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Travel Medicine

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The world is becoming a smaller place through the rapid expansion of the modes of transportation. Over 1 billion people travel each year via plane and substantially more via land and sea. As a consequence of this international travel, holidays are becoming more exotic and travel often more extreme. Advice regarding travel is now a common occurrence in primary care and this resource presents typical scenarios relating to questions on vaccination, advice and treatments for a variety of travel related scenarios. Answer the 10 questions and you will be presented with a certificate awarding 1 hour of continuous professional development that you can use for your learning portfolio.

On completion of this resource, the user should be able to:

Understand the appropriateness of malaria prophylaxis relating to country of travel.

Understand treatment options of travel related conditions as well as the effect of pre-existent conditions upon travel.

Table of vaccines and malaria prophylaxis

The world is becoming a smaller place through the rapid expansion of the modes of transportation. Over 1 billion people travel each year via plane and substantially more via land and sea. As a consequence of this international travel, holidays are becoming more exotic and travel often more extreme. Advice regarding travel is now a common occurrence in primary care and this module presents typical scenarios relating to questions on vaccination, advice and treatments for a variety of travel related scenarios. Answer the 10 questions and you will be presented with a certificate awarding 1 hour of continuous professional development that you can use for your learning portfolio.

On completion of this module, the user should be able to:

Primary Care

A 55 year old man comes to clinic and tells you that he is going to visit Bangkok for two weeks in mid July. He is otherwise fit and well and takes no medication. Which of the following should he have for his holiday?

This man is travelling to Bangkok and staying there for a fortnight. He does not require any 

Question 1

A 23 year old woman has returned from holidays in Tenerife with sunburn which happened on the last day after she ran out of suncream. She has a painful red back. Besides paracetamol, what do you advise?

The most appropriate management of this patient's sunburn would be advice regarding drinking plenty of fluids, keeping the skin cool by using a sponge with lukewarm water, and a cold compress. Applying an emollient such as E-45 will help to moisturise the skin, cooling it and relieving the tight sensation. Aloe vera and calamine lotion can be particularly helpful. Occasionally hydrocortisone cream can be used to reduce the inflammation. It should be used in moderation, avoiding the face, broken or infected skin, or genitalia.

http://www.nhs.uk/Conditions/Sunburn/Pages/Treatment.aspx

Question 2

You are approached by a family who are going on luxury safari to Kenya, staying in a cabins on a game reserve and they ask you about vaccinations they require. What is required in this case?

This family are travelling to a game reserve in Kenya which is a 

. They should take prophylaxis that will protect them against chloroquine-resistant malaria and should be warned about taking precautions to avoid mosquito bites. Mefloquiune (Lariam) is a very effective anti-malarial against chloroquine resistant malaria.

http://www.traveldoctor.info/trip/kenya.3.67.4.html

Question 3

A businessman informs you that he wants to go to Costa Rica on holidays but is likely to go out into the volcanic parks at the Pacific coast for a few days. Which of the following should he have?

Other than the Limon region on the east/Atlantic coast, the risk of 

 is low and does not require any prophylaxis.

Question 4

A 25 year old female returns from a holiday in Majorca complaining of painful urination and a urethral discharge. She informs you that she has had unprotected sex. What do you suggest doing?

This young woman presents with symptoms suggesting a sexually transmitted disease. Rather than just treating this, the woman needs to have counselling, appropriate investigation including a high vaginal swab, potentially HIV testing and also contact tracing if proven to have a sexually transmitted disease. This woman should be advised to attend the local 

 (GUM) Clinic.
Chlamydia is one of the commonest STI's seen in the UK. Patients can be infected without having any symptoms, or it may present in a way similar to this lady with pain on urination, discharge, and bleeding between periods and after sex. It is easily treated with antibiotics. Gonorrhoea is another common example which also presents with these symptoms. It is important to diagnose with simple swabs, as treatment is different to that of Chlamydia. Canesten cream is used for vaginal thrush, and would not be appropriate in this case, unless detected on swabs. An MSU might be considered to rule out a urinary tract infection, which may present with painful urination, however it does not typically present with discharge.

http://www.nhs.uk/conditions/Sexually-transmitted-infections/Pages/Introduction.aspx

Question 5

A 65 year old male has planned a trip to Australia and will be travelling for a period of 22 hours in total. He is a type 2 diabetic but has been converted to twice daily mixed insulin in the last year. He is concerned regarding the carriage of his insulin during the flight. What do you recommend?

 from his doctor explaining his condition and his need to carry needles and syringes with him. He should carry his insulin with him in a cool bag, in his hand luggage. Insulin should not be stored in the hold as it may freeze and then denatured. In addition to this, the patient is taking insulin twice daily, and the flight is 22 hours, therefore he will need to have his insulin in his hand luggage in order to maintain the correct dose of insulin. There are no restrictions on flying with well controlled diabetic patients. Patients should also be advised to carry plenty of snacks with them, and to check their glucose levels during the flight.

http://www.diabetes.org.uk/Information-for-parents/Living-with-diabetes-new/Travel-and-holidays/Flying/

Question 6

A 55 year old woman attends clinic as she is concerned about flying. She has previously had a deep vein thrombosis associated with an orthopaedic procedure and wants to know what she should do regarding the prevention of further DVT. The flight is six hours long. Together with sensible measures and compressive stockings, which treatment option, if any, would you advise?

This woman has had a deep vein thrombosis in the past, therefore she is regarded as high risk on a 

. The risk of a venous thromboembolism doubles after a long haul flight (longer than 4 hours). She should be advised regarding preventative measures including good hydration, spend periods out of her seat and compressive stockings. Most importantly, because she is at high risk, she should be given one shot of low molecular weight heparin just prior to travel.

http://www.patient.co.uk/doctor/Flying-with-Medical-Conditions.htm

Question 7

A 35 year old woman attends clinic requesting advice. She is a German national who is 32 weeks pregnant and has split up with her boyfriend. She wants to return to Germany to her family and enquires whether she can fly in the next week. Which of the following do you advise?

 generally would require a report detailing her dates and that there are no complications associated with the pregnancy if an individual is beyond 28 weeks. Most airlines allow pregnant women to fly up until the end of their 36th week, in uncomplicated singleton pregnancies (multiple pregnancies is 32weeks) Long flights carries an increased risk of DVT so advice should be given to prevent this.

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/travel-pregnant.aspx

Question 8

A 72 year old female is going on a transatlantic cruise with her husband and seeks advice regarding sea sickness. She has done this cruise previously but had problems with sea sickness. She received an injection which settled things down but this cost her £100. She enquires if there is anything that she could get on prescription that might help. She is otherwise a fit and healthy person taking no medication. Which of the following would you advise?

Motion sickness can be quite disabling for the individual. It is thought to be caused by a conflict between what the eyes see and what the inner ears senses. The brain receives mixed information, and brings on the symptoms of motion sickness. These include dizziness, nausea and vomiting. Certain drugs like maxalon and prochlorperazine are typically ineffective. A better and commonly used option is scopolamine (hyoscine), such as transdermal patched which can be worn for three days.

http://www.nhs.uk/Conditions/Motion-sickness/Pages/Treatment.aspx

Question 9

A 28 year old man comes to clinic as he is intending to go on a mountaineering holiday with friends in the Himalayas. He has had problems with mountain/altitude sickness in the past and wonders if there is anything that you can give him that might help. Besides the advice of reducing altitude when feeling ill, which of the following is a useful treatment?

 can be life threatening and emergency oxygen together with rapid descent needs to be used in severe cases as it signifies hypoxia. The decrease in atmospheric pressure makes breathing difficult. Symptoms are headache, nausea, dizziness and exhaustion. In severe cases, fluid builds up on the lungs or brain, and needs to be treated immediately. However, milder cases are quite common and should be noted at an early stage, so that patients can climb down to a lower altitude and acclimatise. Acetazolamide can be of help in milder cases. Altitude sickness causes a changes the chemical balance of your blood. Acetazolamide helps to correct this. It can be taken to reduce the severity of symptoms, and also to prevent altitude sickness from occurring in the first instance.

Travel Medicine

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