Travel medicine: Patient Information

More people are traveling internationally than ever before. This is acting as a double aged sword. On one hand, it enhances global economy and leaves an individual with pleasant experiences. On the other hand, it could expose an individual to infectious agents, injuries related to transportation and certain activities like diving or high altitude hiking. Fortunately, most travel-related health problems can be prevented with a combination of pre-travel planning, immunizations, and safety precautions during travel. For people who are planning travel outside of their home country, an infectious disease expert should be consulted at least one month prior to traveling. The provider can give immunizations, travel medications, and tips for staying healthy during the trip.

Pre-travel Information

The first step prior to travel planning is to consult the infectious disease specialist. Detailed history regarding the general health condition of individual is obtained. This is particularly important while planning a trip for individuals who have weakened immune systems as in post transplant individuals.

Certain important points are recorded on this initial visit:

• Duration of travel
• Season of travel
• Countries and regions that will be visited
• Planned activities during travel
• Place of residence during travel (for example, rural/camp)

Infections

Food/Water borne infections: Diarrheal disease in travelers may be caused by a variety of bacterial, viral, and parasitic organisms, which are most often transmitted by food and water. More than 90 percent of illnesses in most geographic areas are caused by bacteria; the most common organism is enterotoxigenic Escherichia coli (ETEC).

Risk factors:

1. Weak immune systems
2. Improper storage and handling of food
3. Cross contamination of food
4. Transmission of pathogens through food handlers.

Etiology:

Bacteria, viruses and parasites act as pathogens.
Pathogens causing travelers’ diarrhea

Bacteria

1. Enterotoxigenic Escherichia coli
2. Enteroaggregative E. coli
3. Campylobacter jejuni
4. Salmonella species
5. Shigella species
6. Clostridium difficile
7. Vibrio parahaemolyticus (V. cholerae less common)

Viruses

• Rotavirus
• Enteric adenovirus

Parasites

• Giardia lamblia
• Cryptosporidium parvum
• Entamoeba histolytica (not common)

Symptoms:

Common symptoms include nausea, vomiting, abdominal pain, diarrhea, and fever

Treatment:

1. Maintenance of hydration
2. Antibiotics
3. Antimotility agents – Their use should be discouraged as they only control symptoms, but do not destroy the pathogens.

Doctors tips: Prevention

Educated choices in selecting food and drinks is prudent

1. Freezing does not kill the organisms that cause diarrheal disease. Thus, ice in drinks is not safe unless made from adequately boiled or filtered water.
2. Outbreaks of diarrheal disease have been associated with bottled water. In most situations, boiling water is the simplest solution in places with poor sanitation and hygiene.
3. Fruit salads, lettuce, or chicken salads are examples of unwise food choices; the ingredients may have been improperly washed and/or may have been sitting for some time without proper refrigeration.

Do’s and Don’ts of water borne infections

• Do not drink or brush the teeth with unboiled tap water.
• Do not drink beverages that contain ice made from unboiled tap water.
• Drink only boiled tap water, drinks made from boiled tap water
• While bottled water is safer than unboiled tap water, the source of the water and bottling conditions are not standardized; thus, other drinks are probably safer than locally bottled water.

Tips to reduce risk of food borne infections

• Do not eat unpeeled fruit. Peel any fruit yourself before eating it.
• Do not eat raw vegetables
• Do not eat or drink unpasteurized (“raw”) dairy products
• Do not eat raw or rare meat, fish, or shellfish (including ceviché)

Insect and arthropod bites

In certain parts of world, insects like mosquitoes, fleas, bugs and lice, arthopods like ticks and mites can transmit infections like malaria.
Malaria is caused by mosquito- Female anopheles mosquito. The life cycle is complex and is transmitted to man by the bite of the mosquito.
The epidemiology is varied and guidance of an infectious disease specialist is important on deciding about malaria prophylaxis.
Symptoms: Include fever, chills, sweats, headache, myalgias, fatigue, nausea, abdominal pain, vomiting, diarrhea and cough.

Travel advice:

A visit to travel medicine clinic would provide an individual with information regarding:

1. Advice about malaria- Symptoms and signs of the infection.
2. Guidance on mosquito avoidance- By insect repellants and personal protection
3. Chemoprophylactic medications like chloroquin, mefloquin, doxycyline etc.

Tips to reduce the risk of infections:

1. Whenever possible, avoid insect-infected areas.
2. Protective clothing including long sleeved shirts and pants are protective.
3. Good personal hygiene
4. Insect repellents like DEET/permethrin are useful
5. Mosquito nets/nets impregnated with permethrin is to be used.
6. Avoid too much outdoor activity after dark
7. Periodic inspection of skin to remove ticks and insects.

Prophylaxis against malaria is advised while traveling to high risk areas. The infectious disease specialist would provide you with a course of antimalarial drugs to reduce the risk.

Other infections

In addition to food and water, soil and sand can also act as sources of infection. For example, schistosomiasis is common in fresh water in certain parts of world. Swimming in fresh water should be avoided when possible. In these parts, swimming in salt water is safer. Travelers are advised not to walk barefoot or use open footwear on soil that could be contaminated with dog/human feces as this would increase the risk of hook worm infections

Sexually transmitted diseases

Certain infections like hepatitis B/HIV, syphilis, gonorrhoea, Chlamydia are contracted through sexual contact. Contraception is strongly advised to avoid risk of transmission of infection.

Immunizations for travel

This forms an essential element of travel. Travel immunizations can help prevent many of the more serious travel-related health problems. It is important to plan ahead for these immunizations because most of them require four to six weeks to become effective.
A visit to the infectious disease specialist would provide a list of vaccinations [ for example Hepatitis A vaccination, Hepatitis B vaccination, MMR, Poliomyelitis, typhoid vaccine, Yellow fever vaccines and the like] needed to be taken before travel to high risk areas.