Travel Medicine has become a new speciality in Medicine. It is concerned with the promotion of healthy travel, prevention of certain infectious diseases contracted through overseas travel, preservation of traveller’s health and treatment of illnesses acquired during travel. It embraces tropical medicine, infectious diseases, epidemiology of infectious diseases and diseases acquired through flying, sailing, mountaineering, deep sea diving or long land journeys.

Travel Vaccinations
The Travel Medicine doctor advises the traveller on the statutory requirement of certain countries on compulsory vaccinations before they are allowed entry or on their return from the country of visit. For examples, visitors to Saudi Arabia for Haji or Umrah need to be vaccinated against meningococcus strain A, C, Y&W 135 10 days before arrival and visitors to Sub-Sahara African and Central American countries must be vaccinated against Yellow Fever or they will not be allowed to re-enter another country.

Dangerous infections like typhoid, para-typhoid, hepatitis A&B, malaria, Japanese encephalitis, dengue, tetanus, polio, HIV, tuberculosis, leptospirosis, schistosomiasis, rabies, etc prevail in some countries particularly the undeveloped countries. Vaccines are available to prevent some of the infections. The doctor assess the risk and advises the traveller on the prevention of certain infections he is likely to encounter in his travel either by active immunisation or by passive immunisation or by using drug prophylaxis. Anti-malaria prevention often with drugs is necessary if you are travelling to countries with high prevalence of malaria. Outbreaks of infection periodically occur in various countries and traveller need to be informed.

Travellers with Medical Problems
The doctor also advises patients with current medical problems such as diabetes, heart diseases, chronic lung diseases, etc on how to manage their disease conditions during their travel. Insulin-dependent diabetics require special instruction on how to schedule their insulin and the dosage to inject while travelling as the rapid changes in time zones and changes in diet will disrupt their normal routine.

Pre-travel medical assessment for fitness to travel is another aspect of Travel Medicine. Many travellers are elderly and suffer from various chronic medical problems and taking various types of medications. Patients with significant heart or lung disease may find flying a problem in view of the lower oxygen content in the aeroplane cabin. Travellers prone to deep vein thrombosis are at higher risk of getting DVT and Pulmonary Embolism when they fly long distance in view of their prolonged sitting. They need to take special precautions including taking anticougulant or aspirin before flying. Pregnant women beyond 35 weeks of pregnancy are usually not allowed to fly long distance by most airlines.

Prevention or Treatment of Minor Medical Problems during Travel
Millions of people travel overseas for holiday, business, conventions and so on... Falling sick may ruin your holiday or business visit. Some of more common ailments are:

• travellers diarrhoea
• insect bites – mosquitoes, sand-flies
• motion sickness
• sunburn
• influenza
• dry itchy skin, lip chap
• common cold
• minor wounds and injuries
• allergy- skin, nasal, conjunctiva

It is often expensive to see a doctor in a country where you are not familiar. Language may be another problem. If you are travelling with your family or friends, they will also be inconvenienced. It is useful to bring along a medical kit with some medications to treat these minor medical problems.

Travel Health Service
The Wellness Clinic at Normah Medical Specialist Centre has started such a Travel Health Service. We provide pre-travel advice, pre-travel medical check-up, vaccination with vaccination book, anti-malaria prophylaxis and medical kit with basic drugs.

Travellers returning to Kuching from overseas or foreign visitors to Sarawak who fall ill can receive consultation and treatment at the clinic.

GENERAL ADVICE FOR TRAVELERS BEFORE TRAVEL

1. Plan your holiday well ahead.
2. Book your plane ticket early, get your visas ready and make sure your passport is valid for more than 6 months by the time you return home. Arrange for foreign currency. Write down all the necessary details of passport number, travel cheques number, credit card numbers, telephone numbers and addresses of hotels, destinations, flight number and give it to someone close to you in case of loss or some unfortunate accident.
3. Travel insurance is recommended particularly if you are travelling to countries where health care is expensive or health care facilities are poor and repatriation is required.
4. If you are not in the best of health, go for a pre-travel health check-up weeks before your travel. Make sure you are fit to travel particularly if you are suffering from heart disease, chronic lung disease, diabetes or other debilitating diseases. Get plenty of rest before travel.
5. Vaccination against certain infectious diseases may be compulsory or advisable for certain countries.
   For Saudi Arabia - meningococcal vaccination against strain A, C, Y & W135 is required at least 10 days before arrival...
   For Tropical South America and Sub-Saharan Africa - yellow fever vaccination is necessary for travellers entering and leaving countries from this region at least 10 days before arrival.
6. If you are travelling to countries where typhoid and hepatitis A are prevalent, vaccinations are recommended. Frequent travellers to developing countries should receive booster doses every 3 years. Where vaccinations are not possible or there is insufficient time, immunoglobulin injections can be given just before departure.
7. If you are travelling with children, make sure their immunisations against Polio, Diptheriae, Pertussis and Tetanus are all up to date.
8. If you are elderly or have chronic medical problems and going to a cold country or where crowding is likely, example going to a Haj, immunisation against influenza and pneumoccoccal infection are also recommended. Travellers to cold countries must bring along sufficient warm clothings.
9. If you are going to an area where mosquitoes and malaria are prevalent and you likely to be exposed, you should receive anti-malarial drug prophylaxis 1 week before departure. Malaria is prevalent in tropical and sub-tropical countries.
10. Air-lines usually do not allow female passengers more 35 weeks pregnant to fly long distance.
11. If you have any dental problem, take care of it before you travel. You do not want to have tooth-ache while on holiday.

DURING TRAVEL

1. If you are prone to travel sickness or motion sickness, bring some anti-motion sickness tablets along or use elasticated wrist bands (Sea-Bands).
2. Do not drink too much gassy drinks or alcohol during air-flight to avoid abdominal distension. Drink plenty of water or juices to avoid dehydration.
3. To prevent Deep Vein Thrombosis (DVT) or blood clot formation usually in the leg veins, you should exercise your leg muscles intermittently or walk along the aisles on and off. Blood clots in the leg veins can get dislodged and travel to the lung causing Pulmonary embolism and sometimes death People who are prone to blood clots should take aspirin or anti-cougulant before they travel. Always drink plenty of water to prevent dehydration. Pressure stockings are useful useful for those with severe varicose veins.
4. Jet-lag is caused by rapid changes in time zones. Your biological clock become de-synchronised. To reduced jet-lag get some sleep during the flight and do not drink too much alcohol. Once you land, adopt the local time immediately.

AFTER ARRIVAL

1. Adopt local time immediately and try to sleep according to the local time. Acclimatisation to the local weather and local conditions are important.
2. Travellers diarrhoea is very common. Most of the diarrhoeal diseases are mild and self- limiting but they can ruin your holiday or business trip. More serious are typhoid, paratyphoid, cholera, shigellosis, toxic E.coli, Guardia lamblia and amoebiosis. Precautions to take are:-

• Avoid eating uncooked or partially cooked food.
• Avoid drinking water of unknown sterility. Drink boiled, bottled or canned drinks while in developing countries. If necessary use water purification tablets. Bring along enough drinking when you are touring or visiting places of interest.
• Avoid food vendors' street stalls and out of the way places.
• Avoid cooked food that has been held at room temperature for several hours.
• Avoid salads, home-made mayonnaise, and sauces.
• Avoid fruits that cannot be peeled or shelled.
• Eat food that is thoroughly cooked or only hot foods.
• Practise personal hygiene.
• If your diarrhoea lasts 3 days or more or is very frequent, watery, or is associated with fever, vomiting, blood in stool, medical help may be needed. If no doctor is available, oral rehydration salt solution and antibiotics like co-trimozole or ciprofloxacin may be taken.

3. Children with prolonged diarrhoea and/or vomiting get dehydrated easily. Fluid replacement must be started early. Use the commercially prepared oral rehydration salt dissolved in boiled water. Follow the instruction on preparation. Homemade electrolyte preparation can be made from one level teaspoonful of salt and four heaped teaspoonfuls of sugar, dissolved in 1 litre of water. This should not taste salty.
4. If physical activity or outdoor activity is anticipated and injuries are possible, anti-tetanus vaccination should be up to date.
5. If you are going to a country when malaria is common, anti-malaria prevention is necessary. This consists of wearing protective clothing, applying mosquito repellent and taking anti-malaria tablets prophylactically. Dengue fever virus is also carried by mosquitoes. Continue taking your anti-malarial tablets while travelling in the country.
6. Bring some basic medications and first aid pack when you travel. Common ailments encountered during travel are diarrhoeal diseases, cough and cold, motion sickness, pneumonia & influenza. Medical kits are available at our Normah Wellness Centre.
7. Skin Care

• If you are going to a very hot or sunny country or beach bring along sunscreen lotion or cream with Sun Protection factor of at least 15. Wear protective head gear and sun-glasses. A sunburn can ruin your holiday.
• Travellers living in hot and humid countries travelling to countries in the Northern or Southern hemispheres where the air is dry may experience chapping of the lips and itching of the dry skin. Always bring along moisterising cream or lotion and lip balm.
• Sand -flies bites can cause severe itching which can last for many months. Bring along some steroid cream to apply.

8. Safe sex should always be practised if you are visiting prostitutes. Sexually-transmitted diseases are common in some countries. Getting infected with HIV virus can lead to a life-time of misery. Condoms do not provide complete protection.
9. The commonest cause of death during travel is accidents. Less common causes are heart attacks, strokes, infections like pneumonia, meningoccal meningitis, typhoid, dengue, cholera.

A study of US travellers to developing countries and Eastern Europe showed that more than one third had some type of illness during their trip. 20% of them remained ill after their return home and 10% sought medical care for their illness.

Contributed by:
Dr. Pok Yang Hang,
Consultant Physician, NMSC Wellness Clinic