Managing health risks associated with international travel 

Australians are travelling overseas more than ever before, and to increasingly exotic destinations. Pharmacists that cater to their jetsetting clientele can add further value to their service offering by developing and maintaining their knowledge in this area of practice.

International travel is associated with various health risks that travellers may not be aware of. Despite the fact that the majority of Australians purchase travel insurance before travelling overseas, up to 50% of travellers do not get health advice prior to their departure. The accessible nature of community pharmacy positions it as an ideal location for pre-travel advice, which can be supplemented by referral to a doctor when necessary.

Vaccination

International travel is associated with a risk of travel-associated infections. Vaccination needs differ based on travel plans, but all travellers should be up to date with the vaccines included on the National Immunisation Program (NIP), especially measles. Diseases that Australia has successfully eliminated, such as measles and rubella, are still a problem in many popular tourist destinations. This includes destinations that are often overlooked when it comes to pre-travel vaccination, including Europe.

Vaccines that are routinely recommended include diphtheria, tetanus and pertussis, hepatitis B, influenza and varicella. While these are part of the NIP, booster doses may be required.

Other vaccines are destination specific and can be recommended based on your customer’s itinerary. Travellers to some countries should also be up to date with hepatitis A and typhoid vaccines. Pharmacists should also note that other vaccines may be required by the International Health Regulations for entry into certain countries.

Pharmacists can encourage patients to consider their pre-travel vaccination needs and refer patients to a qualified travel doctor for further information.

Mosquito-borne infections

Mosquito-borne infections are of particular concern for travellers visiting warm climates. Mosquito protection remains an important factor for travel in South-East Asia, but prevention should be considered for any warm climate, including southern Europe and North America.

While some mosquito-borne infections can be vaccinated against, such as yellow fever, others like zika virus and dengue fever cannot, so taking measures to avoid mosquito bites (as well as appropriate vaccination) is the recommended advice. This includes: wearing loose-fitting, light-coloured clothing, ensuring accommodation is mosquito proof and using an effective insect repellent.

Insect repellents with up to 10% DEET or picardin are recommended for most situations, but strengths of 15–30% are recommended in high-risk areas. Pharmacies should consider stocking insect repellents with high concentrations of DEET or picaridin for travellers.

Medication to prevent malaria may be recommended for some high-risk destinations. Pharmacists should refer patients to a doctor to assess the need for prophylactic medication.

Traveller’s diarrhoea

Traveller’s diarrhoea is common, affecting between 20–50% of international travellers.8 Treatment relies primarily on hydration and symptom management with anti-diarrhoeal medications such as loperamide. Loperamide therapy alone is not considered dangerous in mild traveller’s diarrhoea and may be used alongside antibiotics if symptoms are severe, or last longer than 24 hours. Antibiotics may be prescribed prior to travel for moderate to severe diarrhoea, particularly if accompanied by other gastrointestinal symptoms.

Routine antibiotic prophylaxis is not recommended in most cases and travellers should instead adopt protective habits while abroad.8 This includes avoiding drinking tap water and not eating unpeeled fruit, or raw vegetables.

Evidence for prevention is mixed. There is some limited evidence to recommend bovine colostrum products (e.g. Travelan®) and certain probiotics (Lactobacillus and Saccharomyces strains), but overall data is lacking.

Health while in transit

Travel-associated health risks start before even setting foot in a holiday destination. Long-haul air travel exposes passengers to a number of factors that may impact on their health and wellbeing.

Prolonged immobility, such as sitting on a long-haul flight, is one of the risk factors for deep vein thrombosis (DVT). The risk of DVT when travelling is increased by the presence of other risk factors, including use of a contraceptive pill, pregnancy, obesity and clotting abnormalities. People with one or more risk factors for DVT require specific medical advice

At the time of writing the use of compression socks (flight socks) to reduce DVT when flying is recommended. One review found that wearing flight socks reduced DVT without symptoms, but did not assess the effect on serious outcomes or symptomatic DVT.

Long periods of time spent in the dry air of an airplane cabin can cause dehydration as well as drying of the eyes and airways. Travellers should aim to stay hydrated and use moisturising nasal sprays and eye drops to combat dryness.

Air travel can also exacerbate some chronic conditions. People living with chronic diseases should consider the effects of air travel on their health and consult with a doctor prior to departure.

Travel-associated health risks start before even setting foot in a holiday destination. Long-haul air travel exposes passengers to a number of factors that may impact on their health and wellbeing.

Products and services that a travel pharmacy can offer

If your pharmacy has a lot of frequent flyers in its customer base, you should make sure you stay up to date on travel health needs. This is also an opportunity for a pharmacy to specialise, differentiate and attract a new customer segment of travellers.

Co-locating items needed for travel makes it easier for customers to find what they need for their upcoming trip.

• Flight socks

While the evidence isn’t completely favourable, there is also no evidence for harm. Recommend that patients put them on well before the flight and remove them once they are walking around. Movement during the flight and during transit stops, and maintaining adequate hydration is also recommended.

• Probiotics and other preventative products

Evidence is mixed for these preparations. If recommending, make sure travellers are aware of the evidence and the storage requirements of the products.

• Oral rehydration solutions (ORS)

Oral rehydration is the best option for rehydration post diarrhoeal illness, especially in hot climates. Ensure that you instruct the consumer to use bottled water when preparing the product for use.

• Anti-diarrhoeal medications

Loperamide is the recommended self-treatment for traveller’s diarrhoea in most cases.

Ensure travellers are aware to seek medical advice if symptoms do not improve in 24 hours.

Other items to consider include sunscreens, condoms and alcohol-based hand rub.

Savvy pharmacists may choose to package together common items in a travel kit. However, care should be taken to consult with each patient to ensure they receive the best possible advice for their travel plans. Referral to a travel doctor may be warranted to consult on travel health needs. Knowing which doctors have a special interest in travel in the local area allows for more useful referrals.