Depending on both the destination and the journey involved, travellers can be at increased risk of a range of different health ailments. Here we consider some typical scenarios that pharmacists might encounter.

Learning objectives

After reading this feature you should be able to:

  • Appreciate the key preparations and precautions that must be undertaken by
    travellers concerned about their health
  • Advise customers on measures for preventing jet lag and keeping healthy during a long-haul flight
  • Explain the NICE recommendations for those at high risk of travellers’ diarrhoea.

 

Hormonal contraception and DVT

Ciara Johnson is about to embark on a two-week fly drive holiday to the West Coast of America with her partner. She is concerned about the potential impact the long flight and time difference may have on her menstrual cycle, and is particularly worried whether the effectiveness of her hormonal contraception will be impaired. Ciara also wants advice on how to mitigate the risk of deep vein thrombosis (DVT) during her trip.

Long-haul travel that crosses time zones can prove challenging for women taking daily hormonal contraception and can be especially tricky with the progesterone-only ‘mini’ pill, which has a strict three-hour time window for dosing.

As Ciara’s trip is of relatively short duration, you could suggest keeping a separate watch or clock on UK time and sticking to her existing dosing schedule, or setting a smartphone to issue 24-hour reminders at the same time as the pill would normally be taken at home.

Alternatively, Ciara could use an online time zone calculator (e.g. timeanddate.com/worldclock/converter.html) to translate her usual pill time to that of the destination country. If that time proves particularly inconvenient (e.g. 3am), then dosing at home can be gradually shifted forwards by a few hours each day before the trip, to align with a better pill time while on holiday.

When manipulating the timing of the contraceptive pill, it is important to shorten, not lengthen, the dosing interval to ensure that contraceptive protection is maintained. Make sure Ciara is aware that some spotting may take place as her body adjusts to the new time zone and changes in the timing of her contraception and that, as always, if any persistent changes in menstruation occur – particularly increased or unexpected bleeding – she should see her GP upon return to the UK.

To reduce the risk of DVT, advise Ciara to wear below-knee compression stockings, commonly known as flight socks, for the duration of her journey to the US. These apply pressure to the lower legs that helps to maintain blood flow, thereby minimising oedema and reducing the risk of DVT.

Class 1 stockings which exert a pressure of 14-17mmHg at the ankle are sufficient in most cases and pharmacy staff can provide advice to ensure the correct size is chosen and the fit is good. This is important as poorly fitting stockings can actually increase the risk of clot formation.

Other key advice to reduce the risk of DVT during a long-haul flight includes wearing loose, comfortable clothing, particularly around the lower legs, drinking plenty of water and avoiding alcohol or sleeping tablets. Above all, it is important to remain active during the flight, walking around the cabin whenever possible and performing anti-DVT leg exercises, such as stretches and leg extensions.

Remind Ciara that some of these tips can be applied to reduce the chance of DVT developing during her fly drive holiday as long car journeys can also raise the risk of DVT.

Combating jet lag

Peter Liu is a seasoned business traveller who makes regular trips between the UK and Hong Kong. Now in his mid-50s, Mr Liu says he is finding the impact of jet lag more pronounced and long-lasting. After a cardiac scare last year, Mr Liu is also looking for tips on how to stay healthy during his next long-haul trip.

Jet lag is the common term used to describe the constellation of symptoms that can occur as the body’s circadian rhythms adapt to a different light-dark schedule in a new time zone. It tends to be worse when flying in an Easterly direction and if seven or more time zones are crossed. Unfortunately, there is little robust clinical evidence to support the efficacy of the various jetlag remedies and supplements currently available, many of which are based on the hormonal neurotransmitter melatonin.

At present, melatonin-based products are not licensed in the UK for the treatment or prevention of jetlag and you should caution Mr Liu against buying these products online. Simple self-care advice that you can recommend to help to mitigate the effects of jet lag includes:

• Setting his watch to match the time of the destination country during the flight itself to aid in adjustment to the new time zone
• Establishing a new routine of eating and sleeping that adheres to the new time zone as soon as possible
• Avoiding napping on arrival and remaining active until as close to bedtime as possible
• Spending time outdoors on arrival, as exposure to natural daylight suppresses melatonin production in the brain and may help synchronise circadian rhythms to the new diurnal pattern.

If Mr Liu finds that temporary insomnia is an issue as he adjusts to Hong Kong time, then simple OTC sleeping remedies containing diphenhydramine hydrochloride can be recommended. To help prevent jet lag from developing, Mr Liu could also consider moving his bedtime an hour or so earlier in the run-up to his trip to ‘prime’ his sleeping routine for the destination, and should also ensure he is well-rested before each flight.

The same DVT prevention advice as was offered to Ms Johnson applies equally to Mr Liu and is particularly important given his history of cardiac problems. Other key tips to help Mr Liu stay healthy while travelling include:
• Drinking plenty of fluids to maintain good hydration during and after the flight
• Limiting caffeine consumption
• Avoiding alcohol and consuming only light meals
• Keeping active during the flight
• Sleeping or napping during the flight – but only if this coincides with night-time at the destination.

Travelling with diabetes

Mary Jackson is 48 years old and a regular pharmacy customer. She was recently diagnosed with type 2 diabetes and is concerned about the impact this will have on the annual family holiday. She asks for advice on how to optimally manage her condition while travelling abroad.

According to Diabetes UK, diabetes is “no barrier” to travel anywhere in the world.1 You can help ensure Mary has a healthy, relaxed and stress-free holiday despite her diabetes by suggesting the following preparations and precautions:1

• Carry diabetes ID and obtain a GP letter detailing her diagnosis and treatment
• As a precautionary measure, she should plan to travel with twice the quantity of medical supplies she would normally use and pack this across separate bags, always including a complete set of essential diabetes supplies in her hand luggage
• Contact her diabetes care team before travelling to discuss any medication or regimen adjustments that may be required. For example, hot temperatures can affect blood glucose control, increase the rate of absorption of insulin from the injection site and influence the accuracy of glucose meters
• If she is on insulin, Mary should contact the manufacturer to check sources/supplies of insulin at her destination in case of an emergency
• Buy appropriate travel insurance and/or apply for a free European Health Insurance Card (EHIC) if travelling within Europe
• Pack extra snacks for the journey, including starchy carbohydrate foods and hypo treatments such as glucose tablets.

Passing through airport security with medical syringes, insulin, glucose monitors, pumps and/or pens should not be a problem, but the Civil Aviation Authority (CAA)’s Advisory Health Unit recommends that people with diabetes contact their airline in advance to discuss the medical devices they intend to take on board the aircraft and always carry a doctor’s letter and copy of their prescription. The CAA says it is important that insulin not being used on the flight is not packed in the hold baggage as this may be exposed to temperatures that could degrade the drug.

Solo travellers with diabetes should let hotel/hostel staff know of their condition upon check-in in case they become unwell during their stay. Diabetics who need to seek medical treatment while abroad should also bear in mind that in some countries, particularly the US, blood glucose is measured in milligrams per 100 millilitres (mg/dl) as opposed to mmol/L as in the UK.

Meeting specific travel needs

Mohammed Muhsin is a 27-year-old solicitor and practising Muslim who, after arranging a month-long sabbatical from work, is planning to embark on the Hajj and Umrah pilgrimage later this year. He is uncertain exactly what this journey will entail and is concerned about the risk of contracting malaria or other diseases while away from home.

Both Hajj and Umrah are important Islamic pilgrimages to Mecca, which is located in the Hejaz region of Saudia Arabia. Hajj is one of the largest annual mass gatherings of people in the world and as such poses unique health risks.

Despite the outbreak of Middle East respiratory syndrome virus (MERS-CoA) in the region, Mohammed can be reassured that there are currently no active travel restrictions to Saudia Arabia and UK Government advice is that the overall risk of contracting the virus is “very low”.2

As the dromedary camel has been pinpointed as the main host species for transmitting the virus to humans, travellers to the region are urged to avoid contact with camels, consumption of camel milk or meat, or drinking any raw milk that may have been contaminated with animal secretions.

In order to obtain a visa for entry into Saudia Arabia, Mohammed will be required to be up-to-date with all his routine immunisations and also have a valid certificate of vaccination against meningococcal meningitis ACW135Y.2 Public Health England and the National Travel Health Network and Centre (NaTHNaC) also provide the following specific health advice for Hajj and Umrah pilgrims, which pharmacy teams should relay to any customers planning this significant journey:3

• Ensure they are as physically fit as possible before travelling as pilgrimage rituals can be demanding and involve walking long distances across hot sands
• Take a sufficient supply of any prescribed medications and always carry a copy of their prescription with them
• Take their own disposable razor for personal use during the Hajj head shaving ritual
• Practise good hand and general hygiene at all times
• Pack a first aid kit
• Take appropriate food and water hygiene precautions while away
• Consider pre-travel vaccination against hepatitis B, rabies and seasonal influenza (in addition to the required meningococcal vaccination).

Melatonin products are not licensed in the UK for treating or preventing jetlag

Malaria is not present in Mecca or its surrounding cities but can be found in the south-western provinces of Saudia Arabia. Mohammed should therefore consider malaria prevention if he is planning on travelling further afield during the pilgrimage. Practising insect bite avoidance methods, particularly the use of DEET-based repellents and mosquito nets, remains prudent advice anyway to reduce the risk of other vector-borne illnesses such as dengue fever.

Many pilgrims will develop a viral respiratory infection known as ‘Hajj cough’ during the pilgrimage, which can range in severity from mild to severe.3 Due to the risk of MERS, Mohammed should be advised to seek immediate medical attention if he develops flu-like symptoms or shortness of breath within 14 days of returning from Saudia Arabia.

High-risk regions

Delores is a recent university graduate who is about to embark on a gap-year, backpacking around South East Asia. She has come to the pharmacy seeking vaccination information, as well as general advice on travellers’ diarrhoea and safe sex.

Vaccinations routinely recommended for travellers to South East Asia include hepatitis A, tetanus and typhoid. Additional vaccinations that Delores may wish to consider, particularly if she is staying in the region for an extended period or likely to be travelling to remote areas, include hepatitis B, diphtheria, cholera, Japanese encephalitis and rabies. Malaria prophylaxis is also essential in risk areas of South East Asia, which currently include Vietnam, Cambodia and Laos.

Delores is right to be concerned about travellers’ diarrhoea, as most of the Asian continent falls into a high risk zone where the chance of developing the condition is >20 per cent.4 NICE suggests the following key management advice for those, like Delores, who are at high risk of contracting travellers’ diarrhoea:
• Emphasise the importance of personal hygiene plus food hygiene and safe drinking water, to reduce the risk of travellers’ diarrhoea
• Warn about the risk of food- and water-borne infections and how to avoid potentially contaminated recreational water
• Ensure that travellers realise there are no universal vaccines to cover all the infections which may cause travellers’ diarrhoea
• Offer advice regarding self-management and when to seek medical advice if diarrhoea develops during the trip.

Although prophylactic treatment for the prevention of travellers’ diarrhoea is not indicated for most travellers, Delores may wish to ask her GP about a prescription for a ‘stand by’ antibiotic to use if needed. She could also consider taking OTC medications (e.g. loperamide and oral rehydration salts) with her to use for symptomatic treatment in the case of diarrhoea developing.

In order to minimise the risk of sexually transmitted infections (STIs) and unplanned pregnancy, advise Delores to use barrier contraception while abroad and to consider taking a supply of condoms with her. This is particularly important when travelling to regions where the incidence of blood-borne infections like HIV and hepatitis is significantly higher than in the UK.

 

Key facts

  • Class 1 below-knee compression stockings are key for reducing DVT risk during long-haul flights
  • Proof of meningococcal meningitis vaccination is essential for anyone travelling to Saudia Arabia for one of the Islamic pilgrimages
  • Patients with diabetes should check what medication or regimen adjustments may be required when travelling
  • Heartburn can often strike while abroad because of unfamiliar foods, so recommend an OTC preparation such as a PPI

 

References
1. Diabetes UK. Travel & diabetes: diabetes.org.uk/travel
2. Public Health England. Latest travel health advice for Hajj and Umrah pilgrims: gov.uk/ government/news/latest-travel-health-advice-for-hajj-and-umrah-pilgrims-published
3. National Travel Health Network and Centre (NaTHNaC). Hajj and Umra: travelhealthpro.org.uk/factsheet/19/hajj-and-umra
4. NICE Clinical Knowledge Summaries (CKS). Diarrhoea – prevention and advice for travellers. Revised May 2013

Originally Published by Pharmacy Magazine

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