Health

The health of any traveller abroad may not be protected by services and legislation well-established at home. Changes in food and water may bring unexpected problems, as may insects and insect-borne diseases, especially in hot countries. Few have at their fingertips the current detailed knowledge needed to advise the traveller going to a particular country and personal reminiscences may not always reflect current or common problems. A danger of generalising is that it may be forgotten, for example, that malaria is a risk in Turkey, poliomyelitis occurs in Europe, and hepatitis A virus occurs worldwide and is not destroyed by many methods of purifying drinking water. Specific advice on which diseases are present in countries to be visited is likely to be complicated. A practical starting point for the traveller seeking advice is to consider which diseases can be prevented by immunisation, prophylactic tablets, or other measures, and decide whether it is appropriate to do so for each individual.
An unpredictable environment is especially a problem for the overland traveller who plans his own journey, and he needs greater knowledge of disease prevention and management than the traveller in an airplane or on a sea cruise, whose environment, food and drink are largely in the hands of the operator. Unforeseen changes in timetables may lead to stays in accommodation not of the expected standard. Delays at airports can take place in overcrowded and unhygienic conditions where the facilities have not kept pace with increased demand, and also insect-borne diseases may be contracted. Jet-lag and exhaustion may prompt a traveller to take risks with food and drink. More experienced travellers tend to have fewer health problems. Better planning, immunisations and experience in prevention may all play a part, as well as salutary lessons learnt on previous occasions.
A questionnaire survey of returning travellers (most of whom had been to Europe, especially the Mediterranean countries) showed that half had had diarrhoea or respiratory symptoms while abroad. Excessive alcohol, sun and late nights can add to the problems. About one in 100 package holidaymakers who take out a health insurance policy make a claim. Diarrhoea and sunburn are principal reasons, but accidents are also common. Injuries occur especially in and around swimming pools, to pedestrians forgetting that traffic drives on the right, and from unfamiliar equipment such as gates on lifts. Sexually transmitted diseases may be contracted and may require urgent treatment.
Long-stay travellers may adapt to these initial problems, but then find themselves suffering from diseases endemic in their chosen country, such as malaria, hepatitis, diarrhoea and skin problems. Two per cent of British Voluntary Service overseas personnel contract hepatitis A within eight months if they are not protected. Car accidents occur while driving on unmetalled roads, and some emotional problems may be resolved only by an early return home.
The traveller should be insured against medical expenses and most policies include the cost of emergency repatriation when appropriate. Such insurance, however, rarely covers a service overseas similar to that available at home. Language and administrative differences are likely to present problems. The Department of Health (website: www.dh.gov.uk/policyandguidance/healthadvicefortravellers) lists the free or reduced-cost medical treatments available in other countries and the documents which the traveller has to have with him or her. Reciprocal arrangements between countries differ and money may have to be paid and then reclaimed in the visited country itself, which can be time consuming. Extra provision should be made for such emergencies. Any reciprocal arrangement between the UK and a country is mentioned in each country's entry.

The European Health Insurance Card (EHIC) entitles the holder to free or reduced-cost treatment in European Economic Area (EEA) countries and Switzerland. The EHIC replaced the E111 in January 2006 and is available via post offices or online (website: www.ehic.org.uk). E111 forms are no longer valid. Only a 'small' supply of medicines for personal use may be taken out of Britain, unless Home Office permission is obtained.

Immunisation

Yellow Fever

This disease is caused by a virus that circulates in animals indigenous to certain tropical forested areas. It mainly infects monkeys, but if man enters these areas the virus may be transmitted to him by mosquitoes whose normal hosts are monkeys. This is jungle yellow fever. It occurs haphazardly and is clearly related to man's habits. If, from an animal source, the virus begins to circulate between man and his own mosquitoes, primarily Aedes aegypti, epidemics of urban yellow fever result. Immunisation protects the individual and is effective in preventing the spread of the virus to countries where Aedes aegypti is prevalent. It is therefore reasonable for such countries to request a certificate of vaccination of all travellers from areas where human cases are occurring. Many national administrations, however, require immunisation of all travellers over one year of age from all countries, or else all travellers over one year from countries where enzootic foci occur. A map of zones where yellow fever is endemic (enzootic) can be found on page 1091. Immunisation is clearly not indicated when travelling outside the enzootic zones. Within the zones, if it is not compulsory, it is not always necessary. For instance, in the absence of an epidemic of yellow fever, a business trip within the confines of Nairobi would be perfectly safe. Nevertheless, local and current knowledge of cases is required for such decisions to be made, so in practice immunisation is recommended to all travellers within enzootic zones. Immunisation in Great Britain is undertaken only at recognised yellow fever vaccination centres.
Once immunised (a single vaccination is used), the vaccination certificate is valid after ten days for ten years. It is not recommended for pregnant women and children under nine months.

Cholera

In 1973 the WHO, recognising that immunisation cannot stop the spread of cholera among countries, deleted from the International Health Regulations the requirement of cholera immunisation as a condition of admission to any country. In 1990 the WHO stated that immunisation against cholera was not effective and they do not recommend it. In 1991 the WHO confirmed that certification was no longer required by any country or territory.

Typhoid Fever

Typhoid fever is endemic worldwide and is usually spread faecal-orally. The risk of infection is increased in areas of high carriage rates and poor hygiene. The risk is not significantly increased for the traveller to areas with public health standards similar to those of Britain - namely, northern Europe, USA, Canada, Australia, New Zealand and Japan - and immunisation for these areas is not necessary. Outside these areas the risks reflect not only local hygiene and carriage rates but also lifestyle. Travelling or living rough, living in rural areas, or 'eating out' make transmission more likely. The risks are therefore small for the air traveller with full board at a reputable hotel, and immunisation is unnecessary. On the other hand, overland travel to Australia would be a clear indication for immunisation. Between these extremes there are many
circumstances for which risks cannot be precisely defined. Typhoid vaccine is now no longer routinely recommended for the
millions of tourists to southern Europe each year, although it may still be advisable not only for those whose lifestyle or occupation increase the risk of such exposure, but also during local outbreaks.

Hepatitis A

The hepatitis A virus is endemic worldwide and spread by the faecal-oral route; protection from symptomatic infection can be provided by active immunisation or passively acquired immunoglobulin. The virus circulates freely in our own population however, and many travellers will be immune already. Protection should be offered to the same groups as are offered typhoid immunisation, as exposure to one infection would imply the risk of exposure to the other. The recurrent tropical traveller may have his antibodies against hepatitis A checked. If antibodies are present, that person is immune. If antibodies are absent, inactivated hepatitis A vaccine should be given. Hepatitis A in children is usually mild and more often asymptomatic, so immunisation is not essential. Immunoglobulin can, however, be given in reduced doses. Hepatitis A vaccine is available for use in children over the age of 12 months. Preparations combined with either Hepatitis B ot typhoid Vi vaccines are available.

Poliomyelitis

A survey undertaken in Scotland in 1989 showed that 20% of the tested population did not have antibodies to all three serotypes of poliovirus. Hence a consultation about travel abroad is a vital opportunity to complete primary courses or boost immunisations which are nationally recommended. Oral poliomyelitis vaccine is given, but supplies of inactivated polio vaccine are available if oral vaccine is contra-indicated.

Tetanus

As with poliomyelitis, all individuals should gain or maintain immunity to tetanus. It is as firmly recommended for life in Britain as for travel abroad. A preparation combined with low dose diphtheria toxoid is recommended for travellers when immunity requires boosting.

Special Rare Diseases

Rabies

Most doctors do not think it is necessary to immunise the ordinary traveller going to areas where rabies is endemic, although it may be advisable for those in remote areas who would be many days' travel away from a source of vaccine and rabies immunoglobulin. However, all travellers should avoid contact with animals, especially cats and dogs. If they do get bitten, wounds should be promptly washed with copious soap and water followed by the application of alcohol (spirits like gin and whisky can be used). If the animal's owner is available, ask whether the animal has been vaccinated against rabies (check certification). A forwarding address or telephone number should be left to enable contact to be made should the animal become unwell over the next two weeks. Seek local medical advice promptly and give details of the incident to the local police. On return, the traveller's medical practitioner should be informed.

Diphtheria

Diphtheria is endemic worldwide, but there are current resurgences in Eastern Europe following decreased immunisation rates. From 1995 to 1997, only five toxigenic isotates were notified in Great Britain, mostly from an imported source. Most morbidity and mortality are in children and they should be immunised as nationally recommended (initial primary course and booster on school entry and school leaving). Adult travellers with a high risk of infection are those in contact with children in poorer areas - for example, health workers and teachers. Travellers may have their immunity boosted by a low dose preparation of diphtheria toxoid. A preparation combined with tetanus toxoid is now also available.

Meningococcal meningitis

Although the bacteria responsible for this illness circulate widely throughout the world, certain areas, like the dry areas bordering the southern Sahara, are renowned for recurrent epidemics and many areas suffer occasional epidemics, as in India, Nepal and Brazil, and during the Mecca pilgrimages in recent years. Immunisation is available for the types of meningococci usually responsible for these outbreaks, and should be recommended for travellers to such areas with outbreaks, particularly those staying long-term.

Tick-borne encephalitis

Tick-borne encephalitis is caused by an arbovirus, transmitted by the bite of an infected tick. Its distribution is confined to warm and low-forested areas in parts of Central Europe and Scandinavia, particularly Austria, Czech Republic, Slovak Republic, Germany and throughout all the republics of former Yugoslavia. The forests are usually deciduous with heavy undergrowth. Those normally at risk are foresters and those clearing such areas, but increasing contact will occur with increased recreational use, such as camping and walking. Most human illness occurs in late spring and early summer. Tick bites are best avoided by limiting contact with such areas, wearing clothing to cover most of the skin surface and using insect repellents on outer clothes and socks.

Japanese B encephalitis

This virus infection is transmitted by mosquitoes in certain rural areas of eastern Asia, the Indian subcontinent and a few Pacific islands. Occasional larger outbreaks develop and this infection tends to have a higher mortality than the many other similar viruses that can cause encephalitis. If planning to sleep in rural areas with a high risk or an active outbreak, immunisation should be considered; this is available from Cambridge Self Care Diagnostics (tel: (0191) 261 5950; fax: (0191) 261 5915). Considerable protection is offered by avoiding mosquito bites (see below in the Malaria Prophylaxis section) and staying indoors at night in rural areas where known cases are occurring.

Plague

Plague is an infection of wild rodents transmitted by fleas. It exists in many rural areas of Africa, Asia and the Americas. The risk to the traveller from the bite of an infected flea is low. Routine immunisation is not recommended. In enzootic areas, usually rural and hilly, contact with rodents should be discouraged by preventing their access to food and waste, avoiding dead rodents and rodent burrows. Fleas can be discouraged by insect repellents. During the plague outbreak in small areas of India in 1994, travellers were advised to avoid infected areas. Immunisation was not part of the general advice given.

Hepatitis B

Vaccination should be considered for groups such as medical, nursing and laboratory staff planning to work among populations with high HBsAg carriage rates. The recommended regimen consists of three doses, the boosters being given one month and six months after the initial dose. Immunity is predicted to last about five years but those who remain at risk should have antibodies checked three months after completion of course. Quicker regimens are used but are less effective and should be boosted again at 6-12 months. A combined hepatitis A and hepatitis B vaccine is available.

HIV

People infected with HIV (human immunodeficiency virus), and who may appear perfectly well, pass on the infection by sexual intercourse or if their blood is inoculated into other people, as in the sharing of needles by drug users, the transfusion of untested blood, or the re-use of injection needles without sterilisation between patients. Certain areas of the world, such as parts of tropical Africa, South America and Asia have a higher number of carriers of HIV. However, the potential for infection exists worldwide and precautions should always be taken whether at home or abroad. The use of condoms and spermicidal cream during sexual intercourse should reduce the level of risk. Thought must also be given to the need for blood transfusions, where blood is not tested for HIV antibodies, and the need for injections where there is doubt about the sterility of the needles (these may be sterilised by placing in boiling water for 20 minutes). Kits containing appropriate needles and syringes are available. Travellers should know their blood group. The World Health Organisation is vigorously opposed to any country requiring travellers to present a certificate stating that they are free from HIV infection. Besides being against International Health Regulations, it is both clinically unsound and epidemiologically unjustifiable as a means of limiting infection. However, at least 40 countries have introduced restrictions, such as compulsory HIV testing or refusal of entry of 'suspicious' visitors, though mostly those planning to stay, work or study long-term.

Malaria Prophylaxis

Malaria is widespread in tropical and subtropical areas of the world and is spread by the bite of a female anopheline mosquito that has been infected by the malaria parasite.
The increasing mobility of the population, especially through air travel, brings a further hazard since travellers may be bitten by mosquitoes at airports en route as well as in the countries where they stay. The speed of travel means that first symptoms may occur in a country and in a context where the disease will not be immediately considered. Mosquitoes may even be brought in airplanes to non-endemic areas and infect, for example, airport staff or travellers' relatives. Infection also occurs through blood transfusion (cold storage does not destroy the parasites) and the sharing of needles by drug users.
The life-threatening form of malaria is caused by Plasmodium falciparum. Because of the travelling habits of those living in Britain, this form of malaria is usually imported from Africa but also from Asia. Prevention is primarily aimed at this parasite. Nevertheless, the same advice is given to those likely to be exposed to the less dangerous P vivax, P malariae, and P ovale, partly to prevent an unpleasant illness but also because P falciparum infection can never be presumed to be absent in any malarious area. There is no immediate prospect of an effective vaccine, so regular ingestion of prophylactic tablets is necessary. This requires habits which some find difficult or even distasteful, beside the possibility of side effects. With increasing resistance to these tablets, they can no longer guarantee protection from illness. Bites must be avoided or reduced (see below) and any flu-like illness with fever and shivers lasting more than two days should be promptly diagnosed. If such symptoms develop after return, even months afterwards, the attending doctor should be reminded of the date and place of travel.
Note: A map showing areas of malarial risk and areas where chloroquine resistance has been reported is printed on page 1119. Source: WHO, Geneva.

Personal precautions against malaria
(1) Avoid mosquito bites, especially after sunset, when the anopheline mosquitoes responsible for transmitting malaria are most active. Long trousers, sleeves and dresses, netting on windows, and mosquito nets over beds help to prevent mosquito bites.
(2) Insect repellents may be used on exposed skin and insecticides inside buildings or on breeding sites. Repellent-impregnated wrist and ankle bands, and electrical insecticide vaporisers may also be used.
(3) Mosquitoes should not be encouraged to breed by leaving stagnant water - for example, in blocked drains or around plant pots.
(4) Prophylactic tablets are necessary because the above measures, although valuable, are unlikely to be fully effective.
Precautions against malaria before travel
(a) Start tablets two weeks before departure to confirm tolerance and obtain adequate blood concentrations before exposure.
(b) Take the tablets with absolute regularity. Prophylactic doses of drugs are not normally curative should infection get established.
(c) Continue prophylaxis for at least four weeks after leaving an endemic area: all forms of the parasite develop first in the liver and only later re-enter the blood, where most prophylactic drugs take effect.
(d) Seek advice on which type of tablet to take from an advice centre (see table).

Children

As children begin to crawl and walk they become more vulnerable to faecal-oral infections and hazards such as bites, accidents and burns. Open wounds should be kept clean and covered with dressings until healed. Deaths from scorpion bites are unusual but mostly occur in children aged under two years. Allowing toddlers to play outside unattended can be particularly hazardous.
Taking adequate malarial prophylaxis should not encourage the traveller to ignore the risks from other mosquito-borne diseases such as dengue, which can be more severe in children. Protection from mosquito bites is also important in those children who are strongly allergic to them. Appropriate clothes and bed or window netting at night are usually more valuable in the long term than insect repellents.

Pregnancy

Live vaccinations are best not given during pregnancy, although if someone unprotected against yellow fever is going to live in a high risk area, the theoretical risk of vaccination is outweighed by the serious nature of the illness. If the vaccine is not given, a doctor's letter endorsed with a health board or authority stamp to say the inoculation is contra-indicated is usually accepted. Inactivated poliomyelitis vaccine may be used instead of oral live vaccine.
A mother immunised against tetanus passes on protection to her baby over the neonatal period and a booster can be given during pregnancy if necessary. Hepatitis A in pregnancy may be more severe and also result in premature labour. Prevention with normal immunoglobulin is generally encouraged for those at risk. Malarial prophylaxis should be maintained throughout pregnancy but the risks of some drugs have to be balanced against the type of malaria and likelihood of its transmission in different areas and specialist advice should be sought.

Contraception

Those using oral contraceptives should be aware that absorption may be affected during gastrointestinal illnesses, that some brands may not be available locally, and that they may be continued over the usual break in the cycle if menstruation is going to occur at an inconvenient time such as during a long journey. They may contribute to the fluid retention that some people experience in hot climates. Reliable condoms are not available in all localities abroad.