12/15/11

General Practice, Chapter 12

Chapter 12 - Travel and tropical medicine

If you can't peel it, boil it or cook it-don't eat it.
Anon

Emporiatics-the science of travel medicine

With over 400 million international trips being taken annually the health problems faced by travellers are
considerable and variable depending on the countries visited and the lifestyle adopted by the traveller. 1
There is evidence that many travellers are receiving inaccurate predeparture travel advice. 2 Travellers to
North America, Europe and Australasia are usually at no greater risk of getting an infectious disease than
they would be at home, but those visiting the less developed tropical and subtropical countries of Africa,
Central and South America and South-East Asia are at significant risk of contracting infectious diseases.
Problems range in complexity from the most frequent and usually benign problems, such as traveller's
diarrhoea, to more exotic and potentially fatal infections such as malaria, Japanese encephalitis and HIV.
It must also be remembered that in some countries with volatile political changes there is the possibility of
injury, incarceration or being left stranded. Travel means transport and thus the potential for accidents and
crippled body and bank balance. Insurance for such contingencies is as important as preventive health
measures.

Key facts and checkpoints

The main diseases facing the international traveller are traveller's diarrhoea (relatively mild) and
malaria, especially the potentially lethal chloroquine-resistant falciparum malaria (CRFM).
Most cases of traveller's diarrhoea are caused by enterotoxigenic Escherichia coli (E.coli)-up to
75%. Enteroinvasive E.coli (a different serotype) produces a dysentery-like illness similar to Shigella.
Traveller's diarrhoea is contracted mainly from contaminated water and ice used for beverages,
washing food or utensils or cleaning teeth.
One bite from an infected mosquito during a single overnight stop in a malaria area can result
in a possible lethal infection.
Infections transmitted by mosquitoes include malaria, yellow fever, Rift Valley fever, Japanese
encephalitis and dengue fever. Preventing their bites is excellent prevention.
Every year over 500 Australians catch malaria while travelling overseas.
Malaria is a dusk-till-dawn risk only, but bites from daytime mosquitoes can cause dengue.
CRFM is steadily increasing, as is resistance to newer antimalarials.
It is important for general practitioners to consult a Travel Medicine Database to obtain specific
information about 'at risk' countries.

Principles of pretravel health care

Advise the patient to plan early-at least 8 weeks beforehand.
Advise a dental check.
Allow adequate time for consultation, e.g. 30-45
minutes. Individualise advice.
Provide current information.
Provide written as well as verbal advice.
Provide a letter concerning existing medical illness and
treatment. Encourage personal responsibility.

Gastrointestinal infections
The commonest problem facing travellers is traveller's diarrhoea but other important diseases caused by
poor sanitation include hepatitis A, and worm infestations such as hookworm and schistosomiasis.
Contamination of food and water is a major problem especially in Third World countries.
Reputable soft drinks, such as Coca-Cola, should be recommended for drinking. Indian-style tea, in which
the milk is boiled with tea, is usually safe, but tea with added milk is not. The food handlers can be infected
and the water used to wash food may be contaminated.
file:///E:/Downloads/murtagh/GP_Murtagh/html/GP-C12.htm

Traveller's diarrhoea
Traveller's diarrhoea is a special problem in Mexico, Nepal, India, Pakistan, Latin America, the Middle
East and central Africa and its many colourful labels include 'Bali Belly', 'Gippy Tummy', 'Rangoon Runs',
'Tokyo Trots' and 'Montezuma's Revenge'. It occurs about 6-12 hours after taking infected food or water.
The illness is usually mild and lasts only two or three days. It is unusual for it to last longer than five days.
Symptoms include abdominal cramps, frequent diarrhoea with loose watery bowel motions and possible
vomiting. Very severe diarrhoea, especially if associated with the passing of blood or mucus, may be a
feature of a more serious bowel infection such as amoebiasis.
Most traveller's diarrhoea is caused by an enterotoxigenic E. coli. Travellers are infected because they are
exposed to slightly different types or strains of E. coli from the ones they are used to at home. 3
The possible causes of diarrhoeal illness are listed in Table 12.1 .
Table 12.1 Causes of diarrhoea in travellers
Causative organism

Bacteria

Escherichia coli
Shigella species
Salmonella species
Campylobacter jejuni
Vibrio cholerae
Yersinia
enterocolitica
Aeromonas
hydrophilia
Staphylococcus aureus
(toxin) Clostridium
perfringens Bacillus cereus

Viruses

Rotavirus
Norwalk
virus

Protozoa parasites Cryptosporidium

Entamoeba histolytica
Giardia lamblia
Strongyloides
stercoralis
Chemicals

Capsicum (chilli)

Type of illness

Traveller's
diarrhoea
Dysentery
Typhoid fever, food poisoning
Traveller's diarrhoea,
dysentery Cholera
Traveller's
diarrhoea
Traveller's
diarrhoea Food
poisoning Food
poisoning Food
poisoning
Children's
diarrhoea
Traveller's
diarrhoea
Amoebiasis
Giardiasis
Strongyloidiasis

Treatment
Refer to Figure 12.1. 3

Mild diarrhoea
Maintain fluid intake-cordial or diluted soft drink.
Antimotility agents (judicious use: if no blood in stools)
loperamide (Imodium) 2 caps statim then 1 after each unformed stool (max: 8 caps/day)
or
diphenoxylate with atropine (Lomotil) 2 tablets
statim then 1-2 (o) 8 hourly.
Imodium is the preferred agent.

Moderate diarrhoea

Attend to hydration.
Patient can self-administer antibiotic-e.g. norfloxacin 400 mg bd for 3 days, or ciprofloxacin; use cotrimoxazole in children.
Avoid Lomotil or Imodium.

Fig. 12.1 Algorithm for adult travellers with acute diarrhoea

Severe diarrhoea (patient toxic and febrile)

? Admit to hospital.
Attend to hydration-use an oral hydrate solution, e.g. Gastrolyte or WHO formulation.
Avoid Lomotil and Imodium.
Antibiotic: norfloxacin or ciprofloxacin.
Note: There is increasing resistance to doxycycline and co-trimoxazole, especially in South-East Asia.

Persistent diarrhoea
Any travellers with persistent diarrhoea after visiting less developed countries, especially India and China,
may have a protozoal infection such as amoebiasis or giardiasis. If the patient has a fever and mucus or
blood in the stools, suspect amoebiasis. Giardiasis is characterised by abdominal cramps, flatulence, and
bubbly, foulsmelling diarrhoea persisting beyond 2 to 4 days.
Treatment
Giardiasis: tinidazole or metronidazole
Amoebiasis: metronidazole or tinidazole
Patient can self-administer these drugs and carry them if visiting areas at risk, but they can have a severe
adverse reaction with alcohol.

Preventive advice
The following advice will help prevent diseases caused by contaminated food and water. These 'rules' need
only be followed in areas of risk such as Africa, South America, India and other parts of Asia.
Purify all water by boiling for 10 minutes. Adding purifying tablets is not so reliable, but if the water
cannot be boiled some protection is provided by adding Puratabs (chlorine) or iodine (2% tincture of
iodine), which is more effective than chlorine-use 4 drops iodine to 1 litre of water and let it stand
for 30 minutes.
Do not use ice. Drink only boiled water (supplied in some hotels) or well-known bottled beverages
(mineral water, 7-up, Coca-Cola, beer).
Avoid fresh salads or raw vegetables (including watercress). Salads or uncooked vegetables are often
washed in contaminated water. Bananas and fruit with skins are safe once you have peeled and
thrown away the skin but care should be taken with fruit that may possibly be injected with water.
Be wary of dairy products such as milk, cream, ice-cream and cheese.
Avoid eating raw shellfish and cold cooked meats.

Avoid food, including citrus fruits, from street

vendors. Drink hot liquids wherever possible.
Use disposable moist towels for hand washing.
The golden rule is: If you can't peel it, boil it or cook it-don't eat it.

Malaria
General aspects:
Travellers to all tropical countries are at some risk.
Malaria is endemic in 102 countries; 4 2.3 billion people are at risk.
The risk is very low in the major cities of Central and Southern America and South-East Asia but can
be high in some African cities.
Malaria is either benign (vax, ovale) or malignant (falciparum).
Resistance to many drugs is increasing:
The lethal Plasmodium falciparum is developing resistance to chloroquine and the antifolate
malarials (Fansidar and Maloprim). 4
Resistance is now reported to mefloquine.
CRFM is common in South-East Asia, Papua New Guinea, northern South America and parts
of Africa.
Chloroquine is still effective against P. ovale and P. vivax (the most common forms).
The long-awaited vaccine will make all the complex drug management much simpler. However, it still
appears to be many years away despite considerable research.
Patients who have had splenectomies are at grave risk from P. falciparum malaria.
People die from malaria because of delayed diagnosis, delayed therapy, inappropriate therapy
and parasite-host factors.
Practitioners should follow updated recommended guidelines, e.g. NH&MRC, WHO.

Malaria risk assessment

The risk of catching malaria is increased by:
being in a malaria area, especially during and after the wet season
a prolonged stay in a malaria area, especially rural areas, small towns and city
fringes sleeping in unscreened rooms without mosquito nets over the bed
wearing dark clothing with short-sleeved shirts and
shorts taking inappropriate drug prophylaxis

Malarial prevention
Travellers should be advised that malaria may be prevented by following two simple rules:
avoid mosquito bites; and
take antimalarial medicines regularly
In order to avoid mosquito bites, travellers are advised to:
keep away from rural areas after dusk
sleep in air-conditioned or properly screened rooms
use insecticide sprays to kill any mosquitoes in the room or use mosquito coils at night
smear an insect repellent on exposed parts of the body; an effective repellent is diethyl-mtoluamide (Muskol, Repellem, Rid)
use mosquito nets (tuck under mattress; check for tears)
impregnate nets with permethrin (Ambush) or deltamethrin
wear sufficient light-coloured clothing, long sleeves and long trousers, to protect whole body and
arms and legs when in the open after sunset
avoid using perfumes, cologne and after shave lotion (also attracts insects)

Important considerations in malaria prophylaxis

1. Minimise exposure to mosquitoes and avoid bites.

2. Know areas of risk:
tropical South America (southern Mexico to northern half South America)
tropical Africa (sub-Sahara to northern South Africa)
Nile region including Egypt
Southern Asia especially tropical areas
3. Know areas of widespread chloroquine resistance:
Asia, tropical South America (rare north of Panama Canal), sub-Sahara, East Africa
4. Consider several factors:
intensity of transmission
season and length of
stay itinerary
urbanhotel urban
non-hotel rural
housing rural
backpacking
resistance patterns
host factors
age
pregnanc
y
associated illness
compliance
5. Know the antimalarial drugs (Table 12.2).
6. Balance risk benefit of drug
prophylaxis: drug side effects versus
risk of CRFM.
7. Visiting areas of CRFM does not automatically require the use of potentially harmful drugs. 1
8. Those at special risk are pregnant women, young children and the immunocompromised.
Advise against travel.
9. No drugs give complete protection.

Table 12.2 Common drugs used for malarial

prophylaxis
Adult dosage

Chloroquine 300 mg base (2 tabs) same day

each week 2 wk before, during, 4 wk
after exposure
Doxycycline 100 mg each day, 1-2 days
before, during, 2-4 weeks after
M efloquine 250 mg (1 tab) same day each week,
1 week before, during, 2 weeks after

Proguanil

200 mg (2 tabs) same day each week

1 day before, during, 4 weeks after

Children's dose

5 mg base/kg
up to maximum
adult dose
> 8 years only
2 mg/kg/day up to
100 mg
Not recommended <
45 kg > 45 kg as for
adults

< 1 year: % tablet

1-4 years:
tablet 5-8 years: 1
tablet

Comments

9-14 years: 1 tablet

> 14 years: adult

Only antimalarial approved for pregnancy

Aggravates psoriasis Beware of retinopathy
Photosensitivity reactions
Side effects:
dizziness, 'fuzzy' head, blurred vision

Beware
of betablocker
s
Safe
lactation

in

and
pregnancy
(give folic acid)
Side effects:
GIT disturbances,
headache,
dizziness, rash

Drug prophylaxis
Guidelines
Accommodation in large air-conditioned hotels in most cities of South-East Asia (duskdawn) for < 2
weeks: no prophylaxis required.
For low-risk travel (urban: duskdawn) in areas of high resistance for < 2 weeks: chloroquine
adequate; use a treatment course of mefloquine if necessary (Table12.3).
For short- and long-term travel to rural areas of high resistance, e.g. South-East Asia including
Thailand, Kenya, Tanzania, Ecuador, Venezuela, Brazil: doxycycline daily alone or mefloquine (once
a week).
Table 12.3 Drugs used for chloroquine-resistant malaria (presumptive breakthrough where
professional medical care unavailable) 5
Adult dose

Mefloquine
Pyrimethamine/sulfadoxine
(Fansidar)

750 mg (3 tablets) statim, then 500

mg after 6-8 hours or 1000 mg statim
3 tablets as a single dose

Children's dose

only recommended if weight

> 45 kg (as for adults)
2-11 months: %
tablet 1-3 years:
tablet
4-8 years: 1 tablet
9-14 years: 2 tablets
> 14 years: 3 tablets

Summary of recommendations
1. CSFM area: chloroquine
2. CRFM area:
mefloquine 250 mg/week
or
doxycycline 100 mg/day
3. Multidrug-resistant area
doxycycline 100
mg/day for stays > 8
weeks
chloroquine
+
doxycycline 50-100 mg/day
Standby treatment: mefloquine + Fansidar 5
CSFM = chloroquine-sensitive falciparum malaria
CRFM = chloroquine-resistant falciparum malaria

Specific infectious diseases and immunisation

Protection from many types of infection is available through immunisation. All travellers should be
immunised against tetanus, polio and diphtheria and measles. Protection against tetanus requires an initial
course of three injections followed by a booster every 10 years.
Vaccinations are required for special circumstances. Yellow fever vaccination is a legal requirement for any
travellers returning from a yellow fever endemic area. Cholera is not usually required.

Some travellers may be exposed to tuberculosis, hepatitis, plague, rabies, typhoid, typhus, and
meningococcal infection. Immunisation against these is available and recommended for those at risk.
Smallpox has now been eradicated from the world and therefore smallpox vaccination is no longer required
for any traveller.

Japanese B encephalitis presents as a special problem to the traveller.

Tabl e 12. 4 outlines a summary of recommendations to consider. 6
Table 12.4 Summary of preventive measures and vaccinations

All travellers, all destinations

Tetanus toxoid and diphtheria booster
if > 10 years since last dose
if > 5 years for Third World travel
give CDT < 8 years ADT > 8
years
All travellers to developing countries free of malaria
Tetanus toxoid booster
Polio immunisation if > 10 years
Measles immunisation (consider MMR)
Yellow fever (if compulsory)
Preventive measures against:
gastrointestinal infections
sexually transmitted diseases
mosquito bites
Travellers to developing and other countries at high risk of
infection As above plus:
Malaria prophylaxis
Hepatitis A-vaccine or immunoglobulin
Hepatitis B
Typhoid
Tuberculosis (BCG if Mantoux -ve)
Other vaccinations: consider
meningococcus (required in some countries)
Japanese B encephalitis
rabies
typhus
plague
anthrax
cholera

Compulsory immunisations
The two vaccinations that may be required before visiting 'at risk' areas are meningococcus and yellow fever.

Yellow fever
Yellow fever is a serious viral infection spread by mosquitoes and, like malaria, is a tropical disease. Yellow
fever vaccination is essential for travel to or through equatorial Africa and northern parts of South America,
and for re-entry to Australia from those countries.
One injection only is required and the immunisation is valid for 10 years. Children aged less than 9 months
should not be given this vaccine. It should not be given within 3 weeks of cholera vaccine.
Note: It is important to check specific country requirements in the World Health Organisation book on
vaccination requirements. 8
According to WHO a certificate against yellow fever is the only certificate that should be required for
international travel. The requirements of some countries are in excess of International Health Regulations.
However, vaccination against yellow fever is strongly recommended to all travellers who intend to visit places
other than the major cities in the countries where the disease occurs in humans.

Meningococcal infection
Meningitis due to this organism is a contagious lethal disease. It is common in Nepal, Mongolia, Vietnam and
parts of Africa and Asia, especially in the dry season. Travellers trekking through the Kathmandu valley of

Nepal and those attending the Haj pilgrimage to Saudi Arabia are at special risk and should have the vaccine.
However, some countries require immunisation for entry. A booster is required after 3 years.

Voluntary immunisation
Precautions against the following diseases are recommended for those travellers who may be at special risk.

Hepatitis A, B, E
Hepatitis A is a common problem in rural areas of developing countries. There is a declining level of
antibodies to hepatitis A in developed countries and adults are at special risk; so 1 or 2 doses of hepatitis
A vaccine should be given. If there is insufficient time a single injection of human immunoglobulin (IG) can
give
protection for 3 to 6 months. It is safe for all age groups but children under 8 years should not need it. A
blood test for hepatitis A antibodies should be carried out to determine a person's immunity.
Prevention
The rules of avoiding contaminated food and water apply (as for traveller's diarrhoea).
Hepatitis B is endemic in South-East Asia, South America and other developing countries. Vaccination is
recommended especially for people working in such countries, particularly those in the health care area or
those who may expect to have sexual or drug contact. If patients have a 'negative' HBV core IgG titre, then
vaccination would be worthwhile (3 doses: 0, 1 and 6 months). Hepatitis E has a high mortality rate in
pregnant women.

Typhoid
Typhoid immunisation is not required for entry into any country but is recommended for travel to Third
World countries where the standards of sanitation are low. It should be considered for travellers to smaller
cities, and village and rural areas in Africa, Asia, Central and South America and Southern Europe.
The parenteral (subcutaneous) vaccine can be used but the new Typhim Vi vaccine or the oral vaccine,
which have fewer side effects, are generally preferred. The oral vaccine, which is given as a series of four
capsules, appears to afford protection for about 5 years but is contraindicated in the immunocompromised.

Cholera
Cholera vaccination is not officially recommended by the World Health Organisation (WHO) because it has
only limited effectiveness. It is advisable for health care workers or others at risk entering an endemic area.
Cholera is given in two injections 7 to 28 days apart. It is not recommended in children under 5 years or
pregnant women.

Japanese B encephalitis
This mosquito-borne flavivirus infection presents a real dilemma to the traveller and doctor because it is a
very severe infection (mortality rate 20-40%) with high infectivity and high prevalence in endemic countries.
The vaccine is prone to give anaphylaxis and is unlicensed in Australia and the United States. It may be
obtained only in very restricted circumstances but can be obtained more readily abroad.
The disease is prevalent during summer in the region bound in the west by Nepal and Siberian Russia and
in the east by Japan and Singapore, especially in Nepal, Burma, Korea, Vietnam, Thailand, China, eastern
Russia and the lowlands of India. Rice paddies and pig farms are areas of risk. The usual preventive
measures against mosquito bites are important.

Rabies
Rabies vaccination is recommended for some international aid workers or travellers going to rabies-prone
areas for long periods. The vaccination can be effective after the bite of a rabid animal; so routine
vaccination is not recommended for the traveller. Affected animals include dogs, cats, monkeys and feral
(wild) animals. A traveller who sustains a bite or scratch or even is licked by an animal in countries at risk
should wash the site immediately with soap or a detergent, and then seek medical help. The prebite
vaccination does not remove the need for postexposure vaccination.

Typhus
Typhus is transmitted to humans by bites from lice, fleas or ticks. Immunisation against typhus is desirable
for doctors, nurses, and agricultural and technical advisers whose work takes them to remote areas of

Bolivia, Burundi, Ethiopia, Mexico, Rwanda and mountainous regions of Asia. A booster injection should be
given at

12 months if the traveller is still in an area of risk.

Plague
Plague is still prevalent in rodents in several countries such as Vietnam, Brazil, Peru, Ecuador, Kenya and
Malagasy Republic. Although not compulsory, vaccination is recommended for those engaged in field
operations in plague areas and rural health workers who may be exposed to infected patients. Two doses
are given to adults (3 to children < 12 years) and a booster every 6 months.

Special problems
Prevention of sexually transmitted diseases
Casual sexual contacts place the traveller at risk of contracting a serious, perhaps fatal, sexually
transmitted disease (STD). The common STDs especially prevalent in South-East Asia and Africa are nonspecific urethritis, gonorrhoea (especially penicillin-resistant strains), hepatitis B, and syphilis. HIV infection
is a rapidly increasing problem, with heterosexual transmission common in Africa and in South-East Asia.
Unusual STDs such as lymphogranuloma venerum, chancroid and donovanosis are encountered more
commonly in tropical developing countries. A practical rule is to assume that all 'at risk' travellers are both
ignorant and irresponsible and advise accordingly.

Prevention
Abstinence or tak e your partner (condoms and diaphragms do not give absolute protection)

Drugs
Possession of and trafficking in drugs is very hazardous and many people are held in foreign prisons
for various drug offences. The penalty for carrying drugs can be death!
Countries that currently may enforce the death penalty are Burma, Indonesia, Malaysia, Singapore,
Thailand and Turkey. Travellers should be warned about taking cannabis while in a foreign country, as it
can cause profound personality changes in the user.
Drug addicts should under no circumstances travel. Young travellers should be wary about accepting lifts or
hitchhiking in countries 'at risk'.

Problems in the returned traveller

Most will present within 2 weeks except HIV infection.
Common infections encountered are giardiasis, amoebiasis, hepatitis A, B or E, gonorrhoea or
Chlamydia trachomatis, malaria and helminthic infestations.
An important non-infected problem requiring vigilance is deep venous thrombosis and
thromboembolism.
The asymptomatic traveller may present for advice about an illness acquired or about
exposure (without illness) such as rabies, malaria, schistosomiasis and sexually transmitted
diseases.

Exposure to STDs
If a patient has had unprotected intercourse and is at definite risk of acquiring an STD such as penicillinresistant gonorrhoea or NSU, the following may be appropriate: 1
ceftriaxone 250 mg IM (as a single dose)
doxycycline 100 mg (o) for 10 days.

Gastrointestinal symptoms
Mild diarrhoea

stool microscopy and culture

look for and treat associated helminthic infestation, e.g. roundworms, hookworms.

Moderate or prolonged (> 3 weeks) diarrhoea

Usually due to Giardia lamblia, Entamoeba histolytica, Campylobacter jejuni, salmonella, Yersinia
enterocolitica or Cryptosporidium.
stool examination (3 fresh specimens)
microscopy
wet
preparation
culture
treat pathogen (c lic k here for guidelines under diarrhoea)
Non-pathogens such as E.coli and Endolimax nana are often reported but do not treat specifically.
Note: Consider exotic causes such as schistosomiasis, strongyloidiasis and ciguatera in unusual chronic
post-travel 'gastro-enteritis'.
Persistent abdominal discomfort
This common syndrome includes bloating, intestinal hurry and borborygmi, and often follows an episode of
diarrhoea. Usually no pathogens are found on stool examination. However, giardiasis can be difficult to
detect and an empirical course of tinidazole (2 g statim) is worthwhile. Any persistent problem then is a
type of postinfective bowel dysfunction or irritable bowel. Reassurance is important.

Fever
Causes range from mild viral infections to potentially fatal cerebral malaria (Table 12.5) and
meningococcal septicaemia.
The common serious causes are malaria, typhoid, hepatitis (especially A and B), dengue fever and
amoebiasis.
Most deaths from malaria have occurred after at least 3 or 4 days of symptoms that may be
mild. Death can occur within 24 hours. Factors responsible for death from malaria include
delayed presentation, missed or delayed diagnosis (most cases), no chemoprophylaxis and old
age. Refer immediately to a specialist unit if the patient is unwell.
Be vigilant for meningitis and encephalitis.
Be vigilant for amoebiasis-can present with a toxic megacolon, especially if antimotility drugs
given. If well but febrile:
First line screening tests
full blood examination and ESR
thick and thin films
liver function tests
urine for micro and culture
Refer immediately if malaria is proven or if fever persists after a further 24 hours.

Malaria
See Figure 12.2 .
incubation period: P. falciparum 7-14 days; others 12-40 days
most present within 2 months of return
can present up to 2 or more years
can masquerade as several other illnesses

Symptoms
high fever, chills, rigor, sweating, headache
usually abrupt onset
can have atypical presentations, e.g. diarrhoea, abdominal pain, cough

Table 12.5 Fever and malaise in the returned traveller: diagnostic strategy model

Note: All fever in a returned traveller is malaria until proved otherwise!

Q.

Probability diagnosis

A.

Viral respiratory illness, e.g.

influenza Hepatitis (may be
subclinical) Gastroenteritis

Q.

Serious disorders not to be missed

A.

Malaria
Typhoid
Japanese B encephalitis
Meningococcal
meningitis Melioidosis
Amoebiasis (liver abscess)
HIV infection

Q.

Pitfalls (often missed)

A.

Ascending
cholangitis Infective
endocarditis Dengue
fever
Lyme disease
Bronchopneumonia
Ross River fever
Rarities
Legionnaires'
disease
Schistosomiasis
African trypanosomiasis
Yellow fever
Rift Valley fever
Spotted fever
Lasa fever

Note: Three causes of a dry cough (in absence of chest signs) are malaria, typhoid, amoebic liver abscess.
Q.

Seven masquerades check list

A.

Drugs
Urinary infection
Investigations (if no obvious
cause)
Full blood examination
Thick and thin blood films
Blood culture
Liver function tests
Urine-micro and culture
Stool-micro and culture
ESR
New malaria tests

Other features
Beware of modified infection.
Must treat within 4 days.

x (reaction to
antimalarials) x

Typical relapsing patterns often absent.

Thick smear allows detection of parasites (some laboratories are poorly skilled with thick
films). Thin smear helps diagnose malaria type.

Fig. 12.2 Clinical features of malaria

If index of suspicion high, repeat the smear ('No evidence of malaria' = 3 negative daily thick films).
Monocytosis is a helpful diagnostic clue. Newer tests e.g. PCR tests and ICT card tests show promise.
Cerebral malaria and blackwater fever are severe and dramatic.

Treatment
admit to hospital with infectious disease expertise
supportive measures including fluid replacement
P. vivax, P. ovale, P. malariae 4 7
(check G6PD first)
chloroquine 4 tabs (o) statim, then 2 tabs in 6
hours, then 2 tabs on day 2 and day 3
+
primaquine 15 mg (o) daily for 14 days
P. falciparum 4 7
uncomplicated:
quinine sulphate 600 mg (o) 8 hourly, 7 days
+
doxycycline 100 mg (o) daily, 7
days or
Fansidar, 3 tablets on day 3
or (alone as alternative to above)
mefloquine (for breakthrough dose)
complicated:
quinine dihydrochloride 20 mg/kg IV (over 4 hours)
then after 4-hour gap 10 mg/kg IV 8 hourly until improved
then
quinine (o) 7 days + Fansidar statim
Note: Check for hypoglycaemia.
Beware if antimalarial use in previous 48 hours.

Typhoid fever

Incubation period 10-14 days.

Clinical presentation
insidious onset
headache prominent
dry cough
fever gradually increases in 'stepladder' manner over 4 days or so
abdominal pain and constipation (early)
diarrhoea and rash (late)

Diagnosis
on suspicion --- blood culture serology not very helpful

Treatment
ciprofloxacin

Dengue fever
Also known as 'breakbone' fever, it is widespread in SE Pacific and endemic in Queensland.

Features
mosquito-borne viral infection
incubation period 5-6 days
abrupt onset fever, malaise, headache, pain behind eyes, severe backache
severe aching of muscles and joints
fever subsides for about 2 days then returns
maculopapular rubelliform rash on limbs --- trunk
generalised erythema with 'islands of sparing'
the rare haemorrhagic form is very severe; may present with shock
later severe fatigue and depression (prone to suicide)

Diagnosis
specific serology

Treatment
is symptomatic with supportive follow-up

Prevention
avoid mosquito bitesno vaccine available

Japanese B encephalitis and meningococcal meningitis

Consider these serious infections in a patient presenting with headache, fever and malaise before neurological
symptoms such as delirium, convulsions and coma develop.

Other tropical infections

Travellers to tropical or subtropical areas are at risk of more unusual infections. Most of these infections
are contracted through contaminated food and water, insect bites and walking barefoot on contaminated
soil. The risk of such infections is highest in rural areas of countries other than Europe, North America and
Australasia.

African trypanosomiasis (sleeping sickness)

Clinical features
incubation period about 3 weeks

fever, headache and a skin chancre or nodule

lymphadenopathy, hepatosplenomegaly

Diagnosis
demonstrating trypomastigotes in peripheral blood smear or chancre aspirate

Treatment
suramin IV
infectious disease consultation essential

Prevention
Avoid bites of the tsetse fly. If visiting areas of East, Central and West Africa, especially the 'safari game
parks', travellers should use insect repellent and wear protective light-coloured clothing including long
sleeves and trousers.

Cutaneous leishmaniasis
This may be encountered in travellers and servicemen and servicewomen returning from the Middle East,
especially the Persian Gulf. The protozoa is transmitted by a sandfly and has an average incubation period
of 9 weeks. The key clinical finding is an erythematous papule. Diagnosis is made by performing a punch
biopsy and culturing tissue in a special medium. Treatment for extensive lesions is with high dosage
ketoconazole for 1 month. Smaller lesions should be treated topically with 15% paromomycin and 12%
methyl benzethonium chloride ointment applied bd for 10 days. 8 A special vaccine is available in some
Middle Eastern countries, e.g. Israel.

Schistosomiasis (bilharzia)
The first clinical sign is a local skin reaction at the site of penetration of the parasite (it then invades liver,
bowel and bladder). This site is known as 'swimmer's itch'. Within a week or so there is a generalised
allergic response usually with fever, malaise, myalgia and urticaria. A gastroenteritis-like syndrome can
occur (nausea, vomiting, diarrhoea) and respiratory symptoms, particularly cough. Clinical findings, such
as trypanosomiasis, include lymphadenopathy and hepatosplenomegaly.
The infestation is caused by parasite organisms (schistosomes) whose eggs are passed in human
excreta, which contaminates watercourses (notably stagnant water) and irrigation channels in Egypt,
other parts of Africa, South America, some parts of South-East Asia and China. Freshwater snails are
the carriers (vectors).

Diagnosis
detecting eggs in the stools, the urine or in a rectal biopsy

Treatment
praziquantel

Prevention
Travellers should be warned against drinking from, or swimming and wading in, dams, watercourses or
irrigation channels, especially in Egypt and other parts of Africa.

Hookworm and strongyloidiasis

Hookworm and Strongyloides are parasites that are acquired by walking barefoot (or wearing thongs or
sandals) on earth contaminated by faeces. The larvae penetrate the skin, travel through the lungs and
settle in the small intestine. The first sign is local irritation or 'creeping eruption' at the point of entry known
as 'ground itch', which is often unnoticed. This subsides within 2 days or so and is followed 1-2 weeks
later by respiratory symptoms, which may be associated with bronchitis and bronchopneumonia.
Eventually a severe
and chronic anaemia may develop. Hookworm infection is the commonest cause of iron deficiency anaemia in
the world. Strongyloidiasis, which usually does not present with anaemia, is an important pathogen since it
remains undetected for decades and presents as a severe infection such as septicaemia when the host
becomes immunocompromised for any reason.

Diagnosis
detecting larvae or ova in the stool

Treatment (adults)

Hookworm-mebendazole
100 mg bd for 3 days
Strongyloidiasis - thiabendazole 1.5 g bd for 2 days (or more)
Adverse effects are common. Beware of these drugs in pregnancy and children.

Prevention
Travellers should be warned to wear shoes and socks in endemic areas to prevent entry of the larvae into
the skin of the feet.

Cutaneous larva migrans

Cutaneous larva migrans (creeping eruption) should be suspected in any pruritic, erythematous lesion with
a serpiginous eruption on the skin, especially the hands and feet of a person from a subtropical or tropical
area. It is caused by the larvae of dog or cat hookworms penetrating and migrating throughout human skin,
the larva always being just ahead of the lesion it causes. The diagnosis is based on the classic clinical
appearance and by eosinophilia. Biopsy is usually not indicated. The problem is usually self-limiting.

Diagnosis
clinical (characteristic appearance), eosinophilia (biopsy usually not indicated)

Treatment
albendazole or thiabendazole 7
antihistamines for pruritus
Note: This is usually a self-limiting problem.

Prevention
As for hookworm. Moist sandy soil contaminated with dog or cat faeces is a common source.

Cutaneous myiasis
Myiasis, which refers to the infestation of body tissues by the larvae (maggots) of flies, often presents as
itchy 'boils'. Primary myiasis invariably occurs in travellers to tropical areas such as Africa whereby the fly
can introduce the larvae into the skin, or it can be due to secondary invasion of pre-existing wounds.
Close
inspection of lesions may reveal part or all of the larva. The simplest treatment is lateral pressure and tweezer
extraction.

Trichuriasis (whipworm)
This common tropical parasite is sometimes seen in northern Australia. When the eggs are ingested with
food, the larvae hatch in the small intestine and develop into adult worms, 3 to 5 cm long, which attach by
means of their whiplike end to the mucosa of the large intestine. The majority of infected persons are
asymptomatic but in heavy infection, abdominal cramps, diarrhoea, distension, nausea and vomiting and
even rectal prolapse may develop.

Diagnosis
identifying characteristic eggs in faecal smears

Treatment
oral mebendazole or albendazole

Scrub typhus
Scrub typhus is found in South-East Asia, northern Australia and the western Pacific. It is caused by
Rick ettsia tsutsugamushi, which is transmitted by mites.

Features
abrupt onset febrile illness with headache and myalgia

a black eschar at the site of the bite with regional and generalised lymphadenopathy shortlived macular rash
can develop severe complications, e.g. pneumonitis, encephalitis

Diagnosis
serological assays and microimmunofluorescence

Treatment
doxycycline 100 mg bd for 7-10 days.

Queensland tick typhus

Queensland tick typhus, which is caused by Rick ettsia australis, is directly related to a tick bite.
The symptoms are almost identical to scrub typhus, although less severe, and the treatment is
identical.

Melioidosis
This serious disease with a high mortality is caused by the Gram-negative bacillus, Pseudomonas
pseudomallei, a soil saprophyte that infects humans mainly by penetrating through skin wounds, especially
abrasions. It is mostly acquired while wading in rice paddies. It is mainly a disease of Third World countries
and occurs between 20 North and 20 South of the equator, mainly in South-East Asia and including
Northern Australia. It may manifest as a focal infection or as septicaemia with abscesses in the lung,
kidney, liver or spleen. It presents with fever, cough and myalgia. It is called the 'Vietnamese time bomb'
because it can present years after the initial infection in Vietnamese war veterans.

Diagnosis
blood culture, swabs from focal lesions, haemagglutination test

Treatment (adults) 7
ceftazidime 2g IV, 6-8 hourly
+ either
co-trimoxazole 320/1600 mg (o) or IV, 12 hourly
or
doxycycline 100 mg (o) or IV, 12
hourly all for at least 14 days
followed by
oral co-trimoxazole or doxycycline bd for 3 months

Prevention
Traumatised people with open wounds (especially diabetics) in endemic areas (tropical South-East Asia)
should be carefully nursed.

Ciguatera
This is a type of fish food poisoning caused by eating tropical fish, especially large coral trout and large
cod, in tropical waters, e.g. the Caribbean and tropical Pacific. The problem is caused by a type of poison
that concentrates in the fish after they feed on certain micro-organisms around reefs. Ciguatera poisoning
presents as a bout of 'gastroenteritis' (vomiting, diarrhoea and stomach pains) and then symptoms
affecting the nervous system such as muscle aching and weakness, paraesthesia and burning sensations
of the skin, particularly of the fingers and lips. There is no cure for the problem but it can be treated with
gammaglobulin. It is unwise to eat large predatory reef fish, especially their offal (mainly the liver).

Pregnancy and travel

Most international airlines do not allow passengers to travel after the thirty-sixth week of pregnancy and
may require a doctor's certificate after twenty-eight weeks. Air travel is contraindicated in the last month of
pregnancy and until the seventh day after delivery. The past obstetric history should be taken into account.
The same health risks apply except that most antimalarial tablets and vaccinations are not recommended.
Only chloroquine is definitely safe. Live vaccinations (measles, rubella, influenza) are generally
contraindicated 9 but the WHO considers it safe to have polio vaccine. Administration of killed or
inactivated vaccines, toxoids and polysaccharides is permitted during pregnancy. Yellow fever vaccine is
considered safe after the sixth month. As a general rule pregnancy and travel to Third World countries do
not mix and
pregnant women should be advised not to travel to these countries.

Tetanus immunisation is important as protection is passed on to the child during early infancy. Immunoglobin
can be safely given as prevention against hepatitis.
The antimalarial drugs chloroquine, quinine and proguanil may be given to pregnant women but all others

mentioned in Table 12.2 are contraindicated.

Children and travel

Although children including infants are good travellers and adapt well, their resistance, especially to heat and
infections, is lower. A child can suffer from acute dehydration very rapidly. 9 Air travel is not recommended for
infants of less than 7 days or premature infants.
The change in atmospheric pressure on landing can cause distressing ear pain, so taking a bottle during
descent is recommended.
In tropical areas it is important to keep children well hydrated and they should wear loose cotton clothing. A
good guide to the health of children is the amount and colour of their urine. If it is scanty and concentrated
they are not getting sufficient fluid.
Most vaccines (diphtheria, tetanus, poliomyelitis, BCG) can safely be given in the first few weeks of life.
Measles is common overseas and it is worthwhile considering it even under 12 months. Yellow fever
vaccine should not be given under 12 months. Hence the importance of protection against mosquito bites.
Malaria prophylaxis is important. Chloroquine, proguanil and quinine may be given safely to infants.
However, as a rule young children should be discouraged from travel.

Air travel
Air travel is safe and comfortable, but jet lag and air sickness are problems that face many travellers.

Jet lag
This is the uncomfortable aftermath of a long flight in which the person feels exhausted and disoriented,
and has poor concentration, insomnia and anxiety. The problem on arrival is poor concentration and
judgment during the daytime.
Other symptoms that may occur include anorexia, weakness, headache, blurred vision and dizziness.
Jet lag is a feature of flying long distances east-west or west-east through several time zones, causing the
person's routine daily rhythm of activity and sleep to get out of phase. The worst cases appear to be in
those travelling eastbound from England to Australia. It can occur with travel in any direction, but the
north-south flights are not so bothersome.

Factors influencing jet lag

Personal factors. These include age, state of health, tolerance to change, preparation for the long trip and,
very importantly, the emotional and mental state.
General factors. Noise, vibration, air humidity and sitting still for long periods can influence jet
lag. Specific factors. Duration of the flight, time of departure, and changes in climate and culture
at the destination affect the severity of jet lag. The problem is aggravated by:
stress of the pretrip planning
last minute rushing and anxiety
lack of sleep during the trip
overeating and excessive alcohol during the flight
smoking

How to minimise the problem (advice to patients)

Before the flight
Allow plenty of time for planning.
Plan a stopover if possible.
If possible arrange the itinerary so that you are flying into the
night. Ensure a good sleep the night before flying.
Ensure a relaxed trip to the airport.
Take along earplugs if noise (75-100 decibels) is bothersome.

During the flight

Fluids. Avoid alcohol and coffee. Drink plenty of non-alcoholic drinks such as orange juice and mineral

water.
Food. Eat only when hungry and even skip a meal or two. Eat the lighter, more digestible parts of
your meals and avoid fatty foods and rich carbohydrate foods.
Dress. Women should wear loose clothes (e.g. long skirts, comfortable jeans, light jumpers) and
avoid girdles or restrictive clothing. Wear comfortable (not tight) shoes and take them off during
flight. Smok ing. Reduce smoking to a minimum. Non-smokers should seek a non-smoking zone.
Sleep. Try to sleep on longer sections of the flight (give the movies a miss). Close the blinds, wear
special eye masks and ask for a pillow. Sedatives such as temazepam (Euhypnos or Normison) or
antihistamines can help sleep.
Activity. Try to take regular walks around the aircraft and exercise at airport stops. Keep feet up
when resting, and exercise by flexing the major muscles of the legs. Avoid resting the calves of legs
against the seat for long periods. Rest without napping during daylight sectors.
Special body care. Continually wet the face and eyes. A wetting agent such as hydromellose 0.5%
eye drops can help those with a tendency to sore eyes.
At the destination
Take a nap for 1-2 hours if possible.
Wander around until you are tired and go to bed at the usual time. It is good to have a full day's
convalescence and avoid big decision making soon after arrival. Allow about three days for adjustment
after the London to Australia flight.

Who is fit to fly?

Patients with these problems should avoid flying: 9
upper airways congested by infection, including
influenza acute gastroenteritis
severe respiratory disease (emphysema, chronic bronchitis,
pneumothorax) unstable heart failure
severe anaemia (below 8 g/dL)
pregnancy beyond 200 days (28 weeks) (up to 36 weeks if necessary)
previous violent or unpredictable behaviour
within 4 weeks of a myocardial infarction
within 14 days of a cerebrovascular accident
within 14 days of major surgery
brain tumour or recent skull fracture
recent eye surgery
severe or poorly controlled
hypertension poorly controlled epilepsy
Special precautions are required by travellers with the following problems:
Colostomy. Patients should wear a large colostomy bag and take extra bags.
Varicose veins. Such patients should wear supportive stockings and exercise frequently.
Plaster casts. Those with broken limbs in plaster should be careful of swelling.
Pacemak ers. Those with pacemakers may have a problem with X-rays at some overseas airports.
Mention it to security officials before passing through security equipment.
Epilepsy. Medication should be increased on the day of travel.
Diabetics. Diabetics should discuss their therapy and control with their doctor. They should
carry sweets.

Travel sickness
Almost everyone is sick when sailing on rough seas. However, some people, especially children, suffer
sickness from the effect of motion on a boat, in a car or in a plane. The larger the boat, plane or car, the
less the likelihood of sickness; travel by train rarely causes sickness. Nearly all children grow out of the
tendency to have travel sickness, but many adults remain 'bad' sailors.
The problem is caused by sensitivity of the semicircular canals of the inner ear. They are affected by the
movement and vibration of travel. Some people have sensitive inner ear canals and are prone to sickness,
especially on certain types of journeys (e.g. winding roads through hills) and in certain vehicles.

The main symptoms of travel sickness are nausea, vomiting, dizziness, weakness and lethargy. Early signs
are pallor and drowsiness, and sudden silence from an active, talkative child.

How to minimise the problem

1. Keep calm and relaxed before and during travel. With children avoid excitement and apprehension
about the travelling. Encourage activities such as looking at distant objects; discourage activities
such as reading and games that require close visual concentration.
2. Lie down, if possible, because this rests the inner ear canals and reduces the urge to vomit.
If travelling by car, stop regularly for breaks. Passengers should use the front seat if
possible.
3. Do not have a large meal a few hours before the journey or during it; avoid milk and fried or greasy
foods. Do not travel with an empty stomach: have a light simple meal about an hour before and do
not drink too much. Glucose drinks such as lemonade are suitable, as are glucose sweets and
biscuits while travelling.

Medication for travel sickness

Many medicines are available for travel sickness. They include hyoscine, various antihistamines and other
phenothiazine derivatives, all of which can cause drowsiness; although a problem to drivers, this sedative
effect may be helpful for children or for those travelling long distances by plane.
Phenothiazine derivatives that provide appropriate anti-labyrinthine activity include prochlorperazine
(Stemetil), promethazine hydrochloride (Phenergan) and promethazine theoclate (Avomine).
Combination antihistamine and hyoscine preparations for travel sickness include Travacalm and Benacine
(Table 12.6).
Hyoscine comes in tablet form, either alone or in combination and in the now popular adhesive patches.
Table 12.6 Medication to consider for motion sickness
Dosage
Drug (genre)

Brand names and formulations

Adults

Children

Antihistamines
Dimenhydrinate Andrumin 25 mg, 50 mg
Dramamine 25 mg, 50 mg
syrup
12.5 mg/5 mL

50 mg statim
then 4 hourly
prn
(max 300 mg/24
hours)

avoid < 2 years

2-6 years: 6.25 mg
6-8 years: 12.5 mg
8-12 years: 25 mg
> 12 years: 50
mg tds
(max 3-4
doses/24 hours)

25 mg bd

< 12 years:
12.5 mg bd

Meclozine

Ancolan 25 mg

Pheniramine

Avil, 10 mg, 50 mg syrup 3 mg/mL 25-50 mg tds

infants 10 mg bd
< 10 years: 10 mg
tds
> 10 years: 10-20
mg tds

Fenamine 50 mg syrup 3 mg/mL

Promethazine
theoclate

Promethazine
hydrochloride

Avomine 25 mg

Related phenothiazines

25 mg statim or nocte
for long journeys

< 5 years: % tab

5-10 years:
tab
> 10 years: 1 tab

Phenergan 10 mg, 25 mg syrup 1 mg/mL

25 mg bd
1-5 years: 5 mg bd
Prochlorperazine Stemetil 5 mg
suppositories 5 mg, 25
mg

5
5-15 mg tds

12 years: 10 mg
bd
0.2 mg/kg bd or
tds
< 10 kg: avoid

Hyoscine
Hyoscine
hydrobromide

Kwells 0.3 mg tab

1-2 tab statim then 1

tab 4-6 hour prn
(max 4/24 hours)

Scop 1.5 mg transdermal

1 patch per 72 hours

Travacalm

1-2 tabs statim

(max 4/24 hours)

2-7 years: %
tab
> 7 years: tab
(max
4
doses/24 hours)
avoid < 10 years

Combinations
Hyoscine
(0.2 mg) +
dimenhydrinate
(50 mg)
+ caffeine
(20 mg)

General
rules

< 2 years: avoid

2-3 years: %
tab
4.7 years: %- tab 813 years: -1
tab
(max 4
doses/24 hours)

All tablets should be taken 30-60 minutes before departure and repeated 4-6 hourly
as necessary (aim for maximum of 4 doses per 24 hours). Antihistamines should be
used less frequently and some may be used once a day. Take care with
drowsiness, pregnancy, the elderly and prostatic problems. Common adverse
effects are drowsiness, irritability, dry mouth, dizziness and blurred vision which are
compounded by alcohol, antidepressants and tranquillisers. Hyoscine overdosage
(from skin discs) can include confusion, memory loss, giddiness and hallucinations.

Recommended medications
Car travel: adult passengers and children
Dimenhydrinate (Andrumin, Dramamine)
or
Promethazine theoclate (Avomine)
or
Hyoscine (Kwells)
These preventive oral preparations should ideally be taken 30-60 minutes before the trip and can be
repeated 4-6 hourly during the trip (maximum 4 tablets in 24 hours).
Hyoscine dermal discs (Scop)
One of these adhesive patches should be applied to dry unbroken hairless skin behind the ear, 5-6
hours before travel and left on for 3 days. Wash the hands thoroughly after applying and removing the
discbe careful of accidental finger-to-eye contact.

Sea travel
Sea travel generally poses no special problems apart from motion sickness and the possibility of injuries in
the aged. The larger the ship the less likely the problem. Those prone to sea sickness are advised to take
antiemetics 60 minutes before sailing and for the first 2 days at sea until they obtain their 'sea legs'.
However, the use of hyoscine transdermal delivery systems is recommended for convenience.

Severe sea sick ness. The standard treatment is promethazine (Phenergan) 25 mg IM injection. If
injections are not possible prochlorperazine (Stemetil) suppositories can be used.
The aged. Generally the elderly travel well but should take safeguards to avoid falls. The Chief Surgeon on P
& O's ship Canberra recommends that elderly people should bring the following:
a letter from their doctor stating diagnosis and
medication a spare set of spectacles

a spare set of dentures

a walking stick (if appropriate)

Altitude sickness

10
High altitudes pose special problems for people who live at low altitude, especially if they
have heart and lung disease. The severity depends on altitude, the speed of ascent, the
temperature and level of activity. The high altitudes of Africa (Kilimanjaro, Kenya), India,
Nepal (Himalayas), Rockies of Canada and the United States, and South America provide such
problems. It is usually safe to trek under 2500 metres altitude but problems may occur over
3000 metres.

Forms
1. acute mountain sickness (mild severe)
2. high-altitude pulmonary oedema
3. high-altitude cerebral oedema

Clinical features
usually within 8-24 hours of exposure
frontal headache (worse in morning and when supine)
malaise, fatigue, anorexia, nausea, insomnia
More severe: fluid retention, dyspnoea, vomiting, dry cough,
dizziness. Serious: marked dyspnoea, neurological symptoms
and signs

Management
Prevention
careful acclimatisation with gradual ascent 10
spend 2-3 days at intermediate altitudes
ascent rate less than 300 metres per day above 3000 metres
ample fluid intake
acetazolamide (Diamox) 250 mg 8 hourly the day before ascent; continue 3-6 days (deaths
from
mountain sickness have still occurred while on this drug)

Treatment
immediate (urgent and rapid) descent to below 2000
metres oxygen
dexamethasone e.g. 4 mg, 6 hourly

Travellers'
kit

medical

If a person intends to travel for a long time the following represents a comprehensive medical
kit. It should not be regarded as an alternative to seeking appropriate medical help if it is
available. Typical examples of general items are included in brackets.

Materials
bandaids and elastoplast dressing
strip bandages (2 cotton gauze, 2
crepe 10 cm) pocket torch
steristrips or 'butterfly strips' (to patch small
cuts) sterile gauze and cotton wool
thermometer
scissors and tweezers
safety pins

Topical items
antifungal cream
chlorhexidine/cetrimide antiseptic cream (Savlon)
insect repellent containing diethyl-m-toluamide (Muskol, Repellem or Rid)
insecticide spray
mosquito net repellent solution: permethrin (Ambush-ICI)
nasal spray or drops
Stingose spray (for bites and stings)
Strepsils
UV antisunburn cream

Medication checklist
Those items marked with * usually require a prescription.
* Antibiotics
norfloxacin 400 mg (6 tablets for 3 days) cotrimoxazole (for children)
Antacid tablets-for heartburn or indigestion
* Antimalarials-where appropriate
* Diamox tablets for acute mountain sickness
* Fasigyn 2 g or Flagyl 2.4 g-for amoebiasis or
giardiasis Laxative (Senokot)
* Imodium or Lomotil-for diarrhoea
Motion sickness tablets (Avomine, Kwells or Phenergan)
Paracetamol tablets-for fever or pain
* Sleeping tablets (temazepam, promethazine) Rehydration mixture (Gastrolyte).

General tips for the traveller

Checklist for 'at risk' countries
'If you can't peel, boil or cook it, don't eat it.'
Boil or purify water, avoid dairy products, icecream, shellfish, food left in open, salads, watercress, ice
and recooked or reheated food.
Never walk around barefoot at night in snake areas (and use a torch).
Always shake your shoes before putting them on.
Never wear nylon items in hot tropical areas.
Never bathe, wade or drink in rivers, lakes or harbours unless you know they are bilharzia-free.
Keep yourself well covered after dark and use a mosquito net.
Use insect repellent on skin frequently.
Use an insecticide spray in your
bedroom.
Seek medical help if bitten by an excited dog, after washing bite.

Other tips
Organise a dental check before departure.
Arrange stopovers on a long flight (if
possible).
Take along a spare pair of spectacles and adequate medication.
Arrange health and travel insurance.
Check out your nearest embassy/consulate when visiting remote areas or politically unstable
countries.
Consider a traveller's medical kit.
Never carry a parcel or luggage through Customs to oblige a stranger or recent acquaintance.
Abstain from sex with a stranger.

Have a credit card that allows a quick cash advance or an airline ticket purchase (for many countries a
policy of 'if you get sick, then get out' is necessary).
Most death and injury among travellers is caused by motor accidents. Avoid buses in India (and elsewhere)trains are safer.

References
1. Oldmeadow M. Travel medicine. Melbourne: Monash University. Proceedings of Update Course
for General Practitioners, 1991, 4.
2. Grayson L, McNeill J. Preventive health advice for Australian travellers to Bali. Med J Aust, 1988;
149: 462-466.
3. Locke DM. Traveller's diarrhoea. Aust Fam Physician, 1990; 19:194-203.
4. Currie B. Malaria. In: MIMS Disease Index (2nd edn). Sydney: IMS Publishing, 1996, 293-296.
5. Hudson B. Travel medicine. In: MIMS Disease Index (2nd edn). Sydney: IMS Publishing, 1996,
521- 530.
6. Munro R, Macleod C. Recommendations for international travellers. Mod Med Aust, August 1991,
50- 57.
7. Mashford L et al. Antibiotic guidelines. Victorian Medical Postgraduate Foundation (9th edn).
1996/97; 60-90.
8. Amichai B, Finkelstein E et al. Think cutaneous leishmaniasis. Aust Fam Physician, 1993;
22:1213- 1217.
9. World Health Organisation. International Health for Travellers, 1996.
10.McDonnell L. Altitude sickness. Aust Fam Physician, 1990; 19:205-208.