Patient professional reference
Global travel trends have meant a huge increase in the numbers of people travelling abroad and to increasingly remote locations. In the 1960s fewer than 100 million people travelled abroad. Now over 900 million people do so every year.
There are no published figures for the number who travel 'off the beaten track' but such destinations are increasingly popular. Their (paradoxical) accessibility means they do not only attract those who are young and particularly fit. It is not unusual to find travellers in their 80s and travellers with significant health issues trekking in the Everest Base Camp region of Nepal, when nocturnal temperatures are beneath −20°C and the partial pressure of oxygen is only 50% of that at sea level. Doctors are increasingly asked to advise such patients on the safest way to manage their journey.
Most significant health incidents are due to injury rather than infectious disease. Amongst travellers visiting developing countries for a month or less the most common source of mortality and morbidity is injury, with road traffic accidents being the most common:
- At least 50% experience a health issue during their trip.
- 8% will see a doctor.
- 5% will be sufficiently ill to stay in bed.
- 0.3% will require hospital admission (either abroad or on return).
- 0.05% will require air evacuation.
- 0.001% will die (only 1-4% of travel-related deaths are due to infectious disease).
Challenges of remote travel
Many of the challenges of remote travel are heightened versions of those encountered in any travel, but others are more specific to developing countries and remote locations. Areas to consider which are specific to travelling to less familiar destinations include:
Modes of transport
When travelling in remote areas or in the developing world the safety of public and private transport may not meet the same requirements as those in the developed world. The suspended cable car wound by hand across a rope over a gorge may make a fantastic photograph but may be as precarious as it looks. Travellers should be reminded not to make assumptions about safety but to make their own risk assessments before using particular methods of travel.
Food and drink
- A safe public water supply should not be assumed without clear information to support it. Bottled water can be trusted only where the seal is unbroken, as used bottles may have been refilled from a tap in order to resell them. Ice should be assumed unsafe, even in hotels.
- Streams and rivers do not contain pure uncontaminated water unless no humans or animals have had access to the water upstream of you. This will not usually be the case. Water purification systems and UV filters reduce the risk.
- Vegetables are likely to have been washed in locally available water and must be assumed to have surface contamination.
- Refrigeration and storage may not meet Western standards. It is common in many places to see meat in the open air awaiting sale or cooking, often contaminated by flies.
- Food served in a luxury hotel is unlikely to be washed in different, purer water than that available in the tap.
- Many local people in developing countries have chronic diarrhoea. Plates and cutlery are therefore easily contaminated.
Quality and availability of medical care
- The presence of excellent doctors, even in remote corners of the world, is undeniable but not always reliable.
- The availability of in-date, recognisable medication is not always guaranteed. Patients on regular medication should take sufficient for their trip.
- Medical equipment in use in remote locations may not always meet the sterilisation standards we are used to. Blood products in some locations may not meet the safety standards of transfusions in the UK.
- Travel involves encounters with infectious disease. Not all can be avoided by immunisation, although travel vaccinations reduce risk significantly.
- Travellers are particularly at risk of gastroenteritis. The range of possible organisms is similar to in the UK; however, the relative likelihood of a bacterial or protozoal cause is often much greater.
- Vector-borne diseases such as malaria and dengue are a serious issue and travellers should be advised on prevention. Those travelling back to a country of origin to visit friends and family often believe they have retained the degree of immunity seen in those still living there; however, this is generally not the case.
- Tropical diseases such as leishmaniasis, hydatid disease and schistosomiasis (bilharzia) are not common in returning travellers, but they do occur and travellers need to be aware of them and of precautions to avoid them.
- Bathing in fresh water (lakes and rivers) may expose travellers to the risk of schistosomiasis in tropical and subtropical areas. Common travel destinations where schistosomiasis occurs include Egypt, Kenya, Tanzania, South Africa and some areas of Brazil. Many cases diagnosed in the UK result from swimming in Lake Malawi.
- The prevalence of sexually transmissible disease across much of the world should always be remembered. The safest sex, in these circumstances, is no sex.
Travellers should seek advice on levels of crime at their chosen destination and should take note of any advice. As strangers to a country, potentially lost (or looking lost), lacking in local language and (to local eyes) relatively wealthy, they can be particularly vulnerable to street crime such as pickpocketing, assault or sexual assault.
Politics and law
There is unrest in many parts of the world, and not all of it makes news headlines in the UK. Careful information gathering, using the government's Foreign and Commonwealth Office (FCO) website, will help prepare. Travellers should be aware that most travel insurance becomes invalid in a particular country if the FCO advises against travel there.
- Travellers should make themselves aware of local laws, customs and expectations, particularly in countries where freedom of speech, expression and religion may not exist to the level with which we are familiar, or where attitudes to alcohol, dress or sexual behaviour are less liberal than in the UK.
- Some UK prescription medication is illegal in some countries. Travellers should check this in advance; as the GP you may need to write a letter, or complete documentation. Drugs considered illicit in the UK are usually illegal and possession often carries extremely heavy penalties.
Aid workers, disasters and war zones
These pose a particular risk to health and safety of travellers. See 'Remote travel advice to aid workers and those providing disaster relief', below.
Any extreme environment poses challenges to the human body, which is designed by definition for conditions which are not extreme. The body will be challenged by extremes of temperature, humidity, weather and altitude, but also by unaccustomed levels of exercise and lack of palatable food and water. In those who are already less well this may be a challenge which ruins the holiday.
Communication and isolation
In the modern world we are used to instant communication, and many remote areas of the world now have phone and satellite signals allowing travellers to remain in close and regular contact with home, work and family. However, this is not invariably the case. Travellers need to consider the extent to which they are assuming that they will remain connected when travelling to remote locations, particularly if travelling alone. A greater psychological resilience may be required than is needed for 'normal' life. Some patients with recent mental health issues may find this particularly difficult.
Increasingly, travellers visit their doctor before departure, asking for advice and support with their health and fitness. This usually falls into several categories:
- Malaria prevention.
- Advice on food and drink and staying well.
- Contraception and sexual health for travel.
- Advice on personal fitness to travel.
- Advice on specific physical challenges of a planned trip - eg, altitude, heat, exercise.
- Advice and help in preparing first aid/medical kit.
- Advice on whether to travel at all.
The patient's own surgery is well placed to advise on these matters. Knowledge of the patient's medical history, including medication and allergies, is essential when advising on management of illness abroad. The consultation should be approached with careful questions about the planned nature and timing of travel, making up the risk assessment and providing the bases for advice and management decisions.
Consider where, when and how the patient is travelling, and for how long. Why are they travelling? The needs of aid and emergency workers differ considerably from those of tourists in looked-after groups. What activities are planned (walking, climbing, base-jumping)? What sort of environmental conditions and hazards will they encounter? Are they travelling in a group or alone? If in a group, will there be a first-aider or doctor present?
- Mode of transport.
- Destination: leading to assessment of expected conditions of hygiene, sanitation, access to medical care, and water quality. It also allows assessment of the risk of exposure to infectious disease, including those which may be emergent, endemic or epidemic.
- Duration of visit - risk generally increases with length of stay.
- Contact with local population (particularly significant when considering the risk of acquiring tuberculosis).
- Likely contact with animals (eg, risk of rabies for volunteers working at animal rescue centres, or for those spending prolonged periods in areas where rabies is endemic).
- Purpose of travel - tourists may be likely to stay in better-quality accommodation than aid or emergency relief workers.
- Behaviour and lifestyle of traveller - riskier activities increase the chances of mishap.
- Pre-existing medical conditions and fitness to travel. Ideally the patient should be as stable as possible, with arrangements made in advance to reduce/eliminate foreseeable difficulties.
- Physical challenges of the environment (eg, altitude, humidity, temperature, UV exposure).
- Planned social behaviour: sexually transmitted infection and blood-borne disease (eg, HIV, hepatitis B and hepatitis C) represent avoidable risks.
Advising against travelling
It is sometimes necessary to advise against travel altogether. This may be because travel may dangerously worsen a patient's condition or impair their ability to manage it, or because the patient's condition means that the trip they have chosen is likely to be beyond their capability. The accessibility of remote destinations in challenging environments means that patients can book trips for which they are not physically prepared. If the doctor believes the risk of travel is unacceptably high then they have a professional obligation to say so. This can be difficult, as patients will be deeply disappointed. Advising against travel will make it difficult, if not impossible, for patients with health issues to obtain travel health insurance, and may therefore prevent their trip.
There are clear published guidelines on fitness in some areas - for example, around fitness to fly. It is obvious that a patient with unstable coronary heart disease or a hypoxic lung condition is at risk from exertion at altitude, and a patient with alcohol dependency is unlikely to manage the privations of remote trekking. However, most patients wishing to travel do not fall into such obviously high-risk categories and it is not always easy to determine the point at which the risk of travel becomes so significant that clear advice not to go must be recorded.
You must make sure that your patient understands the risks. They need to understand both the risk that their trip will worsen their condition, and the risk that their condition will hinder or terminate their trip. People with significant health issues and disabilities make headlines frequently when they complete extraordinary challenges: perhaps your patient is equally extraordinary. It is wise to seek advice of colleagues to be sure you don't stand alone in your view.
A review of vaccination status is an essential part of pre-travel advice. Patients should carry a copy of their travel vaccination history and, where applicable, a copy of their yellow fever vaccination certificate. Follow up-to-date guidelines:
- Ensure routine immunisations are up to date.
- Plan an immunisation programme based on recommendations and compulsory vaccines.
- Recommended intervals between doses and vaccines should be followed to allow optimal antibody production prior to travel. At least 10 days (ideally three weeks) should ideally separate all travel vaccinations so that any adverse reaction can be correctly attributed; however, in practice, many vaccines are often given simultaneously due to time constraints, without ill effect or loss of efficacy. Live vaccines should be administered at least three weeks apart or on the same day.
See separate Malaria Prophylaxis article.
Advice on eating and drinking and staying well
Guidance on eating and drinking is provided in the separate Traveller's Diarrhoea article. However, in many areas and with many types of trip, traveller's diarrhoea is inevitable, occurring, for example, in 100% of trekkers in the Annapurna region of Nepal.
Constipation is also common in travellers, often triggered by dehydration, lack of fresh vegetables (due to sensible caution) or over-use of loperamide. Travellers should be advised to increase their fluid intake and if not passing a daily stool, use oral senna tablets (two daily at first, increasing to 3-4 if not effective in 24 hours) to try to re-establish a comfortable pattern.
- This results from the ingestion of food containing toxin-producing bacteria.
- Onset is very swift and it classically affects multiple people who ate the same meal, within a fairly short time.
- Nausea, vomiting and cramps may be severe.
- Patients are pale, sweaty and unwell.
- Diarrhoea may start with or after the vomiting.
- Recovery is usually within 24 hours with supportive treatment only.
Contraception and sexual health for travel
- Sexually active patients will need advice on contraception for travel.
- Doctors should offer advice regarding how to manage oral contraception in the event of vomiting and diarrhoea.
- Women taking oral contraception should be made aware of the increased deep vein thrombosis (DVT) risk associated with long-haul travel by air and prolonged periods of coach or car travel, particularly if dehydrated. Patients should be advised of symptoms to look out for and on the use of preventative flight socks.
- Women of menstrual age may seek advice on postponement of periods with progesterone. Hormones for postponement of menses do not offer contraceptive protection and may increase the risk of DVT.
- Doctors should advise patients of both sexes to take condoms on their trip and, if being sexually active, engage only in safe sex. Patients should by advised against sexual contact with high-risk individuals such as sex workers in developing countries. Condoms purchased abroad may not be manufactured to the same protective standards as those in the UK. In a Dutch study, 4.7% of individuals who were seen in a pre-travel clinic had casual sexual contact whilst abroad, usually not anticipated prior to travel and frequently without protection (condoms, hepatitis B immunisation). An individual's sexual risk-taking may increase with travel, increasing their risk of contracting HIV, hepatitis B or other sexually transmitted infections. Inhibitions are further reduced by alcohol and drug taking.
- Availability of emergency contraception in the destination country should be considered. Patients might wish to take a 'morning after' pill.
- The safest sexual practice when travelling to remote locations is no sex, or at least, no sex with anyone who is not already the established and trusted sexual partner.
Advice on personal fitness to travel including concurrent diseases
- See separate Flying with Medical Conditions article for information on assessing fitness to fly.
- Patients must inform companies providing medical travel insurance of any pre-existing medical conditions when the policy is obtained, and should make sure that they have treatment cover and repatriation insurance.
- Doctors should discuss and assess the patient's fitness for the activities and environment they plan for their trip
- Exercise, particularly strenuous exercise, is a greater strain on the heart at altitude (where blood oxygen saturation is lowered) and in extreme heat.
- Advising against travel will almost certainly invalidate their insurance.
- Patients on prescribed medication should carry a medical letter with details of the condition and any treatment (ideally, a list of any drug therapy with generic names and dosages).
- Patients should carry sufficient medication to cover the entire duration of the trip and any possible delays, and keep this in their hand luggage for the journey.
- There are fluid restrictions in hand luggage on most flights, so liquid medication may need to be well insulated in the checked luggage. Some medications such as medium- and long-acting insulins should not be allowed to freeze.
- Not all medications can be carried across all borders, even if prescribed. The carriage of controlled drugs across borders is a particularly difficult issue. Most countries will allow patients to bring in packaged medication clearly prescribed for them. Travelling medics may obtain Home Office letters of 'authorisation' to carry specific medications for medical use. However, such letters do not have legal status in other jurisdictions. In the USA, for example, medical diamorphine is an illegal substance in all circumstances.
- Patients should keep a list of routine prescriptions (generic names and doses). All medications should be carried in pharmacy-labelled bottles.
- Treatment for certain conditions (eg, insulin-treated diabetes mellitus) will require adjustment over travel periods.
- Immunosuppressed patients should not receive live vaccines.
- If a patient experiences infrequent but recurrent issues such as vaginal thrush, cystitis or migraine, they should take a course of their usual treatment for this in addition to any first aid kit.
Special patient groups
Remote travel advice to patients with diabetes
Patients with diabetes who use insulin can be referred to the Diabetes UK website for specific advice on caring for insulin when travelling.
- Remote locations may present a particular challenge to keeping equipment clean.
- If exercise levels increase, calorie intake may need to increase and insulin requirements may fall.
- At high altitudes absorption of calories is reduced, so the usual diet may not need the usual insulin dose - patients with diabetes will need to monitor their glucose levels carefully to avoid 'hypos'.
- Patients with insulin-dependent diabetes should be advised that they are at particularly high risk of becoming unwell if they develop severe traveller's diarrhoea. They need to continue taking insulin (possibly at a reduced dose) to avoid ketosis, and they also need to be able to take in calories in order to avoid becoming 'hypo'. This is a difficult situation to manage and they should make sure they are in a position to obtain advice and help should difficulties arise.
- Patients should carry a letter explaining their need to keep insulin and injection equipment in their hand luggage
- Crossing time zones means adjusting insulin.
- Travelling from East to West means lengthening days. If the time zone change lengthens the day by four hours or more, there is likely to be an extra meal which is covered by extra insulin. The dose will be patient-specific. Many patients, particularly those with type I diabetes, cover the extra meal with an extra dose of rapid-acting insulin.
- Patients should be reminded that running slightly high will do them no harm whilst running too low is potentially harmful, as it may result in a 'hypo' when travelling.
- Travelling from West to East shortens the day. If the difference is more than four hours, adjustment is usually advised. This normally entails reducing insulin dosage. Some patients may be advised to leave out medium-acting insulins altogether and switch to short-acting insulins for the period of travel.
- Diabetes tablets do not normally need adjustment for travel, unless the time difference is very great.
Remote travel advice to pregnant women
- No pregnancy can be assumed to be risk-free and travel may hamper access to healthcare, records and good communication in the event of complications.
- Some infectious diseases, such as malaria and hepatitis E, are more serious in pregnant women.
- The recent emergency of Zika virus is a particular concern for women of childbearing age who may be in the first few months of pregnancy. There is no treatment for Zika virus and such patients should be advised to consider postponing their trip.
- All pregnant women travelling to malarial zones should take chemoprophylaxis and avoid being bitten by mosquitoes:
- Chloroquine and proguanil (usually combined) are suitable for areas at lower risk of chloroquine resistance. A supplement of folic acid 5 mg daily should be taken with proguanil.
- Mefloquine is suitable for women in their second or third trimesters.
- Doxycycline is contra-indicated in pregnancy.
- Atovaquone-proguanil (Malarone®) is not recommended due to a lack of safety data.
- Seek specialised advice if a woman is in her first trimester (or intends to become pregnant whilst travelling) and chloroquine-proguanil provides inadequate protection.
- Immunisations are generally avoided in pregnancy, although inactivated vaccines may be used if the risk of disease exceeds the potential risk to the fetus.
- The thromboembolic risk of air travel is raised for pregnant women, and sensible precautions are advised.
- The best window of opportunity for flying in pregnancy is usually suggested as 18-24 weeks. Most airlines require a doctor's note stating expected delivery date, beyond 28 weeks. The Royal College of Obstetricians advises against flying beyond 37 weeks (or beyond 32 weeks in a multiple pregnancy).
- Check that travel insurers are aware of the pregnancy.
Remote travel with children
Increasingly, more families are travelling to more exotic destinations for leisure purposes or to visit relatives. Parents travelling with children may be referred to the patient leaflet: Advice for Travelling to Remote Locations. A discussion of risk is essential, to make sure that parents understand what they are taking on on behalf of their child:
- Children can become swiftly unwell and an unwell adult may have difficulty caring for them. The doctor may prescribe specific paediatric formulations in the travel first aid kit and advise on issues such as management of diarrhoea in children. Parents should be advised that unexplained fever in a child travelling remotely always needs urgent medical review.
- Those visiting family in countries with a malarial risk may assume that they have 'inherited' immunity. However, they will have lost their acquired immunity within several weeks of leaving their 'home' country, and their children, living in the UK, will not have it.
- Routine infant immunisations may be brought forward if children are travelling to high-risk countries for prolonged periods and may have close contact with the indigenous population. Consult product information as to the lower age limit for travel vaccines and the varying ages at which the paediatric dose changes to the adult dose.
- Malarial chemoprophylaxis can be difficult due to issues of compliance, but children are more at risk of the complications of malaria than adults:
- A combination of chloroquine and proguanil is suitable in some areas but neither is palatable. A liquid form of chloroquine (nivaquine) is still available but will not be sufficient prophylaxis alone.
- Mefloquine is not recommended for children weighing less than 5 kg.
- Malarone® (atovaquone-proguanil) comes as a 'chewable' child tablet - but this is also unpalatable. It is not recommended for children under 11 kg.
- Doxycycline is contra-indicated in children aged under 12 years.
Remote travel advice to patients with mental health issues
- Remote travel can pose significant stress (separation from family and existing social support networks, bewilderment and alienation in foreign culture, difficulties with communication).
- This can exacerbate a pre-existing mental disorder or precipitate one for the first time.
- Attitudes and facilities for caring for those with mental illness vary considerably around the world.
- Patients with ongoing mental health issues may be best advised to postpone their challenging travel until they are stable and well.
Remote travel advice for patients with drug or alcohol dependency
Patients with dependency on alcohol or illegal drugs would be ill-advised to travel to remote locations where they may find themselves either in withdrawal without support, or in very difficult legal trouble for possession of illegal substances.
Remote travel advice to aid workers and those providing disaster relief
This group is at particular risk of ill health. They may be staying in difficult conditions, may themselves be subject to contact with the diseases encountered following a natural disaster and will be in close contact with local populations.
- Patients should be advised to travel with a recognised aid organisation rather than going it alone. This ensures the most effective help and provides support and, if necessary, evacuation.
- For those offering aid to others, keeping themselves well is clearly essential. If they don't do so they become part of the problem and may themselves require evacuation.
- Travellers should attend any relevant briefings on health and personal safety.
- They may need to pack more than other travellers: items such as goggles, protective gloves and a torch, candles, malaria nets and water purification tablets (bottled water may not be available).
- Aid workers visiting situations of natural disaster, famine, war or other chaotic or disturbing situations should seek medical advice on their return, even if they feel well. This may be an opportunity not only to make sure that they remained healthy but also to discover that they have had difficult or upsetting experiences and need counselling or support.
Risks of high-altitude travel
Patients travelling to altitude may be advised to read the section on altitude illness in the recommended textbook Pocket First Aid and Wilderness before they leave. See also the separate High-altitude Illness article.
Risks of travel in very hot climates
Significant problems associated with travel to very hot climates are:
- The risk of dehydration increases with the increase in temperature and this is particularly so in patients with diarrhoea and vomiting.
- Children are at particularly high risk.
- Patients could carry oral rehydration salts in their first aid kit.
- Symptoms: weakness, dizziness and nausea.
- Treatment: rest out of the heat until recovered, sipping water.
Heat exhaustion (exercise-related collapse)
- Symptoms: tiredness, dizziness, feeling faint, nausea and vomiting, cramp, rapid pulse.
- Distinguished from heat stroke in part by the fact that the patient is still sweating.
- Treat with shade, rest, rehydration and cooling with fanning or sponging.
- This is a life-threatening condition, when the protective processes which prevent overheating start to fail and body temperature rises.
- Symptoms: fever, with rapid pulse; the patient feels dry and hot, and stops sweating.
- They may lose consciousness or fit.
- Treatment is rapid cooling with sponging, wet sheets, iced water, and fanning.
- Patients also need oxygen and rapid rehydration.
Sun protection and sunburn
80% of skin cancers are thought to be preventable. Excessive sun exposure, and sunburn in children, are a major risk factor for later skin cancer. Skin protection in children and adolescents is crucial. Sun-induced damage is cumulative over a lifetime.
To avoid sun damage patients should:
- Keep out over the 'midday' sun period (from 11 am to 3 pm).
- Stay in the shade.
- Dress to screen from the sun, including wearing T-shirts, long-sleeved shirts and hats.
- Use a broad-spectrum, high-factor sunscreen and replenish it according to instructions.
If burned, apply cold compresses, aloe vera gel or hydrocortisone 1% cream. Painkillers may be needed. For further advice refer patients to the separate Dealing with the Effects of Heat leaflet.
Risks of travel to very cold environments
Very cold environments may include travel to such destinations as Antarctica or Svalbard, but also to high-altitude destinations in countries nearer the equator, including trekking/climbing in the Himalayas and climbing and skiing in the Alps.
A cold environment challenges the body by air temperature, air movement (wind speed), and humidity (wetness). These challenges have to be counterbalanced by proper insulation (layered protective clothing), by physical activity and by controlled exposure to cold. The wind-chill temperature for a given combination of air temperature and wind speed is the equivalent air temperature if there were no wind. It is the best guide for deciding clothing requirements and the possible health effects of cold.
Wind chill 0 to −9: slight increase in discomfort. Dress warmly, stay dry
Wind chill −10 to −27 (eg, winter European ski trips): uncomfortable. Risk of hypothermia and frostbite if outside for long periods without adequate protection. Wear layers of warm clothing, with an outer layer that is wind-resistant. Wear a hat, mittens, a scarf and insulated, waterproof footwear.
Wind chill −28 or colder (eg, winter trips to Svalbard, Everest): exposed skin can freeze in 10-30 minutes. High risk of frostnip/frostbite. High risk of hypothermia if outside without adequate clothing or shelter. Dress in layers of warm clothing, with an outer layer that is wind-resistant. Cover all exposed skin. Wear a hat, mittens, a scarf, neck tube or face mask and insulated, waterproof footwear.
This is needed below 4°C. Clothing should be worn in multiple layers, as the air between layers of clothing provides better insulation than the clothing itself. The inner layer should be able to 'wick' moisture away from the skin to help keep it dry. Clothing should be clean, since dirt gets into air pockets in the material and reduces insulation.
Almost 50% of body heat is lost through the head. A hat will reduce excessive heat loss. Gloves are needed below 4°C. Below −17°C, mittens are advised. Leather boots are suited for trekking in cold, since leather is porous, allowing perspiration to evaporate. They can be 'waterproofed' with some products that do not block the pores in the leather.
One or two pairs of socks. If they are too thick for the boots, they will lose their insulating properties when compressed. If the foot is 'squeezed' blood flow to the feet is slowed, which increases the risk of cold injuries.
In bright snow and at altitude, protection against UV light from the sun and glare from the snow is needed.
Eating and drinking
Balanced meals and adequate liquid intake are essential: many cold environments are very dry. Caffeinated drinks should be limited because they increase dehydration. Caffeine also increases the blood flow at the skin surface, which can increase the loss of body heat. Alcohol should be avoided as it causes expansion of blood vessels in the skin (cutaneous vasodilation) and impairs the body's ability to regulate temperature (it affects shivering). These effects increase the risk of hypothermia.
Hypothermia is defined as core body temperature below 35°C. It usually occurs gradually. Patients should be advised to watch each other for the signs of hypothermia which are:
- Shivering, cold, pale and dry skin.
- Tiredness, confusion and irrational behaviour.
- Slow and shallow breathing.
- Slow and weakening pulse.
For further information refer patients to the separate Dealing with the Effects of Cold leaflet.
Personal first aid kit for a remote trip
The following is a fairly comprehensive first aid kit for two people travelling together to a remote environment. It is based on advice given in 'Pocket First Aid and Wilderness Medicine', a book written by two well-established expedition doctors with experience of looking after travellers in remote locations (listed in Further reading, which can be recommended as a comprehensive pocket information source for travellers, whether medical or not).
Some doctors may feel uncomfortable at prescribing drugs for patients to treat conditions they don't yet have, which will be taken outside the doctor's 'jurisdiction'. The intention is not to encourage patients to bypass medical help and self-treat when unwell. Self-diagnosis and self-medication should be strongly discouraged. A reasonable first aid kit enables them to seek medical help from other travelling doctors and nurses. They may be advised on what to take from a treatment kit pre-approved as being safe (in keeping with their personal health history) by their own doctor. It also means that the drugs are available when needed, as it is unlikely that a passing travelling doctor will carry spare drugs with which to supply others.
Recommended reference book
- Pocket First Aid and Wilderness Medicine. This is an excellent handbook covering what to do as a layperson in most medical situations the traveller might encounter.
- Thermometer (or 'FeverScan'®).
- Tweezers (pointed-end).
- Sewing needle.
- Safety pins x 2.
- 10 ml syringe, 2 ml syringe and needles (in packets, sterile).
- Protective gloves - 1 pair.
- Sticking plasters - 1 pack.
- Blister plasters - 1 pack assorted.
- Gauze squares 5 cm x 5.
- Sterile non-stick dressings x 5.
- Sanitary pad x 1 (for absorbent padding).
- Cotton bandage 10 cm x 1.5 cm.
- Crepe bandage 10 cm x 1.5 cm.
- Duct tape - 1 small roll.
- Wound closures (Steri-Strips®) - 1 packet.
- Alcohol swabs x 5.
- Sunscreen (high-factor if at altitude).
- Burn cream - eg, silver sulfadiazine or aloe vera gel.
- Insect repellent (ideally containing at least 20% DEET).
- Lavender oil - mild antiseptic for wound sterilisation.
- Antihistamine tablets - eg, chlorphenamine 4 mg x 10.
- Hydrocortisone cream 1% 15 g tube.
- Single course of one broad-acting antibiotic - eg, azithromycin 500 mg 3 tabs or ciprofloxacin 500 mg 10 tabs (take your doctor's advice - some antibiotics cannot be taken by children or pregnant women): for severe bacterial diarrhoea.
- Single course of co-amoxiclav or amoxicillin: for chest infections.
- Metronidazole 400 mg 15 tablets (for stays of more than 3-4 weeks); for gastroenteritis caused by giardia or amoeba (a doctor needs to advise you if you may have this sort of diarrhoea).
- Antibiotic ointment (eg, fusidic acid) 15 g tube.
- Antifungal cream (eg, clotrimazole) 15 g tube.
- Loperamide 2 mg (for diarrhoea) - pack of 10.
- Senna tablets x 5.
- Small bottle of antiseptic (eg, Dettol® or Savlon®).
- Antibiotic eye ointment (eg, chloramphenicol).
- Indigestion remedy (eg, ranitidine) 150 mg: 10 tabs.
- Buccastem® antisickness tablets x 5.
- Paracetamol 500 mg x 10.
- Ibuprofen 400 mg x 20.
- Oral rehydration salts x 10 sachets.
- Throat lozenges - 1 packet (eg, Strepsils®, Vocalzone®).
Additional medication for very high-altitude trekking
- Acetazolamide 250 mg tablets (Diamox® - for prevention and management of altitude sickness) x 10-20.
- Discuss with your GP and trekking group whether your very high-altitude trek also necessitates carrying dexamethasone tablets or nifedipine tablets, both used in altitude sickness emergencies by doctors and nurses experienced in altitude medicine.
Travel insurance varies considerably: travellers should be advised to investigate different providers, to ensure that they have adequate medical insurance to cover emergency repatriation, and ideally the maximum amount of coverage for potential medical, surgical and dental costs.
Illness on return
See separate Diagnosing The Tropical Traveller article.
Infectious disease epidemiology, drug resistance patterns and political situations change rapidly. It is essential that those intending to travel have access to up-to-date advice. Sources include:
- The NHS Fit for Travel website: excellent general advice by destination; offers advice on specific diseases together with up-to-date news on outbreaks.
- The National Travel Health Network and Centre (NaTHNaC) runs a general information website offering advice by country.
- The UK Government's 'Travelling and Living Overseas' website page has up-to-date advice on political, economic, health and safety issues by country.
- Public Health England offers malaria guidance, data and analysis.
- Travax offers guidance on UK immunisation schedules.
- An up-to-date map detailing yellow fever vaccination by country can be found on the NaTHNaC Yellow Fever Zone website, together with details of yellow fever outbreaks and information regarding immunisation.
Further reading and references
Fit for travel; Health Protection Scotland
Immunizations - travel; NICE CKS, October 2016 (UK access only)
International Travel and Health; World Health Organization
Spira AM; Preparing the traveller. Lancet. 2003 Apr 19361(9366):1368-81.
Fenner P; Fitness to travel - assessment in the elderly and medically impaired. Aust Fam Physician. 2007 May36(5):312-5.
Assessing fitness to fly; Aviation Health Unit, UK Civil Aviation Authority (2012)
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Hi All, I dont know if anyone has come across this. I have a worm infestation in my face. They travel around under the skin leaving tracks and bursting holes into my skin. they create glass like...nicolamc
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