extra vaccines are sometimes recommended for those with chronic disease, for example, pneumococcal vaccine. If you fall into any of these categories, or you are HIV positive, you should discuss with your doctor which immunisations would be sensible, preferably before deciding finally on a destination.

Finally, remember that immunisation cannot give 100 per cent protection against all diseases, and you must follow advice about food and water hygiene and other commonsense guidelines (see later in the book).

Malaria

Once you have got your immunisations sorted out, you will need to discuss protection against malaria. You may have seen some of the recent media reports of a vaccine but as yet it is only experimental and does not look likely to become available to travellers in the very near future. It is complicated to make a vaccine against this parasite and at present the trials do not demonstrate adequate protection to make the vaccine useful for holiday travel.

So for the moment, you have to take malaria tablets (strictly speaking, they’re antimalarial tablets). Unfortunately they do not provide perfect protection, can be a nuisance to take during your holiday and usually for a month afterwards, and can produce side effects in some people. Therefore it is worth checking carefully whether they are recommended for your chosen destination.

Malaria exists across much of the tropics and malaria maps show many popular holiday countries as endemic zones. However, within these zones there are areas of very low or no risk. As the disease is transmitted by mosquitoes, areas with fewer of them hold less risk and include mountains, dry areas and deserts, and some cities and main resorts.

There are also tropical areas where the disease has naturally never existed, disappeared or been eradicated, for example, the Caribbean islands (except for Haiti and the Dominican Republic).

If you opt for somewhere with little or no malaria you’ll avoid the nuisance of tablet taking and this is a safer bet for anyone who is pregnant or can’t take the tablets for some other reason. When checking whether malaria is present, it is necessary to consider the area and resort, not just the country. For example, in Cambodia, tablets are advised for visiting Ankor Wat but not for the capital city. However, in the large areas of south-east Asia where tablets are no longer recommended you have to remember that a small risk may still exist. This means checking any suspicious symptoms that occur in the few months and occasionally right up to about a year after your trip. Malaria is treatable but it does need treating.

Popular holiday destinations: immunisation and malaria guidelines

These guidelines are for a one- to three-week holiday in hotel conditions. They should be discussed with your GP or travel clinic before travel in case of any special circumstances or recent changes.

For all destinations, check that routine UK immunisations have been taken (including flu for those for whom it is indicated in the UK)

USA, Canada, Australia, New Zealand, northern and western Europe

• Consider tick-borne encephalitis for certain areas, for example, walking or camping in Austria or southern Sweden, especially in spring and summer
• No malaria

Mediterranean countries including Turkey, North Africa (including Morocco and Tunisia) and Eastern Europe

• Consider diphtheria/tetanus/polio, hepatitis A, and occasionally typhoid according to conditions expected. In general the risk increases with travel further south and east and outside main hotels and resorts
• Diphtheria up to date for countries of the former USSR
• Consider tick-borne encephalitis for parts of Eastern Europe, such as areas of the former USSR if camping in spring and summer
• Malaria protection for Turkey (March–November, Antalya eastwards on the south coast and eastern Turkey), and low risk in the summer in some rural areas of Armenia, and some southern areas of Azerbaijan, Georgia, Tajikistan, Turkmenistan and Uzbekistan

The Caribbean including Barbados, St Lucia, Dominican Republic

• Typhoid, diphtheria/tetanus, hepatitis A (typhoid and sometimes hepatitis A less important for stays in first class conditions)
• Yellow fever for rural Trinidad
• Malaria protection for Haiti and the Dominican Republic only

Tropical South America including Brazil and Venezuela

• Yellow fever (see map and yellow fever information)
• Typhoid, diphtheria/tetanus, hepatitis A
• Malaria protection, especially for the Amazon jungle/forested parts of these countries

West and East Africa including The Gambia, Kenya, Tanzania

• Yellow fever (see map and yellow fever information)
• Typhoid, diphtheria/tetanus/polio, hepatitis A
• Meningitis if outbreaks reported
• Malaria protection

Southern Africa, including South Africa and Zimbabwe

• Typhoid, diphtheria/tetanus/polio, hepatitis A (although less risk in the cities only of South Africa)
• Malaria protection for Zimbabwe and for the game parks and rural north east of South Africa and northern Botswana and Namibia

India and Sri Lanka

• Typhoid, diphtheria/tetanus/polio and hepatitis A
• Malaria protection

For longer, rural, backpacking holidays through developing countries

In addition to typhoid, diphtheria/tetanus/polio, hepatitis A and yellow fever (if in yellow fever area)

• Check BCG (TB) for under 16's
• Consider rabies and hepatitis B
• Consider Japanese encephalitis for parts of India across Asia to China and down through south-east Asia
• Consider meningitis for certain areas
• Malaria protection

Tablets for prevention of malaria

Proper name	Common trade names	Interval
Chloroquine	Avloclor	Weekly
	Nivaquine	Weekly
Proguanil	Paludrine	Daily
Mefloquine	Lariam	Weekly
Doxycycline	Vibramycin	Daily
Atovaquone and proguanil	Malarone	Daily

That means that if by any chance you feel ill with a temperature after you get back, right up to about a year later, you should remind your doctor that you’ve been to a possible malaria area so that the condition can be ruled out as a cause of your symptoms or treated if necessary.

If you are pregnant and have set your heart on a tropical holiday, choose one where there is no malaria or only minimal risk (see ‘Women and children only’).

When you’re going somewhere where malaria is a risk, tablets are likely to be recommended. There are a few areas of the world that are not considered ‘resistant’. This means that the more serious strain of malaria (Plasmodium falciparum) is not resistant to the ordinary malaria drug chloroquine (and, increasingly, other drugs too). However, these zones are shrinking all the time as resistance spreads and the only areas where chloroquine alone can be used for prevention are parts of Central America, North Africa and the Middle East, including Turkey. Chloroquine is available without a prescription. The two common trade names by which it is usually known are in the table.

When resistance creeps in, either another drug is given with the chloroquine – usually proguanil (known by its trade name Paludrine) – or a quite separate drug is used.

Several once-weekly malaria tablets have been tried as an alternative to taking a combination of proguanil and chloroquine. As this combination consists of a total of 16 tablets each week, the attraction of a single tablet is obvious. The problem has been that there is no perfect tablet to meet this requirement. The once-weekly ‘wonder drug’ mefloquine (Lariam), greeted enthusiastically around 1990, also has side effects in some people. There are, however, few truly effective drugs that do not produce unwanted reactions in some people and mefloquine is valuable because of its effectiveness for travellers to highly resistant, high transmission areas such as much of Africa. There is now a choice of two other tablets so no one has to take mefloquine; however, where it is considered the best tablet the doctor should check your medical history carefully before prescribing it. More side effects have been reported than in other countries. It is important that these are monitored carefully, and the more serious ones separated from the minor.

The more common complaints include vivid dreams and feeling light-headed (which tend to settle gradually) and nausea, which is reduced if the tablet is taken after the evening meal with water.

The serious concerns include reports of mood change that may go on to depression, anxiety or hallucinations, or even very rare reports of fits. Although these are obviously alarming, it’s important to remember that most people do not experience such problems, and it could be unwise to deny travellers to high-risk areas the option of one of the highest protection tablets. The two other drugs that are an alternative to mefloquine are doxycycline and malarone. Proguanil and chloroquine are still retained for certain areas such as the Indian subcontinent. You should always get up-to-date advice from your GP or travel clinic on individual choice of tablet and action to take if side effects occur.

Proguanil and chloroquine are not without side effects either. They are well known for producing gastrointestinal problems from nausea to diarrhoea. These can be dramatically reduced by taking the tablets after the evening meal. There are few serious adverse effects, although mouth ulcers can be unpleasant and hair thinning worries some people. The hair problem usually only arises on longer trips rather than on an average length holiday. Hair growth usually returns to normal after the end of the course.

Doxycycline, an antibiotic, is increasingly being used as an alternative to mefloquine. This is taken daily and, like all malaria tablets, has advantages and disadvantages. The main advantage as perceived by most travellers is that it does not appear to produce the neuropsychiatric effects that follow mefloquine use in a minority of people.

However, its main downside is that a small proportion (probably about three per cent) of people become allergic to sunlight so that their skin burns more easily. This can mean that they have to stop the doxycycline and seek other forms of protection. Obviously, a high-factor sunscreen is advised to reduce the chance of the reaction. Some women are more prone to thrush while on doxycycline (normally readily treatable); it can make the birth control pill less effective (see ‘Women and children only’) and, although it often prevents travellers’ diarrhoea, it can occasionally cause severe diarrhoea. Doxycycline should be taken with food and water and not within 30 minutes of lying down to prevent heartburn.

Having said this, the side effects are suffered by a minority and are usually felt to be worth the risk to obtain a good level of malarial protection.

The other alternative to mefloquine is a newer tablet, Malarone, which was licensed in 2001. It is a very welcome addition to the range of antimalarials. It is a combination of proguanil and atovaquone, the former being one of the well-established antimalarials and the latter a drug used in the treatment of unusual pneumonias. Malarone, although expensive, has the great advantage of being taken for just one week after leaving the malarial area (all the others need to be taken for four weeks afterwards).

Malarone appears to have neither the psychiatric side effects nor the side effects of doxycycline. As with all of the choices, it can cause gastric symptoms and should be taken after a main meal to reduce them. It appears to be a very useful and effective drug. Its major use to date has been for short trips (usually less than four weeks) to higher-risk areas.

Malarone can be used in children and special paediatric tablets are available for those weighing 11 kg and over. The dose for children is one, two or three tablets daily according to body weight. Doxycycline is not suitable for children under 12 years – a reminder that the choice of antimalarials for young children is not as wide as in adults and of the unsuitability of choosing high-risk malarial areas for family holidays.

Proguanil and chloroquine are the only antimalarial pills that are available over the counter. Chloroquine should not generally be taken by people with epilepsy, and it may make psoriasis worse, although this is uncommon in those with mild psoriasis. Proguanil may not be suitable for anyone who takes drugs (except aspirin) to reduce blood clotting.

Taking malaria tablets both during the holiday and for four weeks afterwards is hard enough for adults, but it is even more difficult to persuade children to do it. It is far easier to plan to avoid malarial areas if at all possible. There are no children’s syrups available as alternatives to most malaria tablets. Doses of medication must be checked carefully with the doctor, nurse or pharmacist, because they may vary from those on the packet.

It is obvious from these descriptions that there are no easy answers when it comes to malaria tablets. However, there are some very important points to bear in mind:

• No tablet provides complete protection against malaria
• Take positive steps to reduce the number of mosquito bites, particularly after dusk
• Get current advice on choice of malaria tablets for you and your holiday
• Remember to continue the tablets for four weeks after leaving the last malarial area (or one week for Malarone)
• Forgetting to take the tablets causes as many problems as drug resistance
• Report any possible symptoms to a doctor for diagnosis and treatment.

With the growth of off-the-beaten-track holidays, there are a few situations where people may need to carry emergency drug therapy against malaria (available only on prescription).

It is always better to obtain competent medical treatment, but there are shortages of medicines in some rural areas and you may need to offer yours to the doctor for use in treating you. The drugs are not supplied with the idea of self-treatment except where there is no medical help at all.

As no tablet provides complete protection, you have to use other means of reducing the risk as well. Malaria is transmitted by the bite of the anopheles mosquito (females only, the males are vegetarian!). The female bites between dusk and dawn so that is the most important time to protect yourself against being bitten.

One way is to put on cover-up clothes before dusk, that is, wear long sleeves and long trousers or a long skirt. Of course this won’t be completely effective. Small mosquitoes may manage to get inside loose clothes and larger ones may bite through the material, but it should reduce the frequency. When there are mosquitoes about apply insect repellent to exposed skin.

There has been a lot of discussion about types of repellent, but the most widely used and effective ingredient is diethyltoluamide (DEET). It has been used on the skin of such massive numbers of people world wide, it would be surprising if there had not been rare reports of toxicity possibly associated with it. As a result of this you must take care not to exceed the manufacturers’ instructions about applying it, especially for children.

Naturally care should be taken to avoid the eyes. A skin-patch test may be a wise precaution for people with sensitive skins. Spray or roll-on formulations avoid spills of repellents, which can mark plastics, including cameras, and reduces the chance of a child trying to drink them.

For those who cannot use DEET, there is a range of other repellent products containing various essential oils. In most cases they do not have quite the same effect. People often ask about the use of vitamin B or garlic pills as insect repellents. They may be effective for some individuals, but, when tested, no consistent protection is demonstrated. There is no doubt that differences in skin excretions make some people more attractive to mosquitoes than others.

Some repellents can be sprayed on to clothing, although some may make a slight mark. This can be useful around collars and trouser legs, and can reduce the amount applied directly on to the skin. Recently, there have been insecticide sprays developed that are designed for spraying on clothes.

You also need to prevent bites while you are in bed at night. Most international hotels have modern air-conditioning systems that discourage mosquitoes. However, they could fly in if someone leaves a door or window open and then you would need to use knock-down insect (fly) killer to spray the room after closing the door and windows. Where you need to sleep with the windows open (because there is no air conditioning) there should be screens on the windows and, in high-risk areas, a mosquito net provided over the beds. Nets are more effective when they are dipped in an insecticide called permethrin. Anyone who has to carry his or her own net, for example, backpacking off the beaten track, should be aware of this.

Smoke coils are burnt to discourage insects in many tropical countries and may be useful when sitting on a veranda. However, they will not burn reliably all night so there is a better alternative to use if there are electrical sockets in your room: a small plug-in device that vaporises a tablet of insecticide placed on it. You will need to remember to carry an international adapter as well.

Besides malaria mosquitoes, there are other insects that transmit disease: sandflies, ticks and other mosquitoes, for example, those that carry dengue fever (not usually as serious as malaria, but certainly very unpleasant). There is a huge upsurge in dengue fever in the Caribbean, Central and South America, and most of Asia. It also exists in a few Pacific Islands and in tropical Queensland. A similar disease, chikungunya, has caused outbreaks in Mauritius, other islands and India in 2006–07. There is no specific prevention or treatment for either of these diseases apart from reducing mosquito bites. Mosquitoes can also be a real nuisance, but not usually dangerous, in many northern holiday destinations such as Canada, Alaska and Scandinavia, and midges in Scotland. The same information on repellents and cover-up clothes applies, but it should be remembered that a lot of insects are daytime biters so the precautions do not apply only to after dark.

Areas of the World where malaria transmission may occur

These guidelines change from time to time, so be sure to check the current situation before making plans

First aid kit

Different people and destinations have different requirements, so treat the lists as a guideline. You’ll only need a basic selection for a short holiday to a major destination. It’s worth discussing any queries with your doctor or pharmacist and make sure that you read the packet information supplied with all medications.

Consult your doctor about the suitability of antibiotics for travel away from medical help. You may also want to have a dental check-up, especially before holidays in developing areas.

First aid kit for adults

Medication

• Antiseptic, dressings and plasters
• Paracetamol or other mild painkiller
• Antacid indigestion remedy
• Dry throat lozenges
• Insect repellent
• Calamine lotion
• Cream to relieve insect bites
• Antihistamine tablets
• Motion sickness tablets
• Diarrhoea ‘stopper’ tablets, for example, loperamide
• Oral rehydration salts
• Laxative
• Athlete’s foot powder
• Vaginal thrush treatment
• Antimalarial pills where necessary
• Supply of any regular medication(s)
• Consider antibiotic for general use or travellers’ diarrhoea if likely to be away from medical help

Equipment

• Thermometer
• Tweezers
• Scissors
• Ear plugs
• Sunscreen
• Lipsalve
• Contact lens solution
• Spare spectacles or prescription
• Water purifying tablets
• Sterile needles and syringe kit
• Condoms
• Tampons

First aid kit for children

Check the package for suitability and dosage for age of child. If in doubt ask the pharmacist or your GP.

Medication

• Children’s paracetamol
• Oral rehydration salts
• Calamine lotion
• Antiseptic, dressings and plasters
• Insect repellent
• Antimalaria tablets/syrup
• Motion sickness preparation
• Supply of any regular medication(s)
• Nappy rash cream
• Teething gel
• Plenty of baby wipes

Equipment

• High factor sunscreen
• Thermometer for children, for example, forehead strips
• Tweezers
• Sterilising equipment for babies’ bottles
• Wet tissues
• Equipment to boil water (and allow to cool) for drinking (where necessary)

Key points

• Consider any health risk before you choose your holiday destination
• Even when no mandatory immunisations are required, take medical advice on health precautions
• Try to plan your immunisations early, but remember that some useful protection can be obtained even at short notice
• Obtain medical advice on choice of malaria tablets, but remember that no tablets provide total protection, so reduce mosquito bites as far as possible and seek medical help if you are ill during or after a visit to a malarial area
• Travel medical insurance is very important (always check the small print)

 

Contents

About the Authors

Introduction

Planning ahead

Women and children only

In good health?

Sensible precautions

Accident prevention

Common health queries

Serious respiratory illnesses

Bites and stings

When you get home . . .

Useful information