BRITISH TRAVEL HEALTH ASSOCIATION JOURNAL

ISSN 1478.680X. Winter 2006. Volume 8

Published by Executive Committee of Contents British Travel Health Association for circulation to members. Inside front cover – Executive Committee Members

Centre of Journal – Travel Wise – Newsletter of the British Travel Advertisements carried in this Health Association, Issue 23, Winter 2006 publication are not endorsed by the editors or the Association and their message and content may not 2 Editorial/Presidents Message represent the views of either. Views expressed in the Journal are not 3 Accidental death and injury in adults and children while necessarily those of its abroad S Janson publishers. 6 Review of Illness in Returning Travellers’: How do symptoms relate to travel destination M Townend 9 The Scottish Connection to Travel Medicine J Cossar The Journal including the quarterly sister publication of Travel Wise: 10 Travellers’ Health in Finland T Puumalainen subscription for non-members £30·00 and £40·00 for overseas subscribers 12 Health Insurance Protection in Australian Travellers’ S Carroll (students: £10·00) per annum, payable 14 The Good Samaritan Response – An Ethical Dilemma and by 31 March. Professional Challenge I MacKay 17 Indemnity for Health Professionals Working or Travelling Abroad Subscription and membership application forms may be obtained 18 Medecins Sans Frontieres BTHA Journal, from: via The Secretary, 19 A History of Quinine and Artemisinin A Allen Diane Jones BTHA 21 A Return to War Ravaged Lebanon M Manook PO Box 336 SALE M33 3UU 23 Have Stethoscope Will Travel A Melrose Tel: 08702 461982 www.btha.org 25 Health Care and an Appeal from Honduras N Potter Scientific Articles and Research 31 Public Awareness of the Health Risks Associated with Trekking to High Altitude G Flaherty, M Umeed, T O’Brien, G Fry Copy date for each issue of Journal and Travel Wise is first of March, June, 31 Travellers’ and Tuberculosis A A MacConnachie, C A Redman, E Walker September, November. Articles to be sent to Editor BTHA PO Box 336 33 Dishwashing in Basic Camps J Hargreaves SALE M33 3UU. 37 Audit of a GP Travel Clinic R Walker 40 Illness during an up country camp for rural cultural development of the university student – common problems and Editorial Sub-committee: incidence. V Wiwanitkit I McIntosh, M Townend, J Gallagher, J Wilson-Howarth, A Jordan. 42 Update for Novice and Expert Deep Vein Thrombosis and Pulmonary Embolism

Flight or Fright: How was it for you E I Foreman Advertising: Enquiries on advertising in the 46 Scenarios from the NaTHNac Telephone Advice Line A Jordan Society’s publications should be addressed to the Secretary. 51 Letter from Honduras N Potter Advertisements carried in this Journal do not necessarily reflect the opinion 52 Book Reviews/From the Journals of editors in regard to their therapeutic value or efficacy. 53 In the News 2 Journal of BTHA, Volume VIII, 2006

Editorial

elcome again to this second issue of 2006. responsibilities and the limitations of professional The very successful Northern European indemnity cover. Attention is drawn to the article on WTravel health Conference in Edinburgh in Medecins Sans Frontieres a charity founded in Good the Spring yielded many interesting presentations and Samaritan responses. BTHA now supports a small some of these we present to members and the wider charity in rural Central America and letter from readership. Honduras describes some of the health problems Conferences provide an opportunity for network- there. ing and authors from Europe and far afield have also Excluding infectious diseas, vaccines and anti- contributed to the contents. They testify to the global malarials there remains a paucity of research and health involvement of the British Travel Health qualitative data on almost every other aspect of travel Association With the next NETHC currently being related medicine to provide an evidence base for good organised in Helsinki, an article from Finland sets the management. If you have undertaken any investiga- scene and is a reminder of the high risk from road traf- tive work within the expanding discipline of travel fic accident and trauma that world travellers can expe- medicine, do consider writing it up and sharing your rience. Those involved in such incidents will bless the findings with colleagues. Our research section pro- protective and supportive umbrella offered by ade- vides a rare opportunity for the novice researcher and quate travel health insurance and we again consider writer to disseminate their thoughts and findings. The the need for appropriate cover for lay and profession- editorial team of Travelwise and the Journal are happy al travellers. Terrorist events are increasing at home to assist and we welcome your material. As always we and abroad and all travelling doctors and nurses seek members views on the publications, good, bad or should be aware of their Good Samaritan professional indifferent to help us create a journal of interest to all. Iain B. McIntosh.

Presidents Message

This is my first letter written for the BTHA Journal Medicine with the Royal College of Physicians and as its President. Surgeons of Glasgow. Helping to formulating accept- It has been exciting and a privilege to have been able standards of travel medicine practice through involved as a founder member and follow its remark- entrance examination, offering opportunities for CME able progress over such a relatively short period of and providing continuing professional support are time. overall key College objectives. It is no coincidence, This year saw the first Northern European Travel and reflects on the success of BTHA, that so many Medicine Conference (NECM) held in Edinburgh and BTHA members including nurses have already been strongly supported by the BTHA both on its commit- awarded Associate, Member and Fellow status by the tees and through the large number of BTHA delegates. College Fellowship Committee – many receiving their This successful event was run in collaboration with awards in person at the College ceremony in July the Scandinavian countries, Ireland and the ISTM. I alongside those gaining other medical, surgical and have just returned from a follow-up meeting in dental specialist qualifications. This surely is a good Helsinki where it was decided to go ahead with a omen for the future of our speciality and the BTHA. NECTM2 in Finland in May 2008 (my return airfare Meantime BTHA membership is increasing. It is was only £110 so hopefully many from the UK will be hoped to run more regional events on the same lines able to attend!). I think these links with other coun- as the recent conference in Northern Ireland. The tries are especially important for the BTHA -Travel Association has an enthusiastic and committed execu- Medicine, by its nature, cannot practice in national tive committee which includes a number of relatively isolation – there are close similarities between new faces. Scandinavia and the UK in the way Travel Medicine is I look forward to seeing the association going from practiced, for example, with a lot of the professional strength to strength during my term as President. responsibility being undertaken by nurses. Another major event this year has been the estab- Eric Walker. lishment of a multi-disciplinary Faculty of Travel Accidental death and injury in adults and children while abroad 3

Accidental death and injury in adults and children while abroad Staffan Janson

Introduction Swedish deaths overseas 763 million people crossed international borders in To my knowledge no paper on Swedish overseas 2004, almost 55% were vacationing and another 15% deaths has formerly been published in English. were on business travel. During the last 15 years inter- Swedish overseas deaths have however increased national travels have increased by 73% despite global steadily in recent years, presumably caused by ever health crises, wars and terrorism.1 Studies on overseas more extensive travel, especially elderly and poten- fatalities and morbidity are sparse and mainly con- tially severely sick people. For the three year period cerning adults, while there is little or no information 2001 – 2003 a total of 1300 persons died abroad, which about children. A study of US citizen travellers for the constitutes 4,6% of all Swedish deaths these years. years 1975 and 1984 was probably the first study Only 4 % were under 25 years of age, 10% 25 – 44, 33% examining a whole overseas population from one sin- 45 – 64, and 53% 65 years or older. Deaths due to acci- gle country. It revealed that half of the almost 5,000 dents or violence were overall 12% with very great overseas deaths were caused by cardio-vascular dis- differences depending on age. In this group one case eases and a quarter of injuries, while infections other of ten was a suicide, while deaths due to assaults than pneumonia accounted for only one percent of the seemed to be very rare. While accidents caused half of deaths. Injury death rates for males were greater than all deaths under 45 this was the cause for only two US age-specific death rates.2 In a following paper by percent of those aged over 65, where the absolute the same group it was stated that most Americans majority died from cardio-vascular diseases. Only 2% who die overseas die in the developed countries of of all deaths were caused by infections. Western Europe, where most Americans live or visit. A major problem with the official Swedish statistics Secondly, and at the time surprisingly, the deaths of is that about 40% of the overseas deaths have incom- Americans in less developed countries were not from plete death certificates or lacks specified causes of infectious diseases, but from chronic diseases, injuries, death. Some cases may also be missing. The figures suicides and homicides. The pattern of deaths in these above are consequently calculated on the remaining countries was similar to death patterns in United 60%. However the Swedish figures confirm interna- States.3 Information regarding almost one thousand tional data where age related death due to “natural Scots who had died while travelling abroad between causes” are most common, with accidents second and 1973 and 1988 confirmed the American picture. In the with few cases due to fatal infections. older age-group cardio-vascular disease was the More than one half of the violent death cases are major cause of death whereas among the younger traffic accidents and one third drowning. One case out traumatic deaths were most common.4 of ten violent causes is suicide while assaults abroad An Australian study concerning overseas travellers leading to deaths are rare, at least in the Swedish sam- 1992 – 1993 showed that death increased with age, ple. Accident deaths in Sweden have continuously reflecting underlying problems in older travellers, decreased while they concomitantly have increased with heart disease being the leading cause (35%).5 for Swedes abroad, now constituting 10 - 20% of the Fatal trauma predominated in younger people. accident mortality. This actually means that preven- Accidents, mainly in traffic, accounted for 18%, sui- tive measures have to be directed specifically towards cides 6% and infections for 2% of all deaths. It was the travellers. concluded that dying while travelling overseas was probably little different from that while staying at Road-traffic injuries abroad home. The low level of fatal infections may have been Road-traffic is probably an underestimated risk for a result of preventive measures. injury and death of overseas travellers. In 2002, an In a study on Canadians dying abroad 62% deaths estimated 1, 2 million people were killed and 50 mil- were due to natural causes, 25% to accidents, 8% to lion injured in road-traffic crashes worldwide. It is murder and 5% to suicides.6 In a recent Medline ranked as the 11th leading cause of death in the world. search, no specific paper on overseas fatalities in chil- Travellers from northern Europe comes from the dren was found. Articles concerning children are gen- region with the lowest road-traffic fatalities, with 11 erally advisory and normally bring up topics like deaths a year per 100 000 population. They are hygiene and immunisations7 and only rarely discuss acquainted to a well organised and fairly safe traffic injury prevention.8 The aim of this paper is to discuss situation and high demand for safe cars. When abroad the importance of injury prevention for overseas trav- the circumstances are often quite different e.g. in near- ellers and for children in particular. by countries in Eastern Europe, where the death rates are double to what they are used to i.e. Latvia 4 Journal of BTHA, Volume VIII, 2006

Accidental death continued

23/100,000. - Tell relatives and young drivers to keep up the The figures are about the same in South East Asia security – it is not a question of being kind (South Korea 22 and Thailand 21 per 100,000), higher - When adults relax during holidays they also seem to in most African countries (mean 28), and even higher change their safety behaviour. They drive more often in some Latin American countries (e.g. 42 and 41 in El without safety devices (mainly short distances) and Salvador and the Dominican Republic).9 The high fig- sometimes forget that they were drinking substantial ures in the latter countries are partly due to socio-eco- amounts of alcohol the night before travelling, which nomic factors exposing local people to dangerous may impair their discerning ability. environments, but some of these risks like heavy, The young adult generation is used to travel to crowded traffic and low safety levels will definitely exotic places and many of them pursue this behaviour have an impact also on foreigners. after having children. This became explicit in the 2004 Tsunami catastrophe where more than 24% of the Travelling with children Swedish fatalities were children under twenty, 9% The greatest health risk when travelling with children were pre-school children and some of them were only are not from infectious diseases but from traffic acci- a few months old. The author of this paper worked in dents. In the Swedish material reported above, only Thailand in the aftermath of the Tsunami and this trig- one child died due to an infection - a meningococcal gered some reflection about how reasonable it is to sepsis, while the majority of cases were accidents and travel far away with small children. When discussing a few cases due to chronic diseases. The reason for the this with young parents they spontaneously answered low infectious fatality is probably, that when travel- that they mainly travelled for their children’s pleas- ling abroad children usually stay in places with high ure. At the same time observed how small children hygienic standard and they are immunised against the had to be kept in restricted areas under shelter to most dangerous contagious diseases. European par- avoid heat strokes and could not swim in the sea due ents are normally also trained to treat their children’s to high waves. The children were quite often upset diarrhoeas with oral rehydration (ORS). On the other during air port check-ins and while in the airplanes. hand most European children are travelling by car Young parents with substantial incomes have been during their holidays, on longer trips or just to stay used to travel a lot with few severe complications. It with relatives or friends. Immigrant children are a vul- therefore seems normal for many of them to carry on nerable group as their families travel long distances to travelling also with small children. When counselling their country of origin, often in older cars and to coun- these parents the following questions should be con- tries with less preventive awareness. In Sweden par- sidered ents of Arab and Latin American origin show a lower - Who wants to go to overseas, the children, the par- awareness of child safety in cars than native born ents or both? ones.10 - Children want to be together with relaxed parents, When children are left in custody of grandparents, but do they want to travel around the world? Will the friends or older siblings, there is an increased risk of children benefit from the journey except for being injury as grandparents often don’t have safety devices together with their loved ones? appropriate for children or they leave them unbelted - Are there children old enough to identify themselves in the front seat of the car, just to be “kind”. More than in case they get lost in a country with a totally foreign 60% of all car crashes are frontal and another 25% are language? side collisions. An analysis of the 1988-95 United - Are their other snakes in paradise? Is it just a ques- States Fatality Analysis Reporting System including tion of infectious diseases or are there other more dan- 26,233 children under thirteen involved in fatal crash- gerous threats like heavy traffic, risk for drowning or es showed, a double risk of dying if placed in the front other injuries? seat compared to the rear – whether belted or not.11 Health staff often find themselves in a tricky situa- Health staff and travel advisers should remind par- tion. Parents usually ask them if it is dangerous to ents of a few considerations before they embark on a travel far away, when they have long ago booked their journey with their children: journeys. What they then want to hear is, that there - Children seldom asking for long trips, particularly are no real threats to their children. Questions can be not pre-schoolers. They want to stay with friends and presented if they can be put forward in a non moralis- relatives. ing manner. Some parents will realise that they have - Children want to move around and play. Frequent not been considerate enough and a few will change breaks are a must. Children also need to move around their plans. The best arrangement is to bring up these in aircraft during long trips. questions in advance i.e. in parental discussions in - Use shelter for the sun. Never leave children alone well baby clinics before journeys with small children sleeping in cars risk of heat stroke! are planned. - Keep an eye on children at stops! There might i.e. be a pond just around the corner. Accidental death and injury in adults and children while abroad 5

Summary References Health staff should be updated about the greatest 1 Hill D. The burden of illness in international travellers. risks for people travelling abroad. Besides immunisa- NEJM2006;254(2):115-7. tions and hygienic instructions people should be 2 Hargarten S, Baker T, Guptill K. Overseas fatalities of United States citizen travellers: an analysis of deaths related to interna- informed of the risk to travel abroad with vascular tional travel. Ann Emerg Med. 1991;20(6):622-6. diseases, with alcohol problems and depressions and 3 Baker T, Hargarten S, Guptill K. The uncounted dead – to be particularly careful with traffic situations usual- American civilians dying overseas. Public Health Rep 1992;107(2):155-9. ly quite different from what they are used to at home. 4 Paixao M, Dewar R, Cossar J, Covell R, Reid D. What do Scots Very little is known about overseas child mortality. die of when abroad? Scott Med J. 1991;36:114-6. Recent Swedish figures however indicate that the 5 Prociv P. Deaths of Australian travellers overseas. Med J Aust. majority of deaths are caused by accidents. Parents 1995;163(1):27-30. 6 MacPherson D, Guerillot F, Streiner D, Ahmed K, Gushulak B, (and grand-parents) should consider if younger chil- Pardy G. Death and dying abroad: the Canadian experience. J dren might be happier spending their holidays in Travel Med. 2000;7(5):227-33. safer and better known places. The Swedish govern- 7 Ferguson L, Parks D, Yetman R. Health care issues for families ment is planning a national child fatality review sys- travelling internationally with children. J Pediatr Health Care 2002;16(2):51-9. tem. Hopefully this will give us a future better picture 8 Neumann K. Family travel. An overview. Travel Med Infect Dis. also of overseas child fatalities. 2006;4(3-4):202-7. 9 Ameratunga S, Hijar M, Norton R. Road-traffic injuries: con- Professor Staffan Janson, fronting disparities to adress a global- health problem. The Paediatrician. Karlstad University, Sweden Lancet 2006;367:1533-40. 10 Swedish road Traffic Institute. Immigrants in traffic (in Swedish). Linköping; VTI-report 2000:454. 11 Braver E, Whitfield R, Ferguson S. Seating position and chil- dren’s risk of dying in motor vehicle crashes. Injury Prevention 1998;4:181-7.

photo by I. McIntosh 6 Journal of BTHA, Volume VIII, 2006

Review of Illness in Returning Travellers’: How do symptoms relate to travel destination Mike Townend

his article is a review of data published by cause was reported the commonest causes were Freedman et al in the New England Journal of malaria and dengue, with infectious mononucleosis, TMedicine1. In their study, Freedman and his col- rickettsial infections and Salmonella typhi &/or paraty- leagues examined data on returning travellers from 30 phi being the next commonest causes. There were vari- GeoSentinel sites, which are specialised travel or trop- ations between regions in their relative frequency, as ical medicine clinics around the world. In all 17,353 ill shown in Table 2. returned travellers were included in the study. They were placed in categories according to the regions to Table 2 which they had travelled, namely the Caribbean, Causes of fever by region in order of frequency Caribbean Central South Sub- South South Central America, South America, sub-Saharan Africa, America America Saharan Central Southeast South Central Asia (the Indian sub-continent) and African Asia Asia 1 Dengue Malaria Dengue Malaria Dengue Dengue Southeast Asia. The illnesses which they presented to (238) (133) (138) (622) (142) (315) Mono- Dengue Malaria Rickettsia Malaria Malaria the travel clinic on their return were grouped into syn- 2 nucleosis (123) (133) (56) (139) (130) dromes such as systemic febrile illness, acute diar- (70) Malaria Mono- Mono- Mono- Salmonella* Mono- rhoea, skin disorders, chronic diarrhoea, etc with 3 (65) nucleosis nucleosis nucleosis (141) nucleosis (69) (79) (10) (26) causative disease or organism cited where possible. Salmonella* Salmonella* Salmonella* Dengue (7) Mono- Salmonella* 4 (22) (4) (4) & nucleosis (26) Salmonella* (17) The “top five” syndromes (7) 5 Rickettsia Rickettsia Putting the results together from all these regions, (10) (16) the five most frequently encountered travel related * = Salmonella typhi & paratyphi syndromes in descending order of frequency were Figures in brackets refer to the number of cases per 1000 travellers febrile illness, acute diarrhoea, skin disorders, chronic diarrhoea and non-diarrhoeal gastrointestinal disor- Causes of acute diarrhoea ders. For most of the individual regions the same five In all regions the largest group of travellers had no syndromes, in differing orders of frequency, were specific cause reported for acute diarrhoea. In those amongst the top five, but in sub-Saharan Africa, South for whom a cause was reported the commonest caus- Central Asia and Southeast Asia non-diarrhoeal gas- es were parasitic diarrhoea (Giardia and Amoeba) and trointestinal disorders were a little lower in the rank- bacterial diarrhoea, presumed bacterial with no ing. In these areas respiratory disorders narrowly beat organism identified, Campylobacter, Shigella and them into the “top five”. In travellers to sub-Saharan non-typhoid Salmonella. There were variations Africa chronic diarrhoea was also not amongst the top between regions in their relative frequency, as shown five, non-specific symptoms taking its place. These in Table 3. Viral diarrhoea was relatively uncommon. findings are summarised in Table 1. Table 3 Table 1 Causes of acute diarrhoea by region in order of frequency The 5 most frequent syndromes in returning Caribbean Central South Sub- South South travellers according to destination of travel America America Saharan Central Southeast African Asia Asia Caribbean Central South Sub- South South America America Saharan Central Southeast Cause Cause Cause Cause Cause Cause African Asia Asia 1 unspecified unspecified unspecified unspecified unspecified unspecified (457) (377) (376) (397) (389) (393) Skin Acute Skin Febrile Acute Febrile 1 disorders diarrhoea disorders illness diarrhoea illness Giardia Amoeba Giardia Giardia Giardia Campylo- (261) (234) (264) (371) (248) (248) (132) & (155) (158) (177) (286) bacter 2 Presumed Acute Skin Acute Acute Febrile Skin bacterial* 2 diarrhoea disorders diarrhoea diarrhoea illness disorders (132) (196) (225) (219) (167) (171) (212) Amoeba Giardia Amoeba Amoeba Presumed Giardia Febrile Chronic Febrile Skin Skin Acute 3 (105) (136) (142) (138) bacterial* (118) 3 illness diarrhoea illness disorders disorders diarrhoea (136) (166) (173) (143) (127) (130) (210) Campylo- Presumed Presumed Presumed Amoeba Presumed Chronic Febrile Chronic Respiratory Chronic Chronic 4 bacter bacterial* bacterial* bacterial* (103) bacterial* diarrhoea illness diarrhoea disorder diarrhoea diarrhoea (46) (94) (106) (99) (116) 4 (132) (153) (130) (77) (129) (97) & respiratory Shigella Presumed Campylo- Campylo- Campylo- Amoeba disorder (97) 5 (37) parasitic* bacter bacter bacter (74) (45) (90) (73) (87) Other Other Other Non-specific Respiratory Non-specific gastro- gastro- gastro- systems disorder systems Non-typhoid Campylo- Presumed Shigella Shigella Non-typhoid 5 intestinal intestinal intestinal (75) (89) (63) 6 Salmonella bacter parasitic* (46) (61) Salmonella (87) (75) (82) (27) (32) & (52) (56) viral (32) Figures in brackets refer to the number of cases per 1000 travellers Viral Shigella Shigella Presumed Presumed Presumed 7 (23) (26) parasitic* parasitic* parasitic* (33) (55) (33) Presumed Non-typhoid Non-typhoid Non-typhoid Non-typhoid Shigella Causes of fever 8 parasitic* Salmonella Salmonella Salmonella Salmonella (26) (9) (13) (14) (29) (12) In all regions the largest group of travellers had no Viral Viral Viral Viral specific cause reported for fever. In those for whom a 9 (5) (7) (4) (9) * = no organism isolated Illness in Returning Travellers’ 7

Figures in brackets refer to the number of cases per 1000 travellers Table 5 Causes of non-diarrhoeal gastrointestinal disorders by region in order of frequency Causes of skin disorders Caribbean Central South Sub- South South Insect bites, with or without subsequent infection, America America Saharan Central Southeast cutaneous larva migrans, allergic reactions and skin African Asia Asia Worm Worm Worm Worm Worm Worm 1 infestation infestation infestation infestation infestation infestation sepsis were the most frequent diagnoses overall. (278) (273) (256) (307) (202) (344) These and other causes are shown in order of fre- Gastritis/ Piles/ Gastritis/ Gastritis/ Acute Gastritis/ 2 peptic ulcer Constipation peptic ulcer peptic ulcer hepatitis peptic ulcer quency in Table 4. (258 (192) (168) (85) (214) (104) Piles/ Gastritis/ Piles/ Acute Gastritis/ Piles/ 3 Constipation peptic ulcer Constipation hepatitis peptic ulcer Constipation Table 4 (124) (91) (117) (76) (101) (74) Causes of skin disorders by region in order of frequency Acute Acute Acute Piles/ Piles/ Acute 4 hepatitis hepatitis hepatitis Constipation Constipation hepatitis Caribbean Central South Sub- South South (62) (91) (102) (54) (84) (61) America America Saharan Central Southeast African Asia Asia Figures in brackets refer to the number of cases per 1000 travellers Cutaneous Insect bites Insect bites Insect bites Insect bites Insect bites larva (235) (156) (194) (201) (179) 1 migrans (299) Relative risk by destination of travel Insect bites Cutaneous Leishman- Skin abscess Skin abscess Cutaneous The authors calculated the proportionate morbidity (187) larva iasis (163) (144) larva 2 migrans (143) migrans for the various syndromes or disease entities encoun- (187) (171)

Allergic Allergic Cutaneous Swimmer’s Allergic Animal bite tered in their returning travellers, the results being reaction reaction larva itch reaction with rabies 3 (148) (128) migrans (177) (177) prophylaxis expressed as cases per 1000 travellers. Table 6 shows (128) (124) the ten conditions with the highest proportionate mor- Case Myiasis Myiasis Allergic Animal bite Skin abscess unknown (101) (100) reaction with rabies (122) bidity for each region. All the conditions not included 4 (55) (100) prophylaxis (90) in Table 6 occurred in a proportion of less than 30 per Fungal Case Allergic Cutaneous Fungal Allergic Infection unknown reaction larva Infection reaction 1000 (45) (74) (97) migrans (64) & (93) 5 (86) cutaneous larva Table 6 migrans (64) Proportionate morbidity by region Skin abscess Leishman- Case Case Case Fungal 6 (34) iasis unknown unknown unknown Infection Caribbean Central South Sub- South South (64) (75) (66) (48) (61) America America Saharan Central Southeast African Asia Asia Superficial Skin abscess Skin abscess Fungal Superficial Case skin (47) (50) Infection skin unknown 7 Chronic Chronic Chronic Falciparum Parasitic Fever infection (65) infection (45) 1 diarrhoea diarrhoea diarrhoea malaria diarrhoea (102) (31) (45) (132) (173) (173) (179) (148) Mite Mite Mite Myiasis Mite Superficial Acute Parasitic Acute Fever Chronic Respiratory infection infection infection (40) infection skin 2 diarrhoea diarrhoea diarrhoea (98) diarrhoea illness 8 (scabies) (scabies) (scabies) (scabies) infection (90) (95) (82) (130) (97) (31) (37) (39) (29) (22) Fever Acute Parasitic Respiratory Bacterial Chronic Swimmer’s Fungal Fungal Superficial Leishman- Mite 3 (82) diarrhoea diarrhoea illness diarrhoea diarrhoea itch (3) & Infection Infection skin iasis infection (88) (80) (76) (96) (97) Animal bite (30) (36) infection (64) (scabies) 9 Larva Fever Fever Acute Acute Acute with rabies (32) (17) 4 migrans (65) (73) diarrhoea diarrhoea diarrhoea prophylaxis (77) (66) (95) (82) (3) Parasitic Insect bites Bacterial Parasitic Respiratory Dengue Superficial Animal bite Leishman- Swimmer’s Swimmer’s diarrhoea (53) diarrhoea diarrhoea illness (78) 10 skin with rabies iasis itch itch (56) (66) (59) (89) infection prophylaxis (64) (3) (9) (31) (3) Bacterial Respiratory Respiratory Chronic Fever Bacterial diarrhoea illness illness diarrhoea (77) diarrhoea Animal bite Superficial Mite (51) (49) (50) (57) (78) 11 with rabies skin infection prophylaxis infection (scabies) Insect bites Bacterial Insect bites Non-falcip. Fatigue Parasitic (13) (9) (12) (50) diarrhoea (52) malaria (50) diarrhoea (45) (52) (55) Swimmer’s Animal bite 12 itch with rabies Respiratory Larva Leishman- Bacterial Blastocystis Insect bites (2) prophylaxis illness migrans iasis diarrhoea (43) (38) (9) (45) (30) (37) (42) Dengue Intestinal Larva Schisto- Insect bites Larva (40) worms migrans somiasis (27) migrans Figures in brackets refer to the number of cases per 1000 travellers bite, (25) (32) (42) (36) with rabies prophylaxis Allergic rash Gastritis & Blastocystis Fatigue Dengue Fatigue (39) gastro- (31) (28) (25) (30) enteritis (23) Causes of non-diarrheal gastrointestinal disorders Figures in brackets refer to the proportionatemorbidity per This group of disorders covered some conditions 1000 travellers which were likely to be travel related and others which may or may not have been travel related. They included worm infestation (Strongyloides and Ascaris), Comment gastritis/peptic ulcer, hepatitis and constipation. They Gastrointestinal disorders are shown in order of frequency in Table 5. As might have been expected diarrhoea figured prominently as a cause of morbidity in all regions. Amoebiasis and giardiasis were prominent amongst the causes of diarrhoea in all regions, which at first sight may not appear to accord with the reader’s expe- rience and knowledge of travellers’ diarrhoea. It must be borne in mind however that this study relates to 8 Journal of BTHA, Volume VIII, 2006

Illness in Returning Travellers’ continued travellers consulting on their return, by which time occurred in the Caribbean. This is probably attributa- many episodes of acute diarrhoea, a high proportion ble to the higher proportion of travellers to the of which would be likely to have a bacterial cause, will Caribbean exposing their skin to contact with contam- have terminated spontaneously or following treat- inated sand on beaches. ment whilst travelling. Acute diarrhoea was found The frequency with which animal bites requiring most frequently in travellers from South Central Asia rabies prophylaxis occurred in Southeast Asia and (Indian subcontinent). South Central Asia (Indian subcontinent) is a useful For those cases in which a bacterial cause for diar- reminder of the need for including rabies in the risk rhoea was confirmed Campylobacter appears to have assessment for travellers to these regions. Animal been the most frequently occurring pathogen, fol- bites requiring prophylaxis also occurred in other lowed by Shigella and Salmonella. regions but not with the same frequency. Although cases of acute hepatitis (types not speci- The highest proportionate morbidity for leishmani- fied) occurred in all regions more cases were reported asis occurred in South America, though it also from South Central Asia (Indian subcontinent) than occurred amongst the causes of skin disorders in from any other region. Central America and to a lesser extent in sub-Saharan Africa and Southeast Asia. Fever Swimmer’s itch was, as would be expected, report- Fever, both non-specific and diagnosed, occurred ed most frequently in travellers to sub-Saharan most frequently in travellers from sub-Saharan Africa. Africa, where there was also the highest proportion- The highest proportionate morbidity for malaria, ate morbidity for schistosomiasis, it was also report- mostly P falciparum, occurred, not unexpectedly, in ed in South Central Asia, Southeast Asia and the sub-Saharan Africa, and that for dengue occurred in Caribbean. Southeast Asia, though both were prominent amongst Mike Townend is editor of Travel Wise and member of BTHA the diagnosed causes of fever in all regions. Dengue Executive Committee. occurred more frequently than malaria in all regions except sub-Saharan Africa. This study reflects the Acknowledgement with thanks: wide spread of dengue from its origin in Southeast Permission granted: copyright© 2006 Massachusettes Medical Society. All rights reserved. Asia. Rickettsial infection, particularly tick-borne, An edited review from an article first published in New England occurred principally in sub-Saharan Africa, where it Journal of Medicine. 2006 354(2):119-130. occurred more frequently than dengue or typhoid as a cause of fever. References Skin disorders 1 Freedman DO, Weld LH, Kozarsky PE et al. Spectrum of disease Cutaneous larva migrans occurred in several and relation to place of exposure among ill returned travellers. regions but the highest proportionate morbidity New England Journal of Medicine. 2006 354(2):119-130. The Scottish Connection 9

The Scottish Connection to Travel Medicine Jon Cossar

he idea of linking Scotland, Edinburgh, Travel between Edinburgh and travel Medicine and history came to me when asked to medicine was an early Travel Tintroduce a speaker talking on ‘How Changes to Medicine Symposium held at the Environment Can Affect International Travel’ at the Royal College of Physicians NETMC, 2006. in 1982. Ensuing Scottish Travel I found myself leafing through my thesis ‘Illnesses Medicine milestones I have been associated with travel’ which had not been opened in privileged to experience over years, looking for the past 28 years include, the inspiration. From there establishment of the teaching Scottish history and an courses Diploma and MSc in ‘old friend’, Robert Travel Medicine at the Louis Stevenson, came University of Glasgow in 1995 and most recently the to my rescue. start of a Faculty of Travel Medicine in Glasgow. At the start of my However in setting the scene for the first speaker I researches into travel returned to the words of Stevenson. In a letter to his medicine 28 years ago I friend Sidney Colvin introducing him to ‘Travels with became fascinated a Donkey’ he wrote, ‘But we are all travellers in what with the writings of John Bunynan calls the wilderness of this world – all, Stevenson who was too, travellers with a donkey; and the best that we find born in Edinburgh in in our travels is an honest friend. He is a fortunate 1850 – the first link! For voyager who finds many. We travel, indeed, to find example in 1879 he them. They are the end and the reward of life. They wrote, ‘For my part I keep us worthy of ourselves; and, when we are alone, travel not to go any- we are only nearer to the absent”. To me, Stevenson where, but to go. I travel for travel’s sake. The great was here alluding to another aspect of travel – a socio- affair is to move’. Over centuries the Scots have cer- philosophical dimension; this seemed to link appro- tainly had a great affair with moving. From mercenar- priately (another new travel medicine dimension) ies to Europe in the 15th Century, to all corners of the ‘How Changes to the Environment can Affect world, followed by waves of emigrants through the International Travel’, but also afforded me the oppor- 17th, 18th and 19th tunity to express the hope that the delegates not only centuries to culmi- enjoyed the First Plenary but also made some ‘honest nating in almost 0.5 friendships’ during their stay in Edinburgh. million at the turn of the last century. Edited introductory presentation given. Northern European on Travel Conference, Edinburgh 2006. Travellers have been one of Dr Jon Cossar, MD ChB FFTM RCPS(Glasg). Scotland’s largest (Primary Care Physician). (greatest?) ‘world He has just returned from climbing Kilimanjaro, Tanzania. exports’. Stevenson himself was well travelled and gives a fascinating account of his Mount Kilimanjaro travel adventures in the Cevennes in France, in his ‘Travels with a Donkey’. In this book, even as early as 1879 he recorded some good travel medicine advice, ‘The good wife was horror-stricken to see me drink over a pint of uncreamed milk. “You will do yourself an evil,” she said,” Permit me to boil it for you.”’ Coming more up to date, a further connection photo by Jon Cossar 10 Journal of BTHA, Volume VIII, 2006

Travellers’ Health in Finland Taneli Puumalainen

inland is perhaps best known for its peacefulness nology. According to the British Embassy in Helsinki, and beauty. With a population of only 5.2 mil- Finnish medical facilities and their staff are as a rule Flion, it is geographically the seventh largest excellent and are widely available for emergency serv- country in Europe. Those keen on statistics will take ices. English is commonly spoken by medical person- delight in learning that Finland has 188,000 lakes and nel. 179,584 islands, 98,050 of which are in the lakes. The Health care in Finland is mainly provided on the rest are located mainly in Europe's largest archipelago, basis of residence and is primarily financed with gen- off Finland's southwest coast. The Finns live mainly in eral tax revenues. There are both public and private the southern part of the country. Helsinki metropoli- sector providers. Primary health services are general- tan area has nearly one million inhabitants, which ly the responsibility of the 431 municipalities and are means that the eastern and especially the northern provided through local health centres. The health cen- parts of the country have much less than the average tres provide residents with physician, dental, labora- 17 inhabitants per square kilometre. The northern tory and radiographic services. The municipalities province of Lapland, or Lappi in Finnish language, is own and operate nearly all hospitals including all five larger than Scotland, but has a population much less university hospitals. than that of Aberdeen. Private sector services provide mainly out-patient In 2005 the Britons travelled at least 233 000 times to care, a few special hospitals for elective surgery or Finland (Finnish Tourist Board statistics 2006). Over rehabilitation as well as all pharmacies. Patients who half of the trips were leisure -related. By far the most use private sector services normally pay the entire cost popular travel destinations were the Helsinki region of the service to the provider, after which they can and Lappi, which attracts especially tourists interest- apply for a partial refund from the Social Insurance ed in winter sports or Christmas – related package Institution (Kansaneläkelaitos, KELA) under the tours (Santa Claus lives in Lappi, NOT at the North Health Insurance Act. Finnish pharmacies are well Pole). This article describes some travel health issues stocked with all the basic medicines. The National relevant to foreign tourists planning to travel to Health Insurance pay a refund of at least 50 per cent of Finland. the prescription drugs costs exceeding a certain fixed rate (currently approximately 8€). All bigger cities Travel health precautions have 24 hour pharmacy services. The small communi- ties may rely on local health centres for night time In the era of international terrorism and travel pharmacy services. restrictions Finland is a very safe country, although Travellers in need of medical aid can contact a most people nowadays lock their cars and houses, at municipal health centre and by presenting a valid least in bigger cities. It is very unlikely that any other European Health Insurance Card (EHIC) prove their factor than occasional snow storm during winter entitlement to services equal to those of Finnish citi- months could complicate travel to Finland. The level zens. Travellers from outside the European Economic of hygiene is very high and the risk of contracting area, may have to pay the full fare for the services, or infectious diseases such as Hepatitis A and B as well present an internationally accepted travel insurance as HIV is very low. card. Some public health centre services are by law, No specific travel-related immunisation is required free of charge, but for certain other services a fee may or recommended before arriving in Finland. The Finns be charged. This varies from one municipality to living in Åland (the semi-autonomous island province the other. For a visit to a general practitioner (includ- between Finland and Sweden) receive an immunisa- ing laboratory and radiology services) or a dentist, tion against tick-borne encephalitis. The vaccine may the health centre usually charges 11 - 22€ (1€ is also be considered for long-term travellers who plan about 64 pence) (subsequent visits may be cheaper). to do trekking in Åland or the Turku archipelago Hospitals require a referral from a physician in order region. The two vaccine alternatives are TicoVac, also to admit a patient. However, in cases of emergency known as FSME Immun (Baxter AG), and Encepur patients can contact a hospital directly. In-patient care (Chiron Behring). A full immunisation series consists charge is currently 26€ per day, but persons under the of three doses over a one-year period, which is not age of 18 years and certain other patient groups may practical for most travellers. An accelerated schedule be entitled to free service. An out-patient visit charge, is possible, but may lead to lower immunity. including all diagnostic tests, is normally 22€. Travellers with a valid EHIC may apply for a refund for their medical expenses accrued during their stay in Finnish health care system Finland (common expenses: private physician/dentist Finland is a modern Nordic country with a high fees and prescription drugs) from the Finnish Social standard of living and advanced economy and tech- Insurance Institution (See www.kela.fi). Travellers’ Health in Finland 11

Nature and wildlife not only considered safe during pregnancy and for young children, but also used as a non-pharmacologi- In addition to common snowboarding and other cal treatment regime for certain medical conditions. sports related trauma, a fair number of tourists endan- Driving in Finland during the winter months can be ger their health while trekking, sailing or fishing. A hazardous. Icy road conditions are common. Winter snow mobile or reindeer safari under the Northern or snow tyres (either studded or non-studded) are a Lights may sound like an ideal winter vacation, but legal requirement from 1 December to 31 March. being lost dozens of kilometres from the nearest vil- Drinking and driving is considered a serious offence. lage, in temperatures of 25°C below freezing point The drink drive limit in Finland is 50 milligrams of may make one regret not following safety instruc- alcohol in 100 millilitres of blood (lower than in the tions. However, rescue services are professional and UK). Public drinking, also considered an offence by the coverage of mobile phone networks is extensive, Finnish law, is a common sight during weekends in so in the majority of cases people are saved without cities. However, drunken Finns rarely pose any dan- fatalities. Common sense, weather wise clothing and ger to anyone but themselves. From a tourist’s point of avoidance of alcohol will prevent most dangerous sit- view it is much more likely they be invited to share a uations. bottle than being hit by one. Mosquitoes can be a major nuisance, especially in Comprehensive travel and medical insurance pro- the far north, in the summer, so having a supply of tection is always advisable for any trip abroad. The repellent (‘Off’ is the common Finnish brand) is a EHIC, for example, does not cover health related good idea. About 1,000 brown bears inhabit Finland, changes in travel schedule. For more information but very unlikely to be encountered in the forest. Elks about travel health in Finland see the links below. on the other hand are very common. The warning Additional information on travel health issues and signs on Finnish roads should be taken seriously, since services in Finland: these large animals can appear suddenly on the road Finnish Social Insurance Institution and are slow to budge. The reindeer is extremely com- www.kela.fi mon in Lappi in the north, and are spotted while driv- Finnish Travel Board www.mek.fi ing above the Arctic Circle. These animals are semi- General tourist information domesticated but are allowed to graze freely across www.visitfinland.com vast areas. The only dangerous wildlife species is the Finnish National Public Health Institution common viper snake. Such encounters are quite rare, www.ktl.fi The UK Department of Health but in the case of a bite medical advice should be www.dh.gov.uk sought immediately. The UK Embassies -> Finland www.britishembassy.gov.uk/ General travel health -> Finland Other travel health advice www.travelhealth.co.uk/ Most tourists will be taken to a Finnish sauna with- www.cdc.gov/travel/ in the first few days of arrival. The question whether a www.who.int/ith lengthy stay in 80-90°C is risky or not, is now relevant. Prof. Taneli Puumalainen MD, PhD, Specialist in paediatric infec- As described by Kukkonen-Harjula and Kauppinen in tious diseases and international health. National Public Health a review article published in International Journal of Institute Mannerheimintie 166, FIN- 00300, Helsinki, Finland. Circumpolar Health (2006; 65(3):195-204) the sauna is Email: [email protected]

Finnish Lakeland 12 Journal of BTHA, Volume VIII, 2006

Health Insurance Protection in Australian Travellers’ Siobhan Carroll

ustralians love to travel. There are 20 million when a doctor has told their patient that they are ‘fit people in Australia, now making over 4.7 mil- to travel’, or that the holiday will ‘do them good’. Alion overseas trips each year.1 An aging popu- Australians are accustomed to traveling large dis- lation means that increasingly, older travellers embark tances, and for long periods of time, but there is little on international journeys. recognition of the toll that this can take on the body. There is also poor understanding of the cost of pro- Age and Pre-Existing Medical Conditions viding international Emergency Medical Assistance. Although insurers want to be able to provide insur- The result is an increasing problem of travellers who ance for older travellers, the high cost of medical are not insured, or who are underinsured. The refusal claims in this sector represents a challenge for to pay to have a Pre-Existing Medical Condition cov- Australian travel insurance providers. ered can cause a catastrophic financial burden in the Rather than deny cover for all senior travellers long term. (over 70 year old), companies such as Mondial The stringency of rules for Australian travel insur- Assistance, who arrange travel insurance and medical ance providers of pre-existing medical care largely assistance to approximately a quarter of the reflects the tyranny of distance. The first consideration Australian travel insurance market, can arrange cover, is the length of the journey to be undertaken, and the taking into consideration the calculated risk of the effect on the potential traveller’s health status. To put traveller’s likelihood to require Emergency Medical it into perspective, a long distance airplane flight is Assistance whilst traveling. often considered to be one of 4 hours duration or Independent of all other factors, age increases the more. It takes over 4 hours to travel from the east to risk of requiring Emergency Medical Assistance under west coast of Australia! It takes approximately 24 a travel insurance policy. For this reason, most policies hours in transit to Europe, which is a considerable have an unavoidable age loading included in the period of time in a sedentary environment. Add to this price. the effect of stress, time zone and climate changes, and It comes as no surprise, however, that the greatest International Travel provides a great challenge to the challenge in providing travel insurance for wellbeing of people who are stable and well-con- International travel is pre-existing disease. Previously trolled in their home environment. published studies mirror the experience of the insur- The second consideration is the cost of medical care ance industry indicating that, after age, the greatest and the cost of repatriation back to Australia. Often predictor of requiring medical care overseas is the the most cost effective treatment for an unwell insured existence of pre-existing disease. is for them to return home. However, Medical Staff This fact underlies the heavy scrutiny placed on will only approve such a long journey once they are travellers with pre-existing disease, before providing confident that the patient is stable enough for such an cover. In order to regulate the cost of premiums, insur- arduous task. This, in itself, can lead to longer term ers need to carefully consider whether or not to pro- stays in international medical facilities than would vide cover to those travellers whose medical history otherwise be necessary. When they are repatriated, it makes them more likely to require medical assistance. is at considerable cost. With the cost of airline facilities In some cases, cover is declined; in others there is an and medical attendants, evacuation costs from the UK associated increased premium to cover the condition. to Australia can exceed $A100,000 (56,000 euros). Even The Medical Assessment Team at Mondial the return of a deceased person's remains from Europe Assistance currently assesses over 30,000 applications can cost in excess of $A10,000! for cover for pre-existing medical conditions per year. Although the majority of assessments are for trav- Australian Travellers in Britain ellers in the age range of 65-80, Mondial Assistance A major reason given by Australians for travel is to regularly sees applications for travelers over 90 and visit friends and relatives in one’s country of origin. occasionally over 100! For many Australians, this is the UK. In 2004 almost Information provided by the traveller’s doctor is one quarter (24%) of the total population in Australia measured against claims statistics, to assess the risk of was overseas-born. Additionally, the 2001 census claim, and a decision is provided as to whether or not showed 26% of persons born in Australia were a sec- to offer cover. ond generation Australian (one or both parents were born elsewhere). Of those born overseas, 25% were The Burden of Isolation born in the UK. Given that international travel is commonplace, As well as the common risk of being underinsured, many Australians consider that it is their ‘right’ to Australians can also misunderstand the limitations of travel, rather than a privilege. The response to a nega- the reciprocal healthcare agreement between Australia tive insurance assessment is predictable, especially and the UK. Although individual medical cover may Australian Travellers’ 13

seem superfluous to some, especially where free med- and their families, to considerable costs by believing ical care is available, the major deficiency of this that they will be safe without it. The Government arrangement is that it will not cover the cost of a med- Department of Foreign Affairs and Trade now advise, ical evacuation back to Australia, leaving the traveller 'If you can't afford travel insurance, you can't afford to liable for these costs. travel'. Siobhan Carroll, Medical Underwriter, Mondial Assistance, Conclusion Australia. As previously stated, Australians love to travel. However, Mondial Assistance, along with other travel References insurance providers, have the challenge of educating 1 Australian Department of Foreign Affairs and Trade the Australian traveller on the importance of seeking http://www.smartraveller.gov.au appropriate cover, or they risk exposing themselves, 2 Australian Bureau of Statistics, Year Book Australia

Travel Health Insurance Gap Year Students It is against the law for an insurance company to It is not just students who take gap years. Research load premiums for a disabled person without statisti- by American Express Travel Insurance shows 56pc of cal evidence to prove that the disabled person is a gap years are taken by the over 25 year olds and 38% greater risk than someone who is not disabled. by the over 55s. Several providers offer specialist gap year cover. Useful websites ACE Traveller Insurance offers gap year cover for www.nationalrail.co.uk those aged 18 to 44 for up to 13 months. The policy www.access-able.com includes up to £1m for extreme activities such as www.disablego.com bungee jumping. www.lonelyplanet.com Endsleigh and Insure and Go companies only offer Age Limits on Travel Policies gap year backpacker cover for those aged up to 36. Age limits of 80 are common on travel policies and Preferential Insurance, offers cover for older trav- restrictions may apply to people as young as 50. ellers for extended trips of up to 184 days. A survey conducted by the British Insurance Studies by RIAS, the over 50s specialist insurer, sug- Brokers Association revealed that people aged 65 and gest that as many as 775,000 of those aged 55 or over over would be turned down by 30 of the 140 annual have taken a holiday abroad of six months or more. travel policies on the market. Travellers of 70 or over The survey shows that as many as one in five over would be refused cover by more than 105 policies. 55s would choose an adventure holiday over a cruise, People aged 65-plus would be barred from 30 of the cultural or beach holiday. 150 single trip policies and people aged over 70 would be ineligible for more than 80 policies. Older Travellers’ Research by Help the Aged found that more than Older travellers should bear in mind that they may one in four of the annual policies examined would not need to be medically screened before cover is offered. cover the 9.4m people in the UK aged 65 and over. The reason why premiums often rise at the age of 65 Elderly customers do claim with similar frequency is down to risk, and travellers over 65 are one and a to the under-50s but the average value of their claims half times more likely to make a claim than younger can be two to three times higher than for the under- travellers, and their claims are, on average, twice as 50s. They have a higher proportion of expensive can- expensive. (Association of British Insurer) Age cellation and medical claims compared to younger Concern estimates over-50s account for 60pc of travellers. Britain’s savings and 80pc of personal assets. The Axa Insurance says that a couple aged between 65 over-50s are the fastest growing group of internet and 79 travelling to the United States for 24 days users. The more adventurous over-50s are opting to could expect to pay £490 for insurance. That compares volunteer abroad, while those who prefer security on with a premium of £85 where the policyholders are their travels are signing up in droves to escorted holi- under 55. days. Classic American sights such as Alaska and Hawaii for the 55-75 age bracket, which is the fastest Useful contacts growing demographic in the US. In the UK, the older RIAS – 0800 0681655 – www.rias.co.uk population is growing twice as fast as the rest of the SAGA – 0800 056 5464 – www.saga.co.uk population. By 2031, 40pc of Britons will be aged over Help the Aged – 0800 413180 – www.helptheaged.org.uk 50 and nearly a tenth will be over 85. Age Concern – 0845 6012234 – www.ageconcern.org.uk 14 Journal of BTHA, Volume VIII, 2006

The Good Samaritan Response – An Ethical Dilemma and Professional Challenge I. MacKay he train journey on the Ghan train is a three-day cardiac thump and energetic CPR brought a positive south to north traverse of Australia across the response and a thready heart beat. Semiconscious he TOutback, from Adelaide to Cairns. This trip on a complained of severe chest pain, radiating to jaw and legendary train was the highlight of a recent visit to down one arm. A classic case of myocardial infarction, Australia and the opportunity to chill out after a hec- the need for prompt hospitalisation was obvious. tic tour of the big cities. The journey was however to “You will need to get him off the train at the next bring professional challenge and raised ethical and stop”, I advised the conductor. He thrust a 2-way legal dilemmas. radio into my hands saying, At peace with the world, idly watching a vivid sun- “Speak to the train manager. Press that button.” set over the desert and anticipating dinner in a splen- Obediently I did so. Situated half way along the did restaurant car, I was taken aback when a train lengthy train, he listened and patched me through to manager approached and queried. the train driver in his cabin about a mile away and just “You are a doctor?” I usually travel incognito and visible on a long loop of track. Battling against static, I was minded to ignore his question. advised him of the emergency and then added “How ”We need a doctor urgently” he continued more soon will you make a stop?” expecting relief within a certainly, few minutes. “You are a doctor aren’t you?” “Two and half hours.“ he said, Wondering how he had discovered my concealed “No” I interjected,”the first road crossing will do.” identity, I reluctantly agreed. Back came the same response. The nearest emer- “We have a passenger with severe chest pain back gency access was indeed two and a half hours away. the train.” ”You had better go as fast as you can then, this man Loath to leave my soup, which had just arrived, I needs urgent medical help.” demurred. Almost immediately the train speeded up, but I was “He is really bad doc. We need your help now.” now left with the prolonged care of a patient who Leaving my partner to her repast, I reluctantly fol- appeared as if he might succumb at any moment. lowed the manager along the swaying train, unaware I returned attention to the patient who was now that it was almost a mile long and the passenger was groaning noisily and occasionally shouting out with in the rear compartment. pain to the interest of surrounding passengers and En route we passed through Gold, Kangaroo and dismay of the two train attendants Economy Class to what was the cruise ship equivalent ”Is there a first aid kit?” of steerage. Every section had its bar and as we passed “Yes,” a young woman helper assured me and then each barman hailed me as “Doc”, although I had not added reassuringly that she was emergency-trained. set eyes on him before and offered a beverage. A wiser Thinking she was a nurse I grunted, ”3 years man might have taken advantage of these offers and course“ then reasonably refused to proffer emergency assis- No “she said “ 2 days”! tance on the grounds that inebriation excluded the I sent the other helper for the first aid kit, which possibility of professional involvement. was located far up the train and took 15 minutes to It took many minutes to transit the train and dusk arrive. had fallen on the way, with train lighting becoming In the interim I raised the obese man’s feet, reas- steadily poorer as we moved from class to class and sured him that help was on the way while praying back the train. At last we came upon tightly seated that the Royal Australian Flying Doctor Service would accommodation largely occupied by aboriginal fami- come promptly to my aid. By chance, I had recently lies. Mid-carriage was a very large Australian who visited their operation unit in Alice Springs and been appeared to be expiring. Scant lighting hindered assured that they usually could reach a patient in examination, but he was slumped over in the seat, was about an hour in emergency. Once again I gripped the very pale, clammy and unresponsive to questions. I radio and embarked on a communications adventure, could not initially feel wrist or carotid pulse under the speaking to the train manager who patched me rolls of flesh obstructing arterial access. through to the train driver who forwarded me to In the very confined space between seats, it proved RAFDS headquarters. With static, Aussie twangs, a major exercise to heave him on to the floor with his Celtic brogue and many intervening miles of radio considerable bulk jamming halfway down. Of necessi- waves, send and receive messages were at times gar- ty, I had to attempt resuscitation of his recumbent bled and all but incomprehensible, I ultimately was form stretched across the passageway. with passen- advised that an emergency flight was being organised. gers stepping over him. Prostration, a very emphatic Relieved, I tackled the first aid rucksack that had final- The Good Samaritan Response 15

ly arrived. By now the train, at speed, was pitching care?.” These were not reassuring considerations and and swaying rather alarmingly, darkness had fallen, to add to my foreboding, word came through from the lighting was very poor and I had difficulty identifying RAFDS that, because of heavy rains, all the emergency the contents while holding on to seats for support. landing spots beside the railway were waterlogged I uncharitably decided that lifting the patient to an and they could not get an aircraft in. They would get alternative site would require block and tackle and he an aeroplane to the nearest township and a land would have to be treated where he was lying, but I ambulance would endeavour to reach the train- was determined to improve the illumination. expected time of arrival 2 hours. “Can we get some extra lighting? “ Aware that my nerves would not permit inaction Yes, I’ll get it “, said a helper who turned out to be and lengthy exposure to the patient’s cries for pain the train electrician. Off he went, to return after a relief, I drew up the morphine and administered it, lengthy walk and time, with a tiny torch, which did with an internal debate for the next half hour on the little to brighten the scene. A small oxygen cylinder appropriate dose for a man of twice normal weight. had however appeared. Inhalation of the gas He obtained some relief and became pain free when, improved the patient’s cyanosis and I felt I was mak- after reflection ,I decided he was under-dosed and ing some progress. gave him some more, concluding that if “in for a The rucksack yielded some aspirin and the patient penny ,I might as well be in for a pound.” ground down on a tablet between his teeth, and swal- To my relief his pain settled and we rocketed on lowed it, with little immediate effect on his groans, so into the night while an ambulance crew was jolting I added another. If nothing else it demonstrated to the across the desert to its remote rendezvous. The prog- many aboriginal watcher passengers, grateful for a nosis still did not look good and I wondered if he break to the tedium of the journey, that I was a med- would survive until the aid team arrived. ical man of action! They were equally impressed by A long two hours ensued as the train snaked across the transdermal patch I placed on his chest. Then in the outback at a speed which was slopping soup off belated recognition of the 3 inches of blubber between plates in the restaurants. Meanwhile aboriginal fellow skin and heart I added another. The observers were passengers were stepping over the patients consider- requested to retake their seats, but most were reluc- able belly as they passed en route to the bar. tant to leave the scene of action and discoursed vol- At last the train jolted to a halt and in the very far ubly in their own language about my activities and off distance a winking blue light promised succour. the likely imminent demise of the patient. The patient ,now fibrillating, had a one half hour jour- Delving deeper into the recesses of the medical bag ney across the desert to face, followed by an emer- I came upon rows of medication, all labelled in script gency flight of 2 hours back to Adelaide – not a prom- so tiny I could not read it without reading spectacles ising prospect for a very ill man. First he had to be that were 15 minutes away down the train. Even with prised from between the seats and along the narrow their aid the instructions would have defied interpre- passage to the carriage platform and then be lowered tation in the dim light of torch and roof lighting. The down steel steps to the track. To the delight of aborig- ones I could read related to drugs peculiar to the ine children mesmerised by the blue light and the Australian scene with trade names I did not recognise. unfolding drama, we prepared for the transition. An added complication was the discovery that the To my consternation the first person to arrive on the patient was on at least 12 routine medications, but he train was a police officer and I wondered fleetingly could not recall their names and they were in his main and guiltily if I was about to be charged with a multi- luggage in a storage car plicity of offences and how they had discovered my With the patient so obviously in extreme pain the misdemeanours so quickly. It transpired that he was need for a decent analgesic was paramount and I also the ambulance attendant. Remarkably uncon- trawled through the drugs looking for a good cerned at the girth of his new patient, with impressive painkiller. To my surprise I found morphine vials, one, efficiency, he organised passengers into a lifting squad which I grabbed gratefully and prepared to adminis- and hustled the ill man from train to ambulance with- ter. out precipitating cardiac arrest. ”What dose for 18 plus stones, What about the Vastly relieved I fought my way back up the train, effect on other drugs.?” to be once again offered a free drink while passing Then suddenly the thought,” What insurance cover each bar. This time I took advantage of the offer and did I have for giving Dangerous drugs?”Belatedly it was in relatively mellow mood when finally regaining came to me that I was not registered as a doctor in the dining room just as it closed for the night. More Australia, I had no authority to administer any drugs than a little peeved at this revelation. I returned to the far less prohibited ones, I could kill the patient, I could cabin to find that wife and table associates had been be investigated for malpractice. I had responded as a imbibing of a free supply of alcohol in my absence, to Good Samaritan ,but was that not for immediate mitigate the loss of their dining companion! emergency care?“When did acute become prolonged Discomfited, I consoled myself that Good Samaritan 16 Journal of BTHA, Volume VIII, 2006

The Good Samaritan Response continued

Acts inevitably involve an element of self-denial. responses in terms of medication? The size and weight Half an hour later however, I found my emergency of the patient had me guessing at appropriate dosage. care had not gone unappreciated and the crew had A radio link to an expert of the RAFDS might have laid on a splendid 6 course dinner with free beverages given me expert advice and reassurance but the com- for me alone. I dined in glory in the restaurant while munications link was tenuous. wondering how the patient was managing. Next The legality of my actions was a greater source of morning the staff patched a radio telephone call worry and concern. Although there are reciprocal through to his bedside, when he assured me that he health arrangements between UK and Australia, I was was in an intensive care unit and feeling much better , not licensed to practice there and could not legally be a fact confirmed by the intern who had stabilised his administering dangerous drugs. If the patient had arrhythmia. died, litigation might have followed and federal legal Pleased with the outcome I had time to ponder the action taken. This at a time when I was probably pragmatic, clinical and ethical issues of my profes- working without medical indemnity. The British sional involvement. The ethical one was perhaps most Medical Defence Societies usually only protect their easily resolved as the GMC expects all health profes- members for work within the UK. Enquiry after return sionals to respond professionally in emergency, with home was not reassuring. Good Samaritan cover for the proviso that they act within their competence and acts provided off British soil was not guaranteed, not when cognitive function may be affected eg. by although medical defence officials rather condescend- previous alcoholic input. My own conscience would ingly advised that there had been as yet no success- not have permitted a refusal to proffer first aid in such ful action against a British doctor abroad. They then a situation, but the episode had proved intimidating, revealed that almost certainly they would not offer stressful and tested skills and experience to the limit. any protection, if the patient was an American, or if Practically there were environmental difficulties such the episode occurred on an American aircraft, or ship, as lighting, treatment space, and availability of treat- or one that was landing on America territory. The ment resources to diminish the value of my input. inference is clear. When called upon in an emergency, Perhaps several treatment kits and emergency lights ensure the nationality of the patient has been estab- should have been located along the train and a defib- lished and CPR skills are competent, before embark- rillator would have been a useful resource on a train ing on any heroics. Good Samaritans beware. operating far from immediate aid. The first aid kit, although comprehensive was poorly labelled and I. MacKay is a retired GP. drugs difficult to identify. How competent were my

photo by I. MacKay Indemnity for doctors working or travelling abroad 17

Indemnity for Health Professionals Working or Travelling Abroad A British Travel Health Association 8 Does this cover extend to countries and/or their citizens for which you would not normally Initiative provide cover? Members have voiced concerns about professional 8. Do you offer similar cover for nurses? indemnity provisions when they undertake travel health related employment abroad. The BTHA has The Medical Protection Society did not reply. In been actively communicating with Medical Defence interviews with staff of the other Unions it was obvi- societies in an endeavour to clarify the protection trav- ous that cover is very limited and that doctors and el health professionals can expect in “the grey areas” nurses are working in these fields without adequate involving expedition, repatriation and ship doctor’s and often without any professional insurance cover. work” and when responding as good Samaritans in Some cruise ship companies provide their own pro- medical crises. fessional insurance and several airlines do the same, The following letter was sent to the: but in many cases it falls to the individual doctor or Medical Defence Union nurse to ensure protection is in place, Medical Protection Society We are endeavouring to standardise the protection Medical & Dental Defence Union of Scotland offered and enhance what is available, but there is And brought the following responses. These reluctance by the Defence Unions to expose them- emphasise a disparity in the cover provided and the selves to what they see as a high risk related environ- risks that doctors may be taking, in working unpro- ment. Individual practitioners should ensure ade- tected against potential litigation in specific areas. quate cover, what is covered before embarking on such ventures and negotiate specific terms for them- Questions: selves before undertaking each project. In an emer- 1 In which countries do you not cover members? gency situation, a good Samaritan response may be an 2 Which countries’ citizens do you not cover ethical and legal obligation, but there may be no cer- reached by your members? tain professional indemnity as protective cover if liti- 3 Do you offer cover to members working in other gation issues were to arise. countries except those specified above for short term working? (for example 3 to 6 months) and/or longer term employment? The Executive Committee of BTHA would like to be advised of the experiences of Doctors and Nurses working in the “Grey Areas” 4 What procedures should such doctors follow with and who have undertaken Good Samaritan Acts. you before taking up such employment? What provisions did you make to ensure insurance protection 5 Do you offer cover for members accompanying was in place and have you knowingly responded in an emergency unaware that you were not insured against litigation risk? travel groups or expeditions? Please write to the Secretary, BTHA. P.O. Box 333, M33. 6 What procedures should such doctors follow with M. Townend, I. McIntosh. you before taking up such activities? 7 What circumstances qualify for “Good Samaritan” cover under which you would cover a doctor acting in an emergency?

Indemnity Cover

Insurer Regular Cover Good Samaritan Cover Other Cover Nurses Medical Defence No cover in, or for nationals of Will discuss overseas USA, Canada, Irael, Bermuda, No information given cover with individual No information given Union Zimbabwe or Australia members Missionary cover for Medical & Dental Defence Mainland UK and Doctors and dentists, voluntary work with a no cover given e.g. on holiday abroad Union of Scotland Northern Ireland only registered charity Medical Protection No reply received No reply received No reply received No reply received Society 18 Journal of BTHA, Volume VIII, 2006

Medecins Sans Frontieres

ince 1971, Medecins Sans Frontieres (MSF) has get to the nearest hospital people have to walk for four had a vital humanitarian presence in the world. hours then take a truck. SIn crisis situations it is often first in and last out. MSF supported returnees with mobile health teams Medecins Sans Frontieres cares for and speaks out on who came every six weeks in June 2005, MSF estab- behalf of people ignored by the outside world. lished a permanent presence providing basic medical Doctors and nurses of the organisation leave home care and psychological support for an area of almost each year for places no-one knows or cares about. 1,000 square kilometres. Some areas of activity are: Medical needs run the gamut from malaria to para- sitosis, leishmaniasis, problems related to reproduc- NIGER tion, complicated births, machete wounds, snake 1,400 MSF national staff and 140 international vol- bites. Emergencies are part of the job. The MSF team unteers are providing emergency nutritional assis- has had to bring seriously ill patients to the nearest tance in 10 therapeutic feeding centres. With careful hospital, either by river or by foot. Patients have feeding and monitoring a severely malnourished included a baby with pneumonia, a child with facial child can recover in just 4-5 weeks. To help meet the burns, a woman with a botched abortion. needs of these children, MSF has also opened two spe- cialist paediatric units to provide free medical care to SOMALIA children under the age of five. MSF teams are also Malnutrition is one of the many scourges of screening moderately malnourished children in their Somalia. Mass poverty and dry “rainy seasons” con- own communities and providing food rations to them tribute to the problem. Edge of the Horn of Africa has and their families via 41 mobile outpatient pro- been without a functioning central government since grammes.More than 3,250 people arrive each week at 1991. With no central government, there’ is no MSF’s feeding centres. Ministry of Health, no national health policy, no coor- dination of medical efforts. COLOMBIA In Xuddur, MSF provides vital services otherwise Colombia’s 50 year old conflict continues to inflict out of reach for the 200,000 impoverished inhabitants intense misery and terror on millions of civilians. of the Bakool region. The health centre has in-patient According to independent estimates, there were three and out-patient departments, a therapeutic feeding million internally displaced people throughout centre, tuberculosis ward and a ward for children who Colombia in 2004. It is in the heart of these displaced suffer from kala azar, or “black fever”. communities, across about a third of Colombia’s expansive territory, that MSF attempts to bring med- HAITI ical aid to people who would otherwise have no In Port-au-Prince, St Joseph’s Hospital (run by access to health care at all. Eight mobile health clinics MSF). The hospital houses the city’s only free emer- currently treat over 250,000 people a year. “In only one gency medical treatment facility. day we reached 400 people who hadn’t seen a doctor Widespread criminal violence and armed insurrec- for here years” says Vikki Steinen, MSF Head of tion has gripped the city since President Aristide was Mission, Bogota. The MSF team faces daily challenges pressured into exile. By early 2005 MSF medical teams of malaria, complicated births, machete wounds, at the unit in St Joseph’s had treated more than 3,100 snake bites. MSF is striving to provide effective med- patients - 1,112 for violence related injuries. Half of all ical care to people in unending crisis. patients are women, children or older people. Massacres, executions, intimidation and massive consequent fear have become an inescapable part of CHECHNYA everyday life for Colombians. More women between In 2005, MSF international staff returned to the ages of 15 and 39 years old die from violence than Chechnya for the first time in eight years. MSF opened anything else (even overtaking complications from two clinics in Groznyy – one gynaecological and one pregnancy and childbirth). It is also the second lead- paediatric - both offering the only free medical care of ing cause of death for boys and girls between the ages the kind in the city. MSF staff in both clinics have been of five and 14. But the human suffering caused by the treating up to 100 people a day. The world may have Colombian conflict goes well beyond statistics and forgotten Chechnya, but MSF cannot. medical data. “In only one day we reached 400 people who had- Support for Medecins Sans Frontieres n’t seen a doctor for three years”, said Vikki Stienson, Call free on 0800 731 6732 during office hours MSF Head of Mission, Bogota. Donate on line at www.uk.msf.org/support Families who dared to return to flee the misery of Over a year, £15 a month buys a dispensary kit con- internal displacement found living conditions far taining drugs and medical equipment to care for 1,000 from easy with no running water or electricity. displaced people for three months. Children were too far away to attend the school and to Article based on literature supplied by MSF. A History of Quinine and Artemisinin 19

A History of Quinine and Artemisinin Sam Allen

hroughout history, the vast majority of the nitus, nausea, rash, and eventual blindness) and is car- world’s population have relied on indigenous or dio-toxic. Ttraditional systems of herbal medicine. Resistance to quinine has emerged, raising concern Hippocrates used an extract of powdered willow bark that an effective treatment for a disease that threatens (Salix spp.) as a cure in 300 BC. Its medicinal value half the world’s population may no longer be relied was rediscovered by Reverend Edward Stone of upon. Chipping Norton in 1763. It would be another 136 years before Bayer® registered aspirin as a patent in Artemisia 1899. Since then aspirin has become the most fre- In 1967, Prof Ying Li of Shanghai University re-dis- quently prescribed drug in the world; and the most covered another ancient cure for malaria derived from widely distributed – Scott took it to the Antarctic, a traditional herbal tea remedy of Qing-hao. This is Hilary to Everest and Armstrong to the moon. It is the annual sweet wormwood Artemisia annua. The estimated that a paper on aspirin is published every active principle, called Qinghaosu (Chinese: ‘the prin- two and a half hours! ciple of qing-hao’), is artemisinin. It is the most potent The Madagascan periwinkle (Catharanthus roseus), anti-malarial agent yet discovered, being about a the May-apple (Podophyllum peltatum) and the thousand times more potent than quinine. Pacific yew (Taxus brevifolia) have yielded important This relatively non-descript and humble-looking agents - vinblastine, vincristine, etoposide and taxol – weed is found in the dry regions of Asia and southern to become the cornerstone of modern cancer treat- Europe. Merchant ships carried vagrant seeds to the ments. Of the estimated 250,000 species of higher Americas where today it has become a popular horti- plant species existing on earth, some 20,000 are used cultural decoration known as Sweet Annie. medicinally. Most of the remainder have never been The drug extract has a rather bitter taste. It was analysed. named by Linnaeus, the plant taxonomist, in 1753 to honour Artemisia, the Saltrap of Mausolus, King of Quinine Carnia (d 350 BC). Her sorrow for the death of her One drug of immeasurable benefit to mankind is husband was so great that she is said to have mixed derived from the shavings of the Peruvian cinchona his ashes with what she drank. The Mausoleion which tree (Cinchona spp.). Three centuries ago in the she later erected at Halicarnassus was one of the seven swampy environs of the English marshes – where wonders of the ancient world; from it is derived the word mausoleum. In Greek mythology, Artemis of the Ephesians (mentioned in the Bible, Acts 19) was regarded as the goddess of nature. In Roman tradi- tion, she is Diana, daughter of Zeus and twin sister of Apollo. The genus Artemisia contains about 300 species including mugwort (Artemisia vulgaris, common wormwood), southernwood (Artemisia abrotanum, ‘old man’, or ‘lad’s love’), wormwood - from which

photo by S. Weller mosquitoes bred - an apothecary’s apprentice -Robert Taylor- introduced Jesuit’s bark, or quinine, to treat Essex smugglers suffering from ‘ague’. Quinine has become the mainstay of treatment of malaria. Although an effective anti-malarial agent quinine has its drawbacks. It can give rise to cinchonism (tin- photo by S. Weller 20 Journal of BTHA, Volume VIII, 2006

A History of Quinine and Artemisinin continued absinthe in made (A. absinthium) - and the well- reconciling their abstruse theories in the realm of known culinary herb, tarragon (A. dranunculus). medical philosophy with the diagnostic and curative However, only Artemisia annua is known to contain procedures they endorse. appreciable levels of artemisinin. Over a million people have been treated successful- Qinghaosu has been used in Chinese traditional ly using artemisinin compounds since their rediscov- medicine since antiquity. Its use as a treatment for ery. To date, there has been no known resistance. From haemorrhoids was found in the book of cures (168 BC) the Amazon to the Zambezi the swift action and ease- discovered in the tombs of the Mawangui Han of-administration of make it an effective alternative dynasty. The earliest reference to its role in the treat- for treatment of multidrug-resistant malaria. ment of malarial fever is to be found in the Chinese The importance of natural sources lies not only in text, Zhou Hou Bei Ji Fang (Handbook of their therapeutic effects but also in their roles as tem- Prescriptions for Emergency Treatments) by Ge-hong plate molecules. The chemical elucidation of in 341AD. artemisinin have spurned several new anti-malarial References to Artemisia were not restricted to the compounds that are currently being tested in con- Chinese world. Pliny extolled the virtues of absinthe trolled clinical trials around the globe. It is expected and mugwort when he wrote: that OZ227, a synthetic artusenate that can be mass- ‘That the traveller or wayfaring man that hath the produced will soon become commercially available. herbe tied about him feeleth no wearisomnesse at all; Artemissinin Combination Therapy (ACT) has been and that he who hath it about him can be hurt by no adopted as the new gold standard therapy by the poysonsome medicines, not by any wilde beast, nei- WHO since June 2004. ther yet by the Sun it selfe.’ Meanwhile efforts continue to develop an anti- In England, Mugwort (Artemifiæ) and absinthe malarial vaccine. A trial of such a candidate vaccine (abfinthij) are listed in the inventory of medicinal carried out in Mozambique between January-June solutions in the first issue of ‘The Pharmacopoeia 2005 showed a 30% overall protection with 60% pro- Londinensis’, 1618 and its use as an analgesic for tection from severe malaria. These somewhat disap- headache was recorded in 1764: pointing results emphasise that until a robust vaccine ‘Flowers of mugwort boiled and applied to the becomes available, persons visiting malarious regions head after washing it with decoction are of great effi- should continue to use anti-malarial prophylaxis and cacy in removing a Hemicrania’. impregnated bednets. In those mediaeval days there were no such things as randomised controlled trials. Disease was blamed First published in Sesame and reproduced by kind permission of on bad humours (blood, yellow bile, black bile and Scientific Expedition Society. lymph). Indeed, throughout the social history of med- Sam Allen BSc(Hons) MBChB DTMH MRCP CCST (Trop Med) icine, University academics and the quacks they Expedition Doctor. affected to despise, have never had much difficulty in

Rain Forest A Return to War Ravaged Lebanon 21

A Return to War Ravaged Lebanon M. Manook

“You’re going to Beirut? Isn’t there still a war there… UK, I’d had little time to fix up exactly what I would or something? Is it safe?” In the summer of 2005, the be doing while in Lebanon. I realised that internation- reaction of friends to my decision to spend my elective al NGO’s were bound to regard such an inexperienced in Lebanon seemed antiquated and ignorant: the war doctor pitching up during a couple of weeks of annu- had been over for 15 years, didn’t they know that? al leave as more of a potential liability than a help. Admittedly, the assassination of the former prime However, I’d made links with some of the local minister, Rafiq Hariri was shocking, and politically groups that had come to light following the onset of unsettling, but the popular revolution thereafter, com- the war, through friends who had become involved in bined with pressure from foreign governments, the relief effort. notably the US, had forced the Syrians to remove their The two NGO’s I worked with, Samidoun (Stead- occupying presence, and I arrived to find Lebanon in fastness) and Mowatinun (Citizenship/Solidarity) are a state of palpable excitement, albeit tinged with testament to a fundamental optimism, determination uncertainty. and courage in adversity. At their inception, they were This summer, their fears were justified. little more than groups of friends sharing similar The kidnapping of Israeli soldiers by Hizbollah ideals, in the case of Samidoun, young Leftists, while fighters from the south of Lebanon in July of this year Mowatinun has much looser associations as it was unlawful and unjustified, but the magnitude and emerged from a group of friends from all aspects of force of the response was outrageously disproportion- the religious and political spectrum who initially start- ate. As the Israeli action escalated, the attitude of the ed making sandwiches for the refugees on the streets. US and our own UK governments in remaining silent Quickly, operations escalated, and by the end of the 34 and refusing to call for an immediate ceasefire, was day war, an army of volunteers were providing widely seen to be providing the Israeli Defence Forces cooked meals for 2600 people at lunchtime, with a fur- with a morally unrestricted period of time in which to ther 3500 receiving daily meal rations, hygiene kits destroy Hizbollah, and with it, Southern Lebanon. and medical attention. Suddenly a country that I had spent almost three Following the ceasefire though, they, like many of months in, where I had met colleagues, and made the aid operations which had adjusted to the needs of innumerable friends was being devastated, in days: the war, found themselves bewildered by the speed the airport, roads, bridges, power plants, houses, with which the refugees left the city, literally within neighbourhoods, villages, people. I have never felt so hours the people they had been caring for had depart- strongly about a political situation in my life. The ed for the desecrated south. No one had really media images of rubble, destruction and bodies being believed that it might hold, but both Mowatinun and rescued from the debris which followed the initial Samidoun had been left with considerable quantities story of the evacuation of foreign passport holders of aid, in the form of supplies and also as cash. What were shocking. Yet I knew from friends in Beirut that, should they do with it all? while the bombings and incessant drones were terri- My arrival was very much at the outset of these fying, a significant aspect of the war effecting Beiruti’s dilemmas. The refugee crisis in Beirut was over, but arose from the numbers of refugees arriving in the city people had returned to homes that no longer existed, from the South. with basic infrastructure that had been blown apart. As the war continued, and my annual leave While they were in Beirut, the situation was relatively loomed, I found it hard to sit back, watch and do noth- easy to respond to: for the most part families were ing. I took the decision to go out to Damascus to either housed in schools. Back in the south, destruction and stay in Syria helping with the displaced people, or damage made finding out where people had gone to, make my way to Beirut. As a lowly FY1 doctor, I did- and their basic needs, were a formidable challenge. n’t like to make any estimations of my usefulness in Samidoun decided to concentrate efforts on three such a situation, and yet, since protests and demon- arterial villages, and had made an impressively com- strations were seemingly ineffective, it was all I could prehensive database of habitable houses, number of do. Fortunately, I didn’t have to appear quite so hero- adults and children therein and health needs they had. ic since between booking my flight, and actually going I offered to help as part of the medical unit and our a fortnight later, the ceasefire was called and, miracu- aim was to take a look at what the mapping team had lously appeared to be holding. I left the UK with the produced, speak to the municipality and find a way of support of well meaning friends, and a generous sum distributing the remains of the mobile medical dis- of donations to allocate as I saw fit. pensary. Samidoun was assessing the possibilities of One of the great features about life in Lebanon, is channelling the medical supplies they would be leav- spontaneity. Trying to organise meetings well in ing behind, to those in need. advance is rarely met by a firm commitment. Equally, It was my first experience of a recent disaster situa- with such an evolving situation, and a busy job in the tion, and of large scale humanitarian relief operations, 22 Journal of BTHA, Volume VIII, 2006

A Return to Lebanon continued and, as such was a steep learning curve. Despite admi- mary and public health. The biggest danger to life and ration for Samidoun, the initial mapping efforts had limb are cluster bombs. The horror of these weapons been completed without sufficient foresight for what can not be over estimated. In the final days of the war, the users of such a database would need. Additionally, estimates suggest that the Israelis fired 1800 of the when we met with a pharmacist working for the bombs, which each contain 250 bomblets, of which 25- municipality as part of the health committee that had 30% fail to detonate on impact. Instead they detonate been set up, we were assured that there was a great when a misplaced foot, or a curious child dislodges deal of need for medicines. But we learned from him them from their resting place. Before reconstruction that the previous day a German mobile health clinic can begin, the bombs need to be cleared. While fami- had passed through and would be returning the day lies live in cramped conditions, sanitation and simple after next, that Randa Berri (the wife of the Speaker of hygiene measures are perhaps the most important. parliament) was also visiting with a mobile clinic, and Most medicines we had available and the needs there were rumours of an Italian group setting up a reported by the mapping team, were for those with field hospital. In addition, my counterparts in chronic illnesses of diabetes and hypertension in the Samidoun and I knew that politically the village was adults and commonly amongst the children, seizure divided between Hizbollah, Amal and Communist related disorders. In addition, particularly in the pop- parties and trusting the word of one official is rarely ulous Dahiyeh, or the Southern suburbs of Beirut, sufficient. where Hizbollah were making headway in clearing A tour of the village revealed the extent of the rub- the rubble, there are many complaints of breathing ble and devastation. Everywhere we saw the tobacco difficulties. The toxic effect of the bombs used and the fields unharvested, for the fear of cluster bombs, and dust created from the rubble is not yet known. Time a mixture of deep pits surrounded by a tangled mess will tell, although human rights organisations are of steel and concrete debris where there had been a focussing on this, and also on reports of use of illegal direct hit, or floors of concrete lying squashed on top weapons indicated by phosphorus bomb related of each other, with no room left for living space. injuries. While the Lebanese are certainly stoic about Contrary to what we had initially been told, there their abilities to live through wars, “over the counter “ were in fact not one but three pharmacists operating anxiolytics have been heavily used. “Lexotanil” was in the village, with more stock than our limited sup- the benzodiazepine of choice, with politicians openly plies. All were willing to consider being part of the declaring that they ‘just popped’ a pill as the bombing relief operations, but as one man angrily pointed out, raids started. Estimating the psychological impact of they couldn’t compete with subsidised or free medi- this war at this stage is difficult, but many of the local cines, and they were particularly concerned that gov- NGO’s have been working with the displaced chil- ernment clinics were charging patients for medicines dren, using cartoon and theatre. which they had obtained for free. Additionally, there It’s true that my visit coincided with a particularly was a resident doctor in the village, although he was chaotic period, but the lack of co-ordination, and in Beirut the day we arrived, and also a clinic, previ- paucity of simple, common-sense measures shocked ously donated by the Finns during the last war, which me. International agencies were, initially, hampered had specialists coming from Tyre for weekly clinics. by bureaucracy and security issues, which meant that There is no shortage of doctors in Lebanon! they were relying entirely on organisations such as With a population of just under 3 million, there are Samidoun to provide information about needs, to dis- an estimated 12,000 doctors. Healthcare is, predomi- tribute available aid and also to act as independent nantly, private. Officially, there is government subsidy spokespeople with a regional and local cultural for those with social security numbers, the reality of a knowledge. As such, there is a huge amount taken on government with $40billion of national debt and trust, with great plans made but, to my mind, insuffi- widespread corruption is that, healthcare is never free. cient attention to detail and accuracy. Undoubtedly During my time as an elective student, I witnessed at there is much good being done, I was just frustrated to first hand the cruelties of such a system. For wealthy see the wastage both of time and resources in the face Beiruti’s healthcare isn’t a problem, rhinoplasty is fre- of such great need, and well intentioned work. quently paid for by health insurance claims. But for the impoverished of the South, with large families For more details, visit: www.easterntales.blogspot.com born to consanguineous parents, healthcare is an Miriam Manook, MBChB. unaffordable luxury. Given the expense of attending a Is currently working with Bedford Hospital. doctor, many people rely on health information from [email protected] relatives and neighbours, using over “the counter” availability of virtually all drugs, to self medicate. During the war many doctors gave their services for free but after the conflict this is not sustainable. The health needs post-war were chiefly those of pri- Have Stethoscope Will Travel 23

Have Stethoscope Will Travel Allan Melrose

he chance sighting of an advertisement in a drated and had a board-like rigidity of his lower medical magazine brought many ventures into abdomen. Pumped full of rehydrating fluids and Thigh and inaccessible places. antibiotics we stretchered him back the return route ”Wanted”, it read “Medical officer to accompany with high winds adding to the hazards of the boat scout/guide expedition to Arctic”. With medical and passage. The swaying, jolting progress across moor leadership experience quoted in the CV, my applica- and mountain and the ensuing boat trip aggravated tion was accepted. Laden with a large Bergen ruck- his condition and I wondered if he would survive. The sack I joined a motley group, intent on scaling remote intervention and care one can offer as an expedition peaks in the Arctic Lofoten Islands. medic depends upon location and resources with nei- Sailing up the long coast of Norway the trip at first ther in my favour. A tortuous , single track road ran appeared a sinecure and an ideal way to explore part between small scheduled ferries, linking the chain of of Scandinavia in summer. No sooner however had islands leading north to the capital and the hospital. It the coastal steamer embarked on the long crossing to took six worrying hours until once again I greeted the the Lofoten Islands leaving the excellent facilities of surgeon and presented another patient with an acute the mainland behind, the idyll was shattered. appendicitis. The surgical team stabilised him and A boy scout had developed abdominal pain and with improvement,he was flown back to Britain and vomiting. Was this the result of injudicious eating or six weeks later had a very diseased appendix the advent of more serious disorder? Clinical exami- removed. nation offered several differential diagnoses. An anx- Chastened by this experience my climbing boots ious coterie of fellow medical travellers gathered to should have been discarded, but a new challenge discuss management. A pharmacist – more suited to came with a group going to the Himalayas. They had drug prescribing, an obstetrician of scant value with acquired massive medical supplies with enough male patients and a pathologist, very ready to offer equipment to permit surgical intervention if required. his opinion if the patient succumbed. As primary care Portered expensively up and down to high base camp, physician they opted to leave the decision to me. they remained virtually untouched and after a suc- I diagnosed an early acute appendicitis, a condition cessful expedition we bequeathed them to an Indian with potentially serious consequences if not operated hospital on return to the plains. upon early. The captain was approached and was Now a conventional tourist group we set of from reluctantly prepared to return the ship to Bodo, the Delhi to visit the Taj Mahal at Agra. One hour into a nearest port with good hospital support, but he pre- four hour trip, one of the leaders started to vomit and ferred to carry on to his next port of call, still several complain of stomach pains. Draped along the rear seat hours away. I dubiously opted for unknown medical of the coach the medics prodded his abdomen, which facilities in the island main town and sweated through was slightly distended and tender maximally over the the next hours as the boys condition worsened. On right side. arrival he was transferred to the small surgical unit All, including the patient, were desperate to view where he promptly lost an inflamed appendix. the great wonder of the world, a prospect denied if we With this medical emergency behind, I relaxed and diverted to the nearest hospital which was back in prepared to enjoy the rest of the expedition assuming Delhi. We also became aware that emergency medica- that in a small party, further abdominal emergency tion was now at a premium and bereft of our former was unlikely. Teenagers were dispersed along the 100 supplies ,we had none! Entreaty to coach passengers mile Lofoten chain of islands with my base at the brought forth a meager assortment of car sickness southern end near the ocean site of the legendary prophlactics, milk of magnesia and aspirin. maelstrom. In a fisherman’s hut poised on stilts above Prescribing the two former we solicitously contin- the water and dwarfed by intimidating glacially ued on our way. scarred mountains , I prepared to bask in the sun and On arrival in Agra he was neither worse not better contemplate line fishing and an occasional foray on to and was vehemently opposed to entering a rural the fangs of encircling rock. Indian hospital. We solemnly carried him on a litter The summons came within 24 hours. Another boy to the entry portal of the magnificent Taj Mahal and was ill in a trio of campers at the southern tip of the laid him by a fountain, to view this priceless scene neighbouring peninsula. Without road access, it had from afar, while we guiltily made its closer acquain- taken 6 hours for the message to arrive across the tance. On our return the vomiting had settled and his intervening wilderness. Hustled into a motor boat, I abdomen although uncomfortable was bearable. Once made a perilous crossing of the Sound separating us again he was laid to rest on the back seat of a coach, from this inhospitable neck of land and climbed across now on its four hour journey to the airport for the UK a 700m. high mountain ridge to finally reach the flight. We weighed the pros and cons of permitting the remote camp site. A 14 year old was vomiting, dehy- long-haul air passage. He vociferously argued in 24 Journal of BTHA, Volume VIII, 2006

Have Stethoscope Will Travel continued favour of a prompt return to UK .Anxiously anticipat- As a climbing expedition doctor I nearly met my ing a deterioration in his condition and with grave own Waterloo , if not on a foreign field near the sum- misgivings, we escorted him back to London where he mit of an Asian peak. Following a difficult rock tra- transferred to Glasgow and a further flight to verse I jumped awkwardly for a narrow stance, Stornoway without incident. missed it and landed heavily on the ledge below. A That night his symptoms returned with a searing pain shot across the lumbar region and down vengeance and he had to be flown down to Glasgow one leg to the toes. Excruciatingly painful I nearly fell by air ambulance. There the surgeons discovered a off the mountain,but clung tenaciously to the rock very inflamed gall bladder full of strange parasites he wall until the agony subsided a little. Gingerly mov- had accumulated while living rough in India. ing upward using both hands to bear the weight, I tied Recovery was complete and he was loud in our praise on to a belay. 4000 metres below I could just see the for returning him to the care of the NHS. We were left track to civilisation and first aid care. Uncertain of to ponder our responses and wonder if we had made spinal fracture or disc lesion I wondered how I could an ethically correct decision or, had been swayed by a possibly cover the intervening terrain. Assisted by desire to view the Taj Mahal to the neglect of the buddies-the expedition doctor was the patient – we patient crawled down the mountain until benighted. Now conditioned in to awareness that expedition Shivering hours in an emergency bivouac jarred the doctoring was not all fun. I went off to the high tops back incessantly and it was a relief to continue the of the Taurus Mountains in remote Turkey. In this slow progress downwards. Agonising acute pain of high arid environment, dehydration and gastrointesti- spinal shock completely immobilised me at times and nal illness were constant companions A rarely visited once it had worn off made the predominant back and region, we were days and not hours away from emer- leg pain almost bearable. gency aid, but all went well until, objectives achieved A landrover and air evacuation followed which did we were leaving high camp. A 16 year old ,out of sight little to quiet back pain which was to continue in of his descending group, fell 10 metres down a gulley decreasing severity over two years. X-rays and scan- and was knocked unconscious. The accident occurred ning revealed a severe disc lesion which made the car- in an area of former volcanic disruption and was a riage of even a first aid kit too challenging a task for jumbled mass of craters, crags, caves, fissures and pin- many months. Over time however pain retreated to a nacles .Initially not aware of his predicament, his com- big toe where it remains if lifting any weight over 20 panions were now searching for the proverbial needle kilos -a useful reminder not to overfill the rucksack. in a haystack. Last to leave the mountain and an hour Adverse memories of expedition doctoring have behind the others I had taken a different route through faded with time and the call of the mountains and this jumbled rock morass. Far below the fallen climber adventure has returned. With experience as an expe- and unaware of his fall, I thought I heard a bird whis- dition medic and a patient I once again comb the tle and peered backwards to identify it. Silence, I advertisements, and respond ”Have stethoscope, will turned to move on, when just within earshot came a travel”. very faint whistle -blown Morse SOS. Guided back up the mountain by the sound, with Allan Melrose, great difficulty, I finally discovered the gulley and saw Expedition Doctor. the patient below unable to surmount the cliff over which he had fallen, He had apparently just become conscious and started to whistle for help. Seconds Lofoten Islands, Arctic Norway later I would have passed on my way and emergency aid might never have appeared. The following year brought climbs on Kilimanjaro and Mount Kenya. Altitude sickness affected half the group but none succumbed although one nearly met his end in the dark ,when falling through an open manhole into a storm sewer in a nearby town. Mount Kenya aged this medic when a group disappeared on its summit. An air search 24 hours after their due return did not find them and 48 hours later fears of their demise were prominent. All had suffered from altitude sickness and were dehydrated on their final return.One suffered a pulmonary embolism, one had been knocked out when a falling rock had severed the climbing rope and all returned psychologically dis- turbed and withdrawn. photo by A. Melrose Health Care and an Appeal from Honduras 25

Health Care and an Appeal from Honduras If You Ain’t Got a Dollar, Give Me a Lousy Dime or, Spare us a Copper, mate! Nigel Potter

t all began with Digna. One day a stranger stopped urged other friends to help. Meanwhile friends in the me in the street and asked if I would see a young U.K. contributed as well. Digna had her operation and Iwoman who was very poor and treat her for a bad then it was a matter of regular out-patient visits to foot. "Bad foot" was something of an under-statement: monitor her progress. it was a stinking nightmare, grossly swollen and Medical expenses for these were low; the high costs deformed, leaking pus on all sides, wrapped in filthy were fares, food and night in a small cheap hotel that rags. The lassie herself was 18, severely depressed, these trips entailed. She did well, our efforts were thinking of suicide. Her father was murdered when rewarded. Here was a young woman who, if she had she was 6 and an older cousin drugged and raped her not been treated when she had been, would have cer- when she was 9. Some time soon afterwards her foot tainly lost her foot (by amputation) and probably her started to rot. I treated her homeopathically and her life too through blood-poisoning. mood improved beyond recognition and the infected Her run of bad luck in other ways continued. hole began slowly to clean itself, discharging bits of During treatment her stepfather was killed in a car dead bone, blood and more pus and other debris. I crash and her boyfriend (without the stinking foot she knew it was not enough and that she obviously need- suddenly became an object of desire) got her preg- ed surgery. Over the years she had visited various nant, promptly dumped her and then the baby was state hospitals and taken tons of antibiotics all without born dead. effect. I took her to one state hospital. It was a long Since then I have lost touch with her. Her family (and for Digna an extremely uncomfortable and diffi- constantly moved house and when I could not walk cult) journey. We encountered the usual chaos, the myself because of a broken ankle I could no longer endless queues and mindless bureaucracy which are visit and keep up with their moves. the everyday reality of Honduran hospitals. By late I had some money in the bank and was able to help afternoon we still had not seen a doctor and had no out in a few other cases. There have been no major prospect of seeing one that day. I decided more dras- expenses like private operations money is scarce, tic action was necessary and took her to a private hos- although we are talking of small donations (peanuts pital. The doctors were appalled by Digna’s condition by European or North American standards). They can but fascinated too, an “interesting case” and they did make a world of difference all the same: the purchase not want to lose it. An operation would be very expen- of catheters and swabs to prevent/treat bedsores of a sive but they would do a deal if I could find the funds. comparatively young bedridden man, rotting slowly Their terms were very generous and I said I would to death with some multiple sclerosis/dystrophy-type see what I could do to raise the money. disease; bus fares to the capital to receive sophisticat- Enter brother Rod, in the UK, “an energetic, good- ed medical treatment, or the purchase of vitamins and hearted man who takes part in sponsored marathons minerals, fruit and vegetables for malnourished chil- for various charities. I told him that if he ran one more dren and even a roof that a poverty-stricken family without making me his favourite good cause I would with small children lost one night in a storm. When a stop speaking to him! It was high time, I said, that he crisis hits a family and threatens to sink it altogether made me his top number one charity and help me for because it has absolutely nothing to fall back on, a few cases like Digna's. It is not that I think official and contributions can help to tide it over until it can find well-known charities do not do good because obvi- its own feet again. ously they do. Yet my experience of dealing with In other cases, it is not a case of sophisticated treat- many of them over the years, I have to say, has made ment nor of any medicine at all but food, vitamins and me somewhat cynical, unless there is someone who I minerals. One family up the road recently lost a 5 year know and trust working in the front-line with some old daughter through malnourishment and a brother say as to how the money is spent. My own sceptical seemed destined to follow, what a difference a few (embittered?) feelings set aside, surely, I argued, it is vitamins made! There is a father on the scene but he more rewarding and much more interesting to know drinks most of what little money he earns. Should the exactly where the money is going, to have some per- children pay for the sins of the father? sonal involvement with a cause or project rather than Another family has the father in prison for stealing, see one's contribution swallowed up by some huge, killing and eating a cow (if he had killed a person he anonymous, charitable institution. Nice to help some would have received a lighter sentence). The mother, desperate child in far-off Africa, but surely nicer to very harassed and exhausted but a struggler, brought help desperate Digna, a “real” person, in far-off me her three children for treatment. They were in a Central America. dreadful state generally and-also ill, so I gave them My brother did not hesitate. He ran his marathon, medicine to tide them over. What they needed was 26 Journal of BTHA, Volume VIII, 2006

Health Care and an Appeal from Honduras continued feeding-up so I doled out vitamins and minerals and For example: I gave a lad with leukaemia homeo- gave the mother a very small fortnightly allowance pathic medicine to help off-set the toxic side-effects of (about $5) to buy fruit and veg. Nothing dramatic in the powerful atom-bomb cocktail of drugs he is taking. itself. The children have come on in leaps and bounds, So far, it seems, with some success. He is taking mas- are cheery rather than lethargic and depressed, and sive doses of cortisone and had- the "moon face" side- are not chronically run-down and ill. A roofless house effect of this drug. His face is now back to normals nei- is not good for the health of small children. The moth- ther has he had the expected hair loss. Those who meet er and granny had no way of replacing it, but the the boy find it hard to believe he is so dangerously ill. materials cost very little and a big-hearted builder did I will go on supplying medicine whenever necessary the job for free. So a little money can go a long way but for as long as I can, but I won't be funding his trips to my fear is the day will come when there is no longer the capital. When there is no more money in "the fund" not even "a little money". to pay the bus fares for him and his dad to get his treat- My work administering these funds is voluntary. If ment, he won't get it and so will die. it is necessary to accompany a patient to hospital (as it I have been well-supported. Better than I dared was with Digna). I charge expenses but nothing more. expect. People from the U.K.., roundabout Christmas I generally refuse pleas for help unless I know the peo- often send unsolicited gifts i.e. cheques. The deal was ple involved. They come to consult me as patients in I would send up-to-date reports and accounts. the first place. In many cases I treat my patients exclu- It came as something of a shock when I sent out a sively with homeopathic medicines and sometimes report Christmas - New Year (2004 - 2005) about the with flower essences (often also recommending fund with a request for more money, I did not get a medicinal plants which are easily and generally avail- single response! I was shaken, but realised perhaps- able) without any recourse to this medical fund. For the fund was no longer the flavour of the month and the consultation and homeopathic medicine I charge it was a mistake on my part, to take people's support what the patients feel they can afford. In other words, for granted. One friend pointed out that the tsunami I leave it up to them. Frequently they pay me nothing diverted people's interest and money. I could well or at best a few pennies. Sometimes they pay me in understand that and I would never wish to play down kind: some eggs, some fruit or veg, an occasional the scale of that catastrophe. Still, the whole idea of chicken and once a big bad dog who guards us faith- "my" fund was the personal aspect: one knew where fully when he is not battling other dogs to the death and to whom the money was going. There was a sense over some bitch. Rarely (and it is all too rare) a patient of individual involvement and the feeling the money pays me well and (rarer still) even really well. was being spent wisely and well. No such guarantee, I make no living from this work and have to dedi- of course, with the tsunami funds. cate myself to other matters like writing. I have been I was down to the last $100 and a worried man but, criticised for this: make it pay, they say, and you could the gods bailed me out. A Dutch couple (an unusual do more, treat more people. combination of potato farmer and lawyer) who were Perhaps, but I find it hard to mix the two, money passing through on holiday later sent me a cheque for and medicine, together. I am afraid someone who $500. Another Scottish couple, old friends from health needs my services but cannot pay will not seek me visiting days, sent me a cheque before I sent out the out. Also I find it impossible after listening to a patient appeal. Then a group of young Brits; who came out in sobbing out details how they were raped or abused as July with World Challenge Expeditions gave me £18 a child (all too common) to turn round and slap a bill for the boy with leukaemia, followed by a $100 bill on them. Yet I am not a soft as I may sound. I have from a teacher with the group that came after; then very definite limits. I spend a small fortune on home- $20 from an American friend and finally a load of opathic liquid potencies (from the U.K.) and the spe- medicines from "Homeopaths Without Frontiers", cial small sugar pills (from Mexico) to prepare the based in Barcelona. medicines as well as the stock bottles of flower In the last 2 months alone within half a mile of my essences (from the U.S.A., Spain, Australia and the house, 2 children of 5 have died and one man died of U.K.). AIDS leaving a widow and 2 small children, one a girl I also have to buy all the equipment: bottles, drop- of 3 still breast-feeding (fund money given to pay for pers and so on and somewhere to keep them protect- H.I.V. testing to start treatment if necessary – anti ed and safe. Then I spend hours sterilising said bottles H.I.V. drugs are available – we may see). and making up the medicines. I live in hope that benefactors will go on supporting The consultations themselves can last an average of this wee medical fund. one hour, and analysing the results of the consultation to select the correct medicine can take up to 2 hours). Nigel Potter. A health visitor who has a small independent health I do my bit and after that it’s god’s hands. care practice in rural Honduras. Public Awareness.....Trekking to High Altitude 27

SCIENTIFIC ARTICLES AND RESEARCH Public Awareness of the Health Risks Associated with Trekking to High Altitude Flaherty G*, Umeed M**, O’Brien T*, Fry G***

Abstract ple and is preventable if recognised early and appro- priately managed. Travel to high-altitude destinations is increasingly Altitude acclimatisation refers to the physiological popular. Travellers with poor awareness of the health processes whereby lowland humans defend them- risks associated with high-altitude travel place them- selves against reduced partial pressure of oxygen in selves at increased risk of illness and death. This study inspired air at high altitude. There is considerable assessed level of awareness of altitude-related health individual variation in the speed and extent to which risks among a sample of travellers attending a travel people acclimatise. The most important risk factors for medicine clinic in Ireland. A questionnaire assessed development of high-altitude illness are rate of ascent, travellers’ knowledge of issues relating to high alti- sleeping altitude, individual susceptibility, history of tude. Most participants were aged 26 - 30 years and high-altitude illness and physical exertion.2 Lack of 57% were male. 44% of trekkers were unaware of max- physical fitness is not a risk factor for acute mountain imum expected altitude for their trek. Twenty-seven sickness3 which is contrary to the common belief percent planned to spend only 2 to 4 days reaching amongst climbers that fit people should be more maximum altitude, while 14% estimated that it would resistant to high-altitude illness. A rule of thumb is take them less than 2 days to reach their highest point. that above an altitude of 3,000m each night’s camp Sixty-two percent of trekkers lacked previous experi- should not be more than 300m above the previous ence of high-altitude travel. night’s one, and there should be a rest day every 2 to Seventy percent of participants were aware of at 3 days or after every 1,000m climbed above 3,000m.4 least one symptom of high-altitude illness. Most who The optimal strategy for preventing high-altitude could not recall any such symptoms were younger illness is gradual ascent to promote acclimatisation. than 25 years and had no previous altitude experi- Only when the climber has acclimatised to current ence. Thirty-two percent were unable to suggest how altitude should further ascent be undertaken. With high-altitude illness might be avoided. Travellers early recognition of impending high-altitude cerebral under 30 years were more likely to erroneously oedema or high-altitude pulmonary oedema, immedi- believe that physical fitness is protective against alti- ate descent and supplementary oxygen are the main- tude illness. There was poor knowledge of the risk of stays of treatment. If descent is delayed because of rabies amongst this group of trekkers. Books and the weather or terrain considerations, treatment in a internet were most popular sources of information on portable hyperbaric chamber may be lifesaving. health risks of high altitude. Only 14% of trekkers Adjunctive medical treatment includes acetazolamide would consult their general practitioner for altitude- with or without dexamethasone for high-altitude cere- related travel health advice. bral oedema or nifedipine for high-altitude pul- There was a lack of awareness of travel itinerary, monary oedema. need for a safe ascent profile, aspects of high-altitude Gaillard et al5 cited an increased awareness of high- illness, and other health risks including rabies. altitude illness among trekkers as the basis for a sig- Specific advice on the health risks of high-altitude nificant decrease in the incidence of acute mountain travel should be aimed particularly at young, inexpe- sickness along the Annapurna trail in Nepal over a 12- rienced travellers. year period. Improved awareness of acute mountain sickness coupled with better management of the con- Introduction dition may not prevent all cases of acute mountain sickness, but may at least prevent the progression of Each year 40 million people travel to altitudes acute mountain sickness to life-threatening high-alti- greater than 2,500m.1 “High-altitude illness” is a col- tude cerebral oedema.5 lective term for a group of syndromes that can affect unacclimatised travellers shortly after ascending to high altitude. High-altitude pulmonary oedema and Methodology high-altitude cerebral oedema are uncommon but A cross-sectional observational study was conduct- potentially rapidly fatal conditions. The more com- ed to assess level of current awareness of health risks mon entity of acute mountain sickness is a public of high-altitude exposure in a group of trekkers health problem affecting many visitors to high-alti- attending the Tropical Medical Bureau clinics for pre- tude locations around the world annually. High-alti- travel health advice and travel vaccinations. Subjects tude illness occurs in previously healthy young peo- were recruited between September 1, 2005 and 28 Journal of BTHA, Volume VIII, 2006

Public Awareness.....Trekking to High Altitude continued

February 1, 2006. A written survey instrument com- 26% were unable to estimate the length of time this prising 18 multiple-choice and open questions was would take, while 14% planned to take less than 2 administered to eligible subjects. The questionnaire days to reach their maximum altitude (Figure 2). Of was preceded by an explanatory document outlining the latter trekkers, one was planning to reach an alti- the background to the study. tude of 15,000-20,000ft in less than 2 days, a second The survey identified demographic data such as traveller planned to trek to over 20,000ft in less than 2 gender and age. Knowledge of travel itinerary was days, while two further travellers planned to reach an assessed by asking respondents to indicate how many unknown maximum altitude in less than 2 days. weeks remained until planned departure, proposed high-altitude destination, duration of their trip, and Figure 1 number of people in their group. Subjects were asked if their trek was a guided one and if they had pur- chased travel insurance. The maximum altitude, if known, was assigned to one of four categories. To determine the ascent profile, data were collected on the number of days it would take to reach the maximum proposed altitude. Previous altitude experience was examined and travellers who had been to high altitude previously were asked if they had suffered from high-altitude ill- ness. Respondents were asked if lack of physical fit- ness increased the risk of altitude sickness. Travellers were asked to identify their main information resources in learning about the health risks of high- altitude travel. Perceptions of the non-altitude illness-related health risks presented by a visit to a high-altitude des- tination were explored by asking if their trek incurred Maximum anticipated altitudes reported by a risk of developing diarrhoea, rabies, malaria, sun- trekkers burn, frostbite, dehydration, or disturbed sleep. P values were calculated by a Chi-Square test to determine associations between factors. Results with a Figure 2 P value less than .05 were considered to be significant.

Results Demographic profile Of the 77 participants 44 (57%) were male and 33 (43%) were female. Thirty-six percent belonged to the 26-30 year age group. Sixty-two percent of those sur- veyed had no previous experience of high altitude. The most popular high-altitude destination in this study was the Inca trail in Peru (65%) which was also the most popular destination for the 20-25 year and 26-30 year ages (Chi2=14.548, P=.024), followed by the Himalayas (15%) with Kilimanjaro and the Himalayas more popular amongst older trekkers. The majority (61%) of respondents reported their trek would be guided. Of the 15 who stated that their trek would not be guided, 10 were planning a trek to the Inca trail. Trekkers’ perceptions of time taken to reach maximum altitude Ascent profile Forty-four percent were unaware of the maximum Knowledge of high-altitude illness altitude involved in their trek (Figure 1). These Seventy percent were aware of the symptoms of trekkers were more likely to be female (Chi2=15.488, high-altitude illness. Forty-four percent correctly P=.004). Twenty-two percent anticipated an altitude of recalled more than one symptom of high-altitude ill- 15,000-20,000ft. Twenty-seven percent stated that it ness (Figure 3). Of the 23 who could not recall any would take 2-4 days to reach their maximum altitude; symptoms of high-altitude illness, 19 (83%) had not Public Awareness.....Trekking to High Altitude 29

travelled to high altitude previously and 11 (48%) Awareness of other health risks were aged 20-25 years (Chi2=6.225, P=.044). The most Subjects were asked if their proposed trek carried a commonly reported symptoms were dizziness (43%), risk of developing health problems other than high- nausea (41%), headache (39%) and shortness of breath altitude illness. Fifty-six percent (n=43) believed that (28%). malaria was a potential health hazard during their Thirty-two percent were unaware of any means of upcoming trek (Table 1). Of these, 27 were visiting the preventing high-altitude illness. The most commonly malaria-free Inca trail in Peru. Fifty-two percent either reported preventive measures were gradual ascent did not believe or were unsure if rabies was a poten- (46%), hydration (33%) and medications (19%). tial health risk on their trek. Thirty-nine percent believed that physical fitness is protective against the development of high-altitude illness. These trekkers were more likely to be female (Chi2=6.388, P=.041) and aged less than 30 years Table 1 (Chi2=14.209, P=.007). When presented with a scenario where one of their climbing companions experienced Trekkers’ awareness of health risks apart from severe acute mountain sickness, 61% of subjects high-altitude illness. advised descent while 43% advocated rest at the same altitude (Figure 4). Figures refer to numbers of trekkers.

Figure 3 Health risk Yes No Unknown

Trekkers’ knowledge of symptoms of high-altitude Diarrhoea 63 4 10 illness Rabies 37 11 29 Malaria 43 14 20 Sunburn 67 3 7 Frostbite 27 28 22 Dehydration 63 4 10 Blisters 64 1 12 Disturbed sleep 55 4 18

Sources of information on altitude-related health risks

Figure 5

Preferred sources of information on the health risks systems of high altitude

Figure 4

Trekker’s suggested management of severe acute mountain sickness 30 Journal of BTHA, Volume VIII, 2006

Public Awareness.....Trekking to High Altitude continued

Discussion. rectly recalled at least two remedies. Vardy and co- While many studies describe the incidence of acute workers10 interviewed a sample of 130 trekkers in the mountain sickness in travellers to various high-alti- Solu Khumbu region of Nepal and asked what action tude destinations, there is a paucity of published liter- they would take if they developed symptoms of acute ature examining the subject of traveller awareness. mountain sickness whilst ascending. With symptoms The majority of trekkers in our sample were male, of moderate to severe acute mountain sickness, 28 per- 40% aged between 26 and 30 years. There may be an cent of trekkers indicated that they would continue inverse relationship between age and the incidence of their ascent. acute mountain sickness;5 thus the majority of trekkers Thirty-three percent of trekkers in this study in our sample belonged to the highest risk group for believed physical fitness to be protective against the the development of acute mountain sickness. The Inca development of high-altitude illness. Milledge et al11 trail was the most frequently visited destination and it concluded that physical fitness does not protect was particularly popular in the 20-30 year age group. against high-altitude illness. This 50km long trail commences at an altitude of 2,750 The most popular single source of information on metres and includes three passes, the highest at 4,200 the health risks of travel to high altitude in this study metres, leading to the famous ruins at Machu Picchu. was the internet with 43% stating that they would use It is usually completed in 3 to 5 days on a well-main- computers to educate themselves on high-altitude ill- tained path but with irregular steps, rocks, steep ness. Thirty percent of trekkers to Nepal (Glazer et ascents and descents that require care.6 al)12 listed the internet as primary source of informa- Knowledge of the ascent profile is of paramount tion. In the present study 13% of travellers listed their importance to the high-altitude traveller. Basnyat7 general practitioner as a reliable source of information comments that health professionals need to improve on high-altitude-related problems no subject would their ability to advise travellers about individual risk consult their general practitioner as their single source of acute mountain sickness and the optimal ascent of information. Perhaps awareness campaigns should rates necessary to prevent it. A third of the sample sur- be directed at general practitioners so that they are veyed in the current study was unaware of the maxi- better equipped to provide preventive health advice mum altitude to which they would possibly be to patients travelling to high altitude. exposed during their trek. Thirty percent of trekkers Other non-altitude illness health risks encountered planned to reach the categories of very high to at high altitude include travellers’ diarrhoea, rabies, extreme altitude (15,000-20,000ft). The ascent rates sunburn, dehydration, blisters, hypothermia and reported are well in excess of those recommended in frostbite. Although malaria transmission does not the literature.8 Forty percent of trekkers planned on occur at altitudes above 2,000-2,500 metres, travellers taking just 2 to 4 days to reach their maximum altitude often pass through malarious areas en route to and while 10% of trekkers planned to reach the maximum from high-altitude destinations.13 It is a concern that altitude, in one case at over 20,000 feet, in less than 2 nearly half of this group of trekkers did not recognise days. This reveals a potentially dangerous lack of rabies as a health risk. Many of the popular high-alti- awareness of the physical demands imposed by a tude destinations are endemic for the rabies virus and high-altitude trek and of the necessity for adequate are located in remote areas, at a considerable distance acclimatisation. from competent medical assistance. Trekkers are rec- Eighty percent were aware of the symptoms of ommended, therefore, to receive pre-exposure rabies high-altitude illness, with 50% of subjects correctly prophylaxis since rabies immunoglobulin may be dif- reporting more than one symptom. In the study by ficult to acquire and may not be adequately screened Gaillard et al5 95.1% of trekkers could mention at least for blood-borne viruses. two symptoms. Of the 6 trekkers in this study who There may be a degree of selection bias in this study were unable to list any symptom of high-altitude ill- since a sample of travellers who seek pre-travel health ness, 4 had not previously been exposed to high alti- advice before embarking on a high-altitude trek may tude. not be representative of the general trekking popula- Three axioms guide the management of acute tion. No effort was made to identify respondents with mountain sickness: further ascent should be avoided medical training which would have been a further until the symptoms have resolved; if patients do not confounding factor. respond to medical treatment they should descend to a lower altitude; and at the first sign of high-altitude Recommendations cerebral oedema, patients should descend immediate- Advice on the health risks associated with travel to ly to a lower altitude.9 Twenty-three percent of high altitude should be targeted at the young, inexpe- trekkers in this study were unable to mention even rienced traveller. one practical step they would take to reduce their risk General practitioners should receive training in high- of developing high-altitude illness. Seventy-seven altitude illness recognition and management. percent of trekkers in the study by Gaillard et al5 cor- Travel agents should be made aware of the risks of Public Awareness.....Trekking to High Altitude 31

high-altitude travel and should be encouraged to refer 7 Basnyat B, Murdoch DR. High-altitude illness. Lancet 2003; 361: travellers early for their pre-travel health consultation. 1967-1974. 8 Houston CS. Disorders caused by altitude. In: Wilkerson JA, ed. Knowledge of the ascent profile is essential and trav- Medicine for Mountaineering and Other Wilderness Activities, 5th el medicine practitioners should be able to advise ed. The Mountaineers Books: Seattle, 2001: 220-239. travellers on the importance of a safe ascent rate. 9 Hackett PH, Roach RC. High-altitude illness. N Engl J Med 2001; Written information should be provided to reinforce 345(2): 107-114. 10 Vardy J, Vardy J, Judge K. Can knowledge protect against acute this advice. mountain sickness? J Public Health (Oxf) 2005; 27(4): 366-370. Risk of rabies amongst trekkers in endemic coun- 11 Milledge JS, Beeley JM, Broome J, et al. Acute mountain sickness tries should be highlighted and rabies vaccination susceptibility, fitness and hypoxic ventilatory response. Eur Respir J 1991; 4: 1000-1003. advised. A list of reputable websites and books should 12 Glazer JL, Edgar C, Siegel MS. Awareness of altitude sickness be provided to trekkers since this study identified among a sample of trekkers in Nepal. Wilderness and these resources as the most popular sources of infor- Environmental Medicine 2005; 16: 132-138. mation to the high-altitude traveller. 13 Pollard AJ, Murdoch DR. Travel related diseases and vaccina- tion. In: Pollard AJ, Murdoch DR, eds. The High Altitude Medicine Handbook, 3rd ed. Radcliffe Medical Press: Abingdon, 2003: 97- References 112. 1 Ward MP, Milledge JS, West JB. History. In: Ward MP, Milledge *Flaherty G. MRCPI, DTM, MFTM JS, West JB, eds. High Altitude Medicine and Physiology, 3rd ed. **Umeed M. RGN, MSc Arnold: London, 2000: 1-21. *O’Brien T. PhD, FRCPI 2. Roach RC, Maes D, Sandoval D, et al. Exercise exacerbates acute ***Fry G. FRCSI, DTM&H mountain sickness at simulated high altitude. J Appl Physiol 2000; 88: 581-585. Thanks are due to Ms Pam Haworth of the Galway Tropical 3 Bircher HP, Eichenberger U, Maggiorini M, et al. Relationship of Medical Bureau Clinic, for her enthusiastic support. mountain sickness to physical fitness and exercise intensity dur- ing ascent. J Wilderness Med 1994; 5: 302-311. 4 Houston C. Acclimatization. In: Sutton J, Jones N, Houston C, *Department of Medicine, National University of Ireland, Galway, eds. Hypoxia: Man at altitude. Thieme-Stratton: New York, 1982: Ireland. 158-160. **Specialist Nurse Practitioner, Glasgow, Scotland. 5 Gaillard S, Dellasanta P, Loutan L, et al. Awareness, prevalence, ***Tropical Medical Bureau, Ireland. medication use, and risk factors of acute mountain sickness in tourists trekking around the Annapurnas in Nepal: A 12-year This research study was presented in abstract form as a poster pres- follow-up. High Alt Med Biol 2004; 5(4): 410-419. entation at the Northern European Conference on Travel Medicine 6 Bauer IL. Inca trail porters: the health of local tourism employ- in Edinburgh (June 2006). ees as a challenge for travel medicine. J Travel Med 2003; 10: 94- 99.

Travellers’ and Tuberculosis A.A. MacConnachie*, C.A. Redman**and E. Walker* Abstract ed individuals staying in a high risk situation is 2.8 cases per 1000 person months of travel. Assuming a Objectives: Recently the Department of Health similar risk for our population this could be expected (UK) announced plans to replace the current universal to result in 3.6 cases of latent tuberculosis per year. bacille Calmette-Guérin (BCG) vaccination program Conclusions: Strategies such as pre-travel BCG or with a targeted vaccination program. The risk of pre and post travel tuberculin skin testing need to be acquiring latent tuberculosis among travellers has considered as these individuals are likely to be travel- been shown to be similar to that of the population in ling in the next 3 to 5 years. the host country for the duration of their stay. We reviewed data from our travel clinic to assess numbers of travellers potentially at risk. Introduction Methods: We analysed pre-travel consultations for The risk of acquiring tuberculosis while travelling the period 1st April 2004 to 31st March 2005. abroad is well recognised.1 A recently published direc- Travellers thought to be at risk of acquiring tuberculo- tive from the Departments of Health (UK) replaced sis were identified for analysis. the current universal bacille Calmette-Guérin (BCG) Results: 365 individuals were identified. They vaccination program with a targeted vaccination pro- stayed for a total of 5453 weeks, equivalent to 1298.3 gram.2 This is likely to have a serious and immediate months (at 4.2 weeks per month). The published risk impact on the resources required for counselling, risk of acquiring latent tuberculosis, in non-BCG vaccinat- assessment and vaccination of travellers going to 32 Journal of BTHA, Volume VIII, 2006

Travellers’ and Tuberculosis continued areas of high tuberculosis prevalence. The risk of gested an overall vaccine efficacy of 52%.4 This is com- acquiring tuberculosis among travellers has been parable to previous data from meta analysis.5 Notably shown to be similar to that of the population in the these studies did not show any loss of efficacy when host country for the duration of their stay.1 Although older patients were vaccinated. BCG is also likely to there is debate about the efficacy of the BCG vaccine, give at least some protection against drug resistant the change in policy will affect pre travel advice given tuberculosis. One of the main issues with regard to to travellers. We reviewed data from our travel clinic BCG vaccination is the difficulty in testing for tuber- in Glasgow to assess numbers of travellers potentially culosis exposure, using TST, after BCG vaccination. at risk. However, the recent introduction of tests of latent infection which are not affected by previous BCG vac- Patients and Methods cination are likely to supersede TST.6 Our travel clinic in Glasgow gives pre travel advice Alternatively, travellers could undergo pre and post and vaccinations to around 1000 individuals each travel TST to identify TST converters and hence indi- year. Demographic and geographic information viduals with tuberculosis infection. Although this including destination(s), duration of stay and purpose technique has been used routinely in non-BCG vacci- of visit are collected for each pre travel consultation. nated individuals to assess exposure, it is estimated We analysed this data for the period 1st April 2004 to that up to 30% of individuals do not re-attend travel 1 31st March 2005. World Health Organisation regions clinics after they return. Therefore, a substantial num- with an incidence of 100/100 000 were regarded as ber of cases are missed using this screening method. high risk for tuberculosis.3 Individuals travelling for 4 Presumably TST converters would be offered prophy- weeks or more in regions recognised as high risk for lactic anti-tuberculous antibiotics to reduce the risk of tuberculosis (for occupational reasons, backpacking, active tuberculosis. Besides exposing well patients to going on adventure holidays, student electives potential drug toxicities, high levels of drug resistance and/or as volunteers) were identified for analysis; in many parts of the world makes the choice of pro- these groups were considered to be most at risk of phylactic antibiotics difficult. exposure to tuberculosis. A region called Eastern It is estimated that up to 15% of patients with latent 7 Europe, including countries with estimated tuberculo- disease will develop active tuberculosis. Assuming sis incidence of greater than 100/100 000 was also similar numbers of travellers each year, this equates to identified. Those visiting family and/or friends (who one person every two years from our clinic. Therefore, would have already been vaccinated under the new both follow-up with assessment of exposure to tuber- guidance) and package tourists were omitted from the culosis or vaccinating non-BCG vaccinated individu- analysis. als should be considered for all high-risk travellers. Current guidance suggests that all travellers to areas Results of the world with high tuberculosis incidence should be assessed for the need for BCG if staying in that 365 individuals were identified as being at risk of country for at least 4 weeks. Although length of stay is acquiring tuberculosis (Table 1). They stayed for a important with regard to TB exposure, equally perti- total of 5453 weeks, equivalent to 1298.3 months (at nent is the nature of contact with local populations 4.2 weeks per month). It has been previously reported during that stay. As most UK travellers have until now that the risk of acquiring tuberculosis in non-BCG vac- had BCG, the recent changes to the vaccination pro- cinated individuals staying in a high risk situation is gram are likely to have a significant effect on the pre 2.8 cases per 1000 person months of travel for non- 1 travel advice, counselling and vaccination offered to healthcare related travel. Assuming a similar risk for travellers in the near future. our population this could be expected to result in 3.6 cases of tuberculosis per year. References 1 Cobelens FGJ, van Deutekom H, Draayer-Jansen IWE, Inez WE Discussion et al. Risk of infection with Mycobacterium tuberculosis in trav- Unless other methods such as pre-travel BCG or pre ellers to areas of high tuberculosis endemicity. Lancet 2000;356:461-465. and post-travel tuberculin skin testing (TST) with use 2 Department of Health. Tuberculosis: Improvements to BCG of prophylactic antibiotics for TST converters are immunisation programme. London: DOH, 2005. employed, the absence of a universal BCG program (PL/CMO/2005/3, PL/CNO/2005/3, PL/CPHO/2005/3) could account for 3.6 cases of tuberculosis infection 3 World Health Organisation. Tuberculosis fact sheet No 104. Revised April 2005. Geneva: WHO; 2005. Available at per year from individuals attending our travel clinic http://www.who.int/mediacentre/factsheets/fs104/en/ 1 alone. These issues need to be addressed quickly as index.html non-immunised travellers are likely to be travelling in 4 Aronson NE, Santosham M, Comstock GW, Howard RS et al. large numbers within the next 3 to 5 years. Long-term efficacy of BCG vaccine in American Indians and Alaska natives. A 60-year follow-up study. JAMA There is much controversy over the efficacy of BCG, 2004;291(17):2086-2091. however a recent large study in North America sug- 5 Colditz GA, Brewer TF, Berkey CS, Wilson ME et al. Efficacy of Travellers’ and Tuberculosis 33

BCG vaccine in the prevention of tuberculosis: Meta-analysis of * Brownlee Centre, Gartnavel General Hospital, 1053 Great the published literature. JAMA 1994;271(9):698-702. Western Road, Glasgow, G12 0YN 6 Ewer K, Deeks J, Alvarez L, Bryant G et al. Comparison of T-cell based assay with tuberculin skin test for diagnosis of ** Health Protection Scotland, Clifton House, Clifton Place, Mycobacterium tuberculosis infection in a school tuberculosis Glasgow, G3 7LN outbreak. Lancet 2003;361:12950-12959 7 Vynnycky E and Fine PEM. Life time risks, incubation period Correspondence to Dr A MacConnachie, Specialist registrar in and serial interval of tuberculosis. Am J Epidemiol 2000;152:247- infectious diseases, Brownlee Centre, Gartnavel General Hospital, 63. 1053 Great Western Road, Glasgow, G12 0YN 8 Department of Health. Immunisation against Infectious Disease Tel: 0141 2111096 Fax: 0141 2111097 (Green Book). HMSO: London, 2005. E mail: [email protected] http://www.dh.gov.uk/assetRoot/04/12/44/92/04124492.pdf

Table 1: Travellers to regions with estimated tuberculosis incidence greater than 100 cases per 100 000 population.3

Africa Western Eastern South Eastern All Pacific Europe East Mediterranean Asia Number of Travellers 117 150 12 229 18 365

Mean No. months in high risk TB areas 6.2 ± 0.3 (range 1 - 49) per journey ± standard error

Mean age ± standard error (years) 27.4 ± 0.5 (range 0 - 104)

The number of visitors in regions do not total 365 as many travellers visited more than one region in a journey.

Dishwashing in Basic Camps Jo Hargreaves Introduction the third (Figure 1). Generally it worked well, but there were a few problems such as; difficultly cleaning On expedition or travel in remote places there are utensils in water which soon became filthy, objections often very few facilities. Water is usually collected to the taste of disinfectant left on utensils, skin reac- from rivers, and toilets tend to be holes in the ground. tions possibly due to, or worsened by, disinfectant Diarrhoea is often the most common illness suffered (sunlight, low humidity and Doxycycline were also by wilderness travellers, occurring in about one third 1,2 factors), non compliance by those thinking a system of expedition participants the incidence may be up was unnecessarily complex, and shortages of water. to 74% on adventure trips.3In the wilderness consis- tent use of water disinfection still leads to high rates of Figure 1 The Established Three-bowl Washing-up System diarrhoea, implying that wilderness diarrhoea is not caused solely by waterborne pathogens, and that poor hygiene, with faecal-oral transmission is also a con- tributing factor.4 Hand hygiene and cleaning of cook- ing utensils maybe more important than treating 5 water. There is little research into the best methods for I discuss my findings regarding dishwashing dur- hand washing or dishwashing in the wilderness. ing expeditions or adventure travel staying in basic Various systems are in use and differ depending on camps (no running water, pit latrines, cooking on the environment, number on people in the party, open fires), for medium to large groups (average size length of stay and water availability. of 10-20 people) rather than individuals or smaller I decided to look into dishwashing in basic camps groups. after being an expedition medic on three youth expe- I considered the following: What dishwashing sys- ditions (two to jungle areas and one to a desert envi- tems are being used? Is there a “best” system? Will it ronment) with two companies. On each, a three-bowl work in practice? system was used for dishwashing; this consisted of three washing-up bowls. The mess tins, cutlery and cooking utensils were washed until visibly clean in What systems are in use? the first bowl, rinsed in the second and disinfected in To see if my experiences were reflected across other 34 Journal of BTHA, Volume VIII, 2006

Dishwashing in Basic Camps continued

expeditions and similar trips I sent a questionnaire to Figure 3. Disinfectants used for dishwashing among 56 UK based expedition and adventure travel compa- the companies that responded nies, these represent the main companies and were taken from a well known travellers’ magazine. Half the companies responded, of which 27% used the three-bowl system as described. Additionally slightly fewer use a two-bowl variation, without the middle rinse bowl, first washing in detergent solution then disinfecting. Several other systems were also in use. (Figure 2)

Figure 2 Dishwashing systems used among the companies that responded Number of companies

Disinfectant

71% of companies using the established three-bowl system or a similar variation thought it improved the Number of companies illness rates on their trips. Most of these had no prob- lems with it, others complained of taste issues, skin reactions, and environmental worries. One company pointed out an important benefit to using a three-bowl system; that it instils good hygiene discipline amongst participants. Using a system different to that used at Dishwashing system used home makes clients notice the additional risks and reminds them of the importance of good hygiene. Two Two thirds of responding companies used disinfec- companies not using the three-bowl system or a simi- tant for dishwashing, of these 50% used Dettol which lar variation thought they might have higher diar- is a well known household product containing rhoea and vomiting rates because their systems were Chloroxylenol and 25% used bleach which is based not effective. Nearly half those not using a three bowl on sodium hypochlorite. Other disinfectants used method thought a simpler system was needed. include, Iodine, Savlon, Potassium permanganate and Less than 20% of companies had written protocols unspecified local brands. (Figure 3). The amount of for important hygiene measures such as hand wash- disinfectant used seems haphazard; 22% stated they ing; even fewer had protocols for dishwashing. did not know what concentration was used, 17% used Several companies did say the leader verbally briefed the recommended amount but did not state what this the group, but the standard of the brief may be very was, 11% used “a splash”, 11% used “a capful”, and variable. It is not known how much training the lead- 6% used a 1 in 200 dilution. 60% of companies used ers receive on maintaining good hygiene, or how water that they consider not clean enough to drink for much influence they have on the hygiene standards of washing-up. Presumably the use of disinfectant coun- the participants, or other staff. teracts this as long as it is in the final bowl. Of the 30% of companies not using disinfectant over half used potentially unsafe water for washing-up. 68% used Is there a “best” system? cold water for washing-up, which is not surprising as The aims of any washing-up system are obviously hot water is time consuming and uses precious fuel to to clean the utensils, and remove food waste, it is also produce in such basic camps. 58% air dry utensils important to kill potential pathogens, and prevent ill- after washing rather than use a cloth. T-towels would ness. Reducing possible side effects from detergent or be difficult to wash and are a well known source of disinfectant residues left on the utensils is also impor- bacteria.6,7 Washing-up tended to occur after meals but tant. Considerations when thinking about a washing- sometimes before as well. Dishwashing pre-meals up system for use in basic camps include the fact that means mess tins are wet and increases the potential hand hygiene is difficult, therefore dirty hands will be problem of disinfectant taste in food; but if the nature washed during the dishwashing process, risking dis- of the trip means mess tins e.t. can be contaminated ease by faecal-oral transmission of pathogens from between meals it should reduce this risk. hands to eating utensils. Remote basic camps tend to Dishwashing in Basic Camps 35

be in environmentally sensitive areas, which should water is very scarce, if carrying three bowls is difficult, be protected; disposal of washing-up water, food or if a final rinse bowl is not safe; the first two bowls residue, and chemicals needs to be considered. of the system can be used alone; providing good bac- Another consideration is the quality of the water used, terial killing and mess tin cleansing with just the which may be contaminated from its source, for exam- disadvantage of some disinfectant residues.8 ple a local river. Washing-up of plates, cutlery and cooking utensils, ideally should not take place in rivers because of group safety and environmental reasons. However, this may be acceptable for very small parties moving on every day and being careful not to pollute the water with detergents and food residues. For group safety washing-up directly in rivers is not ideal. In the tropics, especially, at least one meal is likely to be Review of literature adds points. If at all possible before dawn or after dusk. Washing-up from a river- hot water should be used,9,10 probably in bowl 1. If a bank in the dark increases the risk from the water scourer or sponge is needed it should be used in bowl itself and other animals that use the water. Groups 2 with the disinfectant, to prevent contamination of will need to use bowls nearer the eating area. If one the scourer.9,11 After washing, utensils should be washing-bowl is used the water soon becomes filthy allowed to air dry.6,7,12 After use the washing-up bowls and unsuitable for washing-up, so further washing- should be cleaned and left to dry, if the bowls are wet bowls are added to make sure mess tins etc are clean. before use they may be harbouring potentially harm- All these considerations have lead to the develop- ful bacteria so should be suitably cleaned, probably ment of the established three bowl system, but as dis- with disinfectant11. If there is an out break of diar- cussed this has its problems. I carried out some labo- rhoea and vomiting the concentration of bleach ratory research to try to find a “best” system, the should probably be increased up to 100ml 4% details are published elsewhere.8 Results show that a hypochlorite in 5 litres which is similar to the concen- different three bowl system is probably better than the trations used for cleaning in hospitals during viral established three bowl system, and other variations. gastroenteritis out breaks.13 All other aspects of camp The alternative, better, three-bowl system is to remove hygiene, especially hand washing, should be main- most food residue and grease with a detergent solu- tained at a high level. tion in bowl one, then wash in bleach solution (10ml 4% hypochlorite in 5 litres water) until visibly clean in bowl two. Then if safe water can be used in a suitably cleaned bowl three, the utensils can be rinsed to remove disinfectant residue (Figure 4).8 This provides very good bacterial killing, leaves the mess tins clean, not greasy, and not smelling of bleach. The better bac- terial killing of this system may be because utensils are washed in disinfectant, not just quickly dunked, therefore increasing contact time.8 This research shows bleach is probably a better disinfectant to use than the currently more popular Dettol. A final rinse bowl should remove the smell and pre- sumably therefore the taste of disinfectant from mess tins and rinses hands presumably reducing the risk of skin reactions. A final rinse in water that may be con- taminated from its source, the washing-up bowl or incorrect use could be dangerous. To avoid these prob- lems the washing-up bowl should probably be cleaned, disinfected, and preferably stored dry away from potential contamination; the water used should be treated to the same standard as drinking water; and photo by I. McIntosh the group educated that bowls must be used in the correct order, and only for washing-up. If these stan- dards cannot be met a final rinse may not be a safe Will it work in Practice? option. On another jungle expedition with 20 members An additional benefit to the alternative system is staying in a remote static camp with no pre-existing that if three bowls cannot be used; for example if facilities, bar a small river, the established three-bowl 36 Journal of BTHA, Volume VIII, 2006

Dishwashing in Basic Camps continued washing-up method, with Dettol was used for half the to suggest this new system is popular and reduces time (10 days) and the new alternative three-bowl some of the problems previously reported with the method with bleach was used for the rest of the time. established three-bowl system. The next step is to The team members filled out a questionnaire at the conduct a larger field study to see if illness rates are end regarding the two methods and their feelings reduced by better dishwashing systems. Other about expedition washing-up. aspects of camp hygiene especially hand washing Twelve members preferred using the new method, also need much more investigation. 5 preferred the established method and 3 had no pref- erence. Ten thought the new method got their mess Jo Hargreaves, MA, MB, BChir(hons) DTM&H, DTM, Devon. tins cleaner, 4 thought the established method did and [email protected] 6 did not notice a difference. With the established method 8 people had to finish removing food residue in bowl 2 (water) more than half the time, usually References because bowl 1 had become too dirty. 8 people also 1 Dallimore J, Cooke FJ, Forbes K. Morbidity on Youth found that this method fairly or very often left the Expeditions to Developing Countries. Wilderness and Environmental Medicine 2002; 13: 1-4. taste of Dettol on their mess tins, which most of them 2 Anderson SR, Johnson.CJ. Expedition Health and Safety: A Risk found unpleasant. With the new alternative method, Assessment. Journal of Royal Society of Medicine 2000; 93: 557-562. washing is supposed to be finished in bowl 2 with 3 Ahlm C, Lundberg S, Fesse K, Wilstrom J. Health Problems and bleach solution; all but 3 people found this very or Self-medication among Swedish Travellers. Scandinavian Journal of Infectious Diseases 1994; 26: 711-717. fairly easy to achieve. Only 3 people found that the 4 Boulware DR. Influence of Hygiene on Gastrointestinal Illness new method left the taste of bleach on their mess tins among Wilderness Backpackers. Journal of Travel Medicine 2004; fairly or very often. 2 team members commented that 11: 27-33. having to use purified water rather than straight river 5 Welch TR, Welch TP. Giardiasis as a Threat to Backpackers in the United States: A Survey of State Health Departments. Wilderness water in bowl 3 with the new method was rather and Environmental Medicine 1995; 6: 162-166. inconvenient. Only 2 participants thought a three 6 Ojima M, Toshima Y, Koya E. Hygiene measures considering bowl system was over the top. actual distributions of microorganisms in Japanese Households. Journal of Applied Microbiology 2002; 93: 800-809. The group were also asked to prioritise a list of fac- 7 Speirs J, Anderton A, Anderson J. A Study of the Microbial tors regarding their importance when washing-up. Content of the Domestic Kitchen. International Journal of The equal top three priorities were to remove food Environmental Health Research 1995; 5: 109-122. residue from mess tins, kill bacteria and to reduce ill- 8 Hargreaves J. Laboratory Evaluation of the 3-Bowl System Used for Washing-Up Eating Utensils in the Field. Wilderness ness rates among team members. Other priorities in and Environmental Medicine 2006: 17: descending order of importance were; ease of use, 9 Mattick K, Durham K, Domingue G et al. The survival of food environmental considerations, getting hands clean, borne pathogens during domestic washing-up and subsequent and being kind to hands. transfer onto washing-up sponges, kitchen surfaces and food. International Journal of Food Microbiology 2003; 85: 213-226. 10 Mattick K, Durham K, Hendrix M et al. The Microbiological Quality of washing-up Water and the Environment in Domestic Summary and Commercial Kitchens. Journal of Applied microbiology 2003; 94: 842-848. Hygiene is an important part of maintaining a 11 Josephson KL, Rubino JR, Pepper IL. Characterisation and healthy camp, dishwashing is just a small part of Quantification of Bacterial Pathogens and Indicator Organisms this. A variety of washing-up systems are currently in Household Kitchens With and Without the Use of a in use, mainly including disinfectants. In laboratory Disinfectant Cleaner. Journal of Applied Microbiology 1997; 83: 737-750. studies the most effective system to reduce bacterial 12 Hautenne-Dekay D, Mullins E, Sewell D, Hagan DW. Wet- contamination and to clean mess tins without leav- Nesting of Foodservice Dishware: Investigation and Analysis of ing a disinfectant residue is to first remove most food Potential Bacterial Contamination. Journal of the American waste in a detergent solution, then wash until visibly Dietetic Association 2001; 101(8): 933-934. 13 Chadwick PR, Beards G, Brown D et al. Management of clean in a bleach solution, and finally to rinse if con- Hospital Outbreaks of Gastro-enteritis due to Small Round ditions are safe. A small scale trial in the field seems Structured Viruses. Journal of Hospital Infections 2000; 45: 1-10. Audit of a GP Travel Clinic 37

Audit of a GP Travel Clinic Dr Raymond Walker

Reason for the audit take away the focus on the important messages.6 (written prior to the audit, therefore in present tense) Secondly, advice must be tailored to each individual traveller. Unless travellers perceive pre-travel health ll GPs are obliged to provide travel health advice as relevant and achievable in their situation, advice and basic NHS vaccinations where they are unlikely to follow it.7 Aindicated, unless they opt out of this service.1,2 I plan to audit travellers’ perception of the helpful- Most practices delegate this to practice nurses, as ness of the advice given. we did for many years. 5 years ago our practice nurs- es were finding this task increasingly time-consum- The bottom line ing, and as I was interested in this field I undertook to Running a travel clinic in general practice can be assess, advise and vaccinate prospective travellers time-consuming, especially if you see all travellers myself, with practice nurses involved only with boost- yourself, as I do. 7 or 8 double appointments per week er vaccinations. are set aside for travellers. In addition to the day-to- I found that I had become de-skilled, so I took and day running of the clinic, a large amount of time is passed the Diploma in Travel Medicine from the taken every day, in my own time at home, keeping up Royal College of Physicians and Surgeons of Glasgow. to date with the rapidly changing patterns of infec- Later, I applied for and received accreditation as a yel- tious diseases and other hazards world-wide, using low fever vaccination centre and in 2004 I started a internet resources,8,9,10 and exchanging information travel clinic for the practice, for our own patients and ideas on professional travel medicine discussion under the NHS. fora.2,11 While I greatly enjoy this work, it concerns me that It is therefore important for the practice that my col- the service has not been audited and at present I do leagues, i.e. GP partners, practice nurses and practice not have a clear idea whether or not it is effective. staff, see a travel clinic as a worthwhile service, and Audit is necessary to ensure that services provided are not a waste of doctor’s time. I hope this audit will help meeting the needs of the patients who use them.3 to clarify the situation. If it shows that the travel clin- ic is either not effective in preventing serious illness, What I plan to audit or not perceived as helpful by patients (or both), then 1 Avoidance of serious morbidity associated with travel changes will have to be made to the service. The out- The primary goal of travel medicine is to protect come of this audit is highly relevant to the practice travellers from serious disease and death, and the sec- and to me as an individual practitioner. ondary goal of travel medicine is to minimize the impact of illness through self-treatment. 4 It would be Criteria appropriate to assess the success or otherwise of this 1 The majority of travellers who pass through the endeavour, i.e. whether the travellers remained practice travel clinic should avoid serious illness asso- healthy or got ill, were hospitalised abroad or flown ciated with travel home, or managed to treat their own illness. Clearly, if 2 Travellers should find clinic advice helpful a large number of travellers who have passed through the travel clinic are getting seriously ill abroad, then Standards there may be a deficiency in the service that needs to 1 75% of travellers passing through the travel clinic be addressed. should avoid serious illness. 2 90% of travellers should find the travel clinic advice 2 Helpfulness of advice given helpful. It is important that travel health advisors help indi- Comment: Discretion has to be used to judge what viduals to be responsible for their own health and is meant by ‘serious’ illness. For example, travellers’ welfare when travelling abroad,5 so it is essential to diarrhoea is extremely common, affecting 30-70% of ensure that advice for the traveller is easily under- travellers to developing countries in the first 2 weeks stood and followed. of their trip,12 and though it can be a considerable nui- Contrary to most people’s perception, advice is sance and can ruin a trip, is rarely lethal or requiring more important than vaccination. Immunisation can hospitalisation.13 at best protect against only a small proportion (about 5%) of the health hazards to which travellers are Preparation and plannin exposed.5 • Discussed and agreed with colleagues the pro- This leaves vast scope for effective pre-travel health posed audit, the reason and need for it, as education.5 detailed. However there are two caveats regarding pre-trav- • Agreed with colleagues on criteria and standards. el advice. Firstly, too much advice is harmful as it can Helped by senior partner, who has much experi 38 Journal of BTHA, Volume VIII, 2006

Audit of a GP Travel Clinic continued

ence of audit, in simplifying criteria and standards sional: 2 (2%) and make them easier to measure. Self-treated with medication prescribed by me: 7 • Considered time-scale for the project. Decided to (7%) collect data over one calendar year, from travellers 2 Nausea 1 (1%) consulting me 1 Jan 2005 to 31 Dec 2005. 3 Broken toe: 1 (1%) • With the help of the practice manager, GPASS 4 Sore throat 2 (2%) searches were made to identify travellers who had consulted me during the year. Standard 2 • With help of reception staff, notes were pulled Number who found the pre-travel advice helpful: and consulted by myself to see which travellers 95 were likely to have returned recently. 98% • A questionnaire (sample enclosed) was sent by post Standard set: 90% to travellers who were likely to have returned STANDARD REACHED recently, with a stamped addressed envelope for Number who did not find pre-travel advice helpful: 2 reply. Each was labelled with the patient’s name, (2%) and the patient made aware of its confidentiality. 1 One ticked ‘difficult to adhere to’ regarding food • Names of those still likely to be abroad were kept advice and they were sent questionnaires later. 2 One ticked ‘waste of time’ • I kept the master list up to date regularly with Number of (unsolicited) positive comments: 29 details of questionnaires sent, questionnaires (30%) (See separate file) returned and questionnaires pending. Number of negative comments: 1 (1%) • Questionnaires sent to reach travellers as soon as Nature of negative comments: possible after travel,while the traveller’s memory of • One ticked advice ‘was helpful’ and added “but the pre-travel con-sultation was still fresh. overdone – should doctor’s time be used for organ- • Returned questionnaires were kept in a file in ised group tours/experienced travellers?” alphabetical order. Comments on Data collection ONE Results & interpretation of data collection ONE 97% of travellers who returned their questionnaires Number of travellers who consulted me at the avoided serious illness. This was a great deal higher Travel Clinic between 1 Jan 2005 and 31 Dec 2005=158. than the standard of 75%. Questionnaires sent: 127 (excluded those still 75% avoided any illness, even mild. abroad, and children) 98% found the pre-travel advice helpful. The stan- Questionnaires returned: 97 dard was set at 90%, and was therefore exceeded by a Response rate: 76% substantial amount. Audit denominator=97 responders. Only one traveller found that the food advice was Number who reported any illness: 24 (25%) difficult to adhere to. This is considerably less than in Number with serious illness: 3 (3%) previous studies, which have shown that more than 90% of travellers make errors in food and beverage Standard 1 choice within a short time of arrival at the travel des- Number who avoided serious illness: 94 tination.14 Nevertheless, this traveller turned out to 97% be 6 weeks pregnant during travel, and if she had Standard set: 75% been exposed to food-borne pathogens, e.g. Listeria, STANDARD REACHED the pregnancy might have been compromised. (Number who avoided any illness, even mild: 75%) Conclusions Breakdown of illnesses Results of this audit have been gratifying, with both standards exceeded by substantial amounts. Serious Illness However, it was necessary to do it because the travel 1 LRTI in China. Admitted to hospital, IV antibiotics clinic had not been audited before and good results for 3 days. Felt unwell for 3 weeks. were not guaranteed. If results had been poor, e.g. 2 Frostbite at 7670m in the Himalayas. Required sur- with a high incidence of morbidity associated with gery after return to UK, recovered. travel, or a low perception of the helpfulness of the 3 Giardiasis. Onset after return to UK from Gambia, pre-travel advice, then urgent changes to the service lasted 3 months. would have been required. The audit has shown that the Travel Clinic is an Non-Serious Illness and Accidents effective service, highly appreciated by patients, and a 1 Travellers’ diarrhoea 17 (17%) good use of doctor’s time. It is a useful contribution to Required treatment abroad from a health profes- the range of services provided by the practice. Audit of a GP Travel Clinic 39

One cannot be complacent, and the service should Travellers who have found pre-travel advice helpful 120 be re-audited in the future. 100 Main learning points from this exercise 1 Enthusiasm and genuine interest in helping 80 patients will be perceived and appreciated 2 The two comments that the pre-travel advice was 60 ‘overdone’ and a ‘waste of time’ have been given some thought. In these two cases, I may have fallen 40 into the traps described above of giving too much advice, distracting the patient from the key mes- 20 sages, or not tailoring advice to the traveller’s indi- vidual needs. This has been a useful reminder of 0 Number of Travellers Travellers who found Standard (90%) these important principles, and I have altered my pre-travel advice helpful consultation style accordingly. Travellers who reported any illness, compared to Raymond Walker, MB, ChB, DTM, AFTM, RCPS(Glasg). incidence in travel medicine literature

References 1 http://www.bma.org.uk/ap.nsf/Content/ InfoOnPrescrib0904~TravelVacc 2 www.travax.nhs.uk 3 Calvert L. Provision of travel clinic services. In: Lockie C et al (eds). Travel Medicine and Migrant Health. UK: Churchill Livingstone; 2000. 60% 4 Steffen et al. Introduction and Basic Concepts. In: Manual of Travel Medicine and Health 2nd ed. BC Decker 2003. 5 Cossar J. Historical aspects of travel medicine. In: Lockie C et al 25% (eds). Travel Medicine and Migrant Health. UK: Churchill Livingstone; 2000. 6 Rombo L. Travel Health Advice – a personal approach. Journal Any illness Incidence of literature of the British Travel Health Association 2005. 7 Raeside F. Risk Assessment. In: Lockie C et al (eds). Travel Medicine and Migrant Health. UK: Churchill Livingstone; 2000. Travellers who avoided serious illness 8 www.who.int 120 9 www.promedmail.org 10 http://www.nathnac.org/pro/index.htm 100 11 www.istm.org 12 Shlim D. Self-diagnosis and treatment of travelers’ diarrhea. In: 80 Keystone et al (eds). Travel Medicine. Edinburgh: Mosby; 2004: 201-204. 13 Ostrosky-Zeichner, Ericsson. Prevention of travelers’ diarrhea. 60 In: Travel Medicine. Edinburgh: Mosby; 2004: 185-189. 14 Hill D. Starting, organising and marketing a travel clinic. In: 40 Keystone, Kozarsky, Northdurft et al., eds. Travel Medicine. Edinburgh: Mosby; 2004. 20

0 Number of Travellers Travellers who avoided Standard (75%) serious illness 40 Journal of BTHA, Volume VIII, 2006

Illness during an up country camp for rural cultural development of the university student – common problems and incidence Viroj Wiwanitkit Abstract Derived data were collected and analysed. and descriptive statistical analysis as percentages per- The up country camp for rural development is formed. The difference of rate of illness among each a common activity of university students during group of university students was tested by propor- summer vacation. Since students spend most tional Z test at statistical significant level, p = 0.05. of their daily life in urban university, exposure to the rural community can bring some health prob- Results lems.This pilot study, reports type and incidence of ill- ness of university students. of Chulalongkorn 111 university students in programme (male = 35, University. Thailand, in rural camp work There were female = 76), age ranging from 16 to 20 years.There 111 university students in programme (male = were 20 consulting cases, 20 episodes. All cases were 35,female = 76)., with 20consultation cases. None not serious and completely recovered after primary were serious and completely recovered after primary care. (See Table 1) care. The three most common illness were upper res- The three most common illness were upper respira- piratory tract infection (URI), conjunctivitis and der- tory tract infection (URI), conjunctivitis and dermati- matitis. Incidence of illness was 18 %. Male students tis (Table 1). Incidence of illness was 18 %. Male stu- presented a higher rate of illness than females (P < dents presented higher rate of illness than the female 0.05). The importance of the rural camp physician and (P < 0.05). there was no significant different of rate of promotion of self-care behavior by the students for illness between the science- based and humanistic and every rural camp is emphasised socialistic students (P > 0.05). Keywords: university student, illness, rural camp. Discussion Introduction Direct experience can bring more knowledge than Country camp for rural cultural development is a "inside university teaching." Therefore, rural devel- common summer vacation activity of university stu- opment rural camps for students are held in many dents. It is considered an important activity by the universities. The health status of the university stu- Student Affairs Department of the universities. With dents who participate is of concern. Changing from an average of two rural camps set each year in many the familiar environment to a foreign environment can 1 Faculties . bring health problems to the traveller. Since students spend most of their daily life in Travelling from urban to rural lifestyle can bring urban university, exposure to the rural community health problems. Camp programs differ in many can bring health problems which may relate to; long ways, especially in scheduled activities, availability of transportation time to the rural community and man- skilled medical support for the health care staff, and ual type of work in field. Illness during rural camp can environmental conditions, Camp administrators be considered a work and travel related health prob- should use medical guidelines (Table 2) provided to lem, and in the absence of previous reports on this develop camp-specific protocols for day and residen- 2 topic futher study is necessary. This investigation tial camps. reports on the experience of a field physician for the According to this study, detected illness was not university in a rural development camp in serious and not a major health problem. However, Thailand,with illness studied for type and incidence. more serious incidents such as accident can be expect- ed in other settings. As in previous reports in the Western press,2 the most common illness among stu- Methodology dents is URI, the most common health problems for A descriptive pilot study. of a rural camp part ,a the traveller worldwide.3 Some of these URI cases rural development project of the General Education require antibiotic treatment and if there is no rural Unit, Chulalongkorn University. from May 4 - 9, 2002. camp physician, the irrational and improper use of by the field physician.The setting, was Non Samran antibioticmay occur. Antibiotic are not normally Village, Wangchai. included in the list of drug in the routine ambulance All details of the consulting cases of students illness bag used for rural camp work. were recorded Cohort included science, humanistic Other common illnesses during rural camp life are and socialistic based students.Duration of observation conditions associated with exposure to the foreign (follow up) was the whole period of campus term. environment including irritants and allergen. Illness during an up country camp 41

Conjunctivitis and dermatitis were common in this Table 1 study. Advice to the student to prevent contact with Types of illness of the university students these substances is necessary.4 Sex Faculties Only one case of knife wound was recorded.which Type of Illness Male Female Science Non Science was not serious but required further treatment with based based (n = 13) (n = 7) (n = 3) (n = 17) tetanus prophylaxis. Other expected accidents in camp life include fire burns and car accident which URI 11 4 2 10 require consideration. Promotion of self care behavior Conjunctivitis 0 2 0 2 for campers camp is recommended.5 Dermatitis 0 0 0 3 Faculty members have the responsibility to supervise Accident 1 0 0 1 student activities on field trips. And should advise students Diarrhea 1 0 1 0 about violation of State laws, local regulations, and University rules regarding alcohol and drugs. Constipation 0 1 0 1 According to this study, the incidence of illness among the male is higher than female. This fact may Table 2 be due to male do more labour work or more careless Medical guidelines for rural development camp of the student concern for their health than in females. There was no significant difference of illness between science-based Items Description and non science-based students. The high incidence as 1 necessary • information on known allergies 18 % highlights the importance of health care for the • Food handlers should be subject to health laws students during rural camp life. We estimated 3.3 • Basic health care equipment and primary drug cases/day suggesting the field physician is necessary (as analgesic, antihistamine, antiseptic, ORS and etc • Control for bringing of alcohol or illegal drugs for student rural camp work. Limitations of this study • Health insurance, life insurance are the short study period and small cohort but it con- 2 less necessary • Nurse or physician in charge firms the need for a larger study. • Camp records should include emergency contacts for all children Conclusion • All camps should have written health policies and protocols that have been approved by a physician URI was the most common health problem at this with a particular knowledge rural camp. The authors emphasise the importance of Adapted from the guidelines of American Academy of Pediatrics Committee on School the rural camp physician and promotion of self care Health.2 advice for participating studnts. References 1 Amazing Thailand Year 1998 - 1999 Tourist’s health concepts. Chula Med J 1998; 42: 975 - 84. 2 American Academy of Pediatrics Committee on School Health. Medical guidelines for day camps and residential camps. Pediatrics 1991;87:117-9. 3 Habib NA, Behrens RH. Respiratory infections in the traveler. Curr Opin Pulm Med 2000 May;6(3):246-9. 4 Sonneville A. Advice for allergic travellers. Allerg Immunol (Paris) 1999 Sep;31(7):238-41. 5 Bratton RL. Advising patients about international travel. What they can do to protect their health and safety. Postgrad Med 1999 Jul;106(1):57-64.

Viroj Wiwanitkit MD, Lecturer, Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok Thailand 10330. photo by I. McIntosh 42 Journal of BTHA, Volume VIII, 2006

UPDATE FOR THE NOVICE AND EXPERT Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

PE is usually due to a thrombus from the venous ent; in more severe cases there will be evidence of circulation embolising to the pulmonary arterial circu- right heart strain. lation. Thrombi usually arise in the calf veins, but can Pulse oximetry – hypoxia is a cardinal feature and arise in the pulmonary arteries. significant PE will nearly always result in saturation There are approximately 65,000 cases each year in of 92 per cent or less. the UK, 1-1.7 per 1,000 population. The potential over- Chest x-ray. all mortality ranges from 10 to 30 per cent. Prolonged Plasma D-dimer measurement. air travel increases chances of DVT and PE. The presence or absence of focal pleuritic pain will Outcomes neither diagnose nor exclude possible PE – pleuritic Death – Mortality can be reduced from 30 per cent in pain may not be apparent in the early stages, and untreated cases to below 10 per cent by rapid and often not a feature at all even when a PE has been effective treatment. proven. Pleuritic type pain is not an uncommonly Pulmonary hypertension. presentation in primary care and most cases are minor Right ventricular failure. chest wall problems or non-serious infections. Normal chest examination does not exclude a PE – the Smaller pulmonary embolism diagnosis must be suspected on the basis of a good history. Symptoms and signs will depend on the size of the Patients with anxiety will present with dyspnoea embolus – very small emboli may be symptomless. and tachycardia and even chest pains – an acute PE Dyspnoea – the commonest symptom, is usually of may result in similar symptoms as well as causing sudden or rapid onset, worse on exertion and may not great anxiety. be apparent at rest. Economy class flights are popularly assumed to be Chest pain – usually sudden onset and may be pleu- a major cause of DVTs and PEs, but the risk factor is ritic; typical chest pains may be absent; chest pains relatively prolonged immobility together with dehy- usually occur at a later stage than the acute event. dration, and DVT and PE are quite unusual sequelae Cough, usually dry and difficult to suppress. of flying in patients with no other risk factors. Haemoptysis may be present at a later stage, and is sometimes massive and fatal. Sweating, fever, apprehension and fear may occur in Do compression stockings prevent any combination. DVT on airlines? There may be evidence of a dvt, usually in the calf Cochrane review veins This review assessed the effects of wearing com- Tachypnoea is the commonest sign, often accompa- pression stockings versus not wearing them among nied by tachycardia. people travelling on flights lasting at least four hours. Chest examination may reveal a friction rub, Ten randomised trials (n=2,856) were included; localised wheezing or rales. nine (n=2,821) compared wearing stockings on both legs versus not wearing them, and one(n=35) com- Differential Diagnosis pared wearing a stocking on one leg for the outbound Myocardial infarction flight and on the other leg on the return flight. Pleurodynia Of the nine trials, seven included people judged to Pneumonia be at low or medium risk (n=1,548) and two included Pleurisy high-risk participants (n=1,273). All flights lasted Pneumothorax seven hours. Anxiety, with hyperventilation Fifty of 2,637 participants with follow-up data Dyspepsia, gastro-oesophageal reflux, cholecystitis available in the trials wearing stockings on both legs Pericarditis had symptomless DVT; three wore stockings, 47 did Congestive heart failure not (odds ratio 0.10, 95 per cent confidence interval 0.04 to 0.25, P<0.00001). There were no symptomless Investigations DVTs in three trials. If PE is suspected, the sooner the diagnosis is made No deaths, pulmonary emboli or symptomatic and treatment started the better. First line tests are DVTs were reported. Wearing stockings had a signifi- limited in primary care to: cant impact in reducing oedema (based on six trials). ECG – will usually show tachycardia if a PE is pres- No significant adverse effects were reported. Update for the Novice and Expert 43

Conclusions Wales between 1995 and 2000 estimated the annual Airline passengers similar to those in this review incidence of diagnosed cases at 7.4 per 100,000 people. can expect a substantial reduction in the incidence of 4,040 acute infections reported. In adults injecting symptomless DVT and leg oedema if they wear com- drug use was reported in 55% of males and 43% of pression stockings. We cannot assess the effect of females. Sexual contact was the second most frequent- wearing stockings on death, pulmonary embolus or ly reported risk factor. Around 12% of cases were asso- symptomatic DVT because no such events occurred in ciated with travel to areas with high or intermediate these trials. prevalence of infection, where transmission occurred mainly through sexual contact or medical treatment. The Cochrane Library. Patients infected with hepatitis B need to be aware www.thecochranelibrary.com of their potential to infect others, particularly through sexual contact and exposure to contaminated blood. Foods the pregnant should avoid They should therefore be advised to use condoms for when travelling abroad oral or penetrative sex, especially for casual sex or sex with a regular partner who has not been fully immu- Unpasteurised milk, soft mould-ripened cheeses, nised. such as Camembert, Brie and blue-veined cheese, pate The hepatitis B virus is very resilient and can persist (including vegetable pate), uncooked or undercooked on surfaces such as table tops, razor blades and nee- ready prepared meals cause listeriosis with mild flu- dles for at least a week without losing infectivity. It is like symptoms and risk of miscarriage, stillbirth and therefore important to avoid sharing household items, severe illness in neonate. for example razor blades, toothbrushes and towels, Uncooked or cured meat, such as salami cause tox- that may be contaminated with infected body fluids. oplasmois with malaise, lethargy lymphadenopathy Injecting drug users should also avoid sharing nee- and fetal CNS (intracranial calcifications, hydro- dles, syringes and any other item that may be con- cephalus), blindness. taminated. Liver and liver products cause vitamin A toxicity In the UK, pre-exposure vaccination is used for with cranial-neural-crest tissue defects. individuals who are at risk of hepatitis B infection Raw shellfish, such as oysters cause Hepatitis A and because of their lifestyle, occupation or other risk fac- listeriosis with Hepatitis A: rash and viral illness. tors. Injecting drug users; healthcare professionals; Shark, swordfish and marlin cause relatively high frequent travellers to areas with high prevalence of levels of methylmercury and fetal CNS. chronic hepatitis B infection; sexual and household Raw or partially cooked eggs or food that may con- contacts of known carriers; men who have sex with tain them (eg mayonnaise), raw or partially cooked men; and individuals who frequently change their meat, especially poultry cause salmonella with diar- sexual partner. rhoea and vomiting. Travellers to endemic countries can be vaccinated against hepatitis B, but not at NHS expense. Hepatitis B Infection Hepatitis B is an important global problem. With Drug and Therapeutics Bulletin. 180,000 people in the UK infected. In England and

EHIC Credit card style EHIC replaced the old E111 form state health care. Some areas such as Benidorm in this year, and entitles the holder to free or reduced Spain, only have private hospitals, so it cannot be cost state medical treatment resulting from accident or used. illness in EU countries plus Iceland, Liechtenstein, Some insurance companies require an EHIC, and Norway and Switzerland. It is valid between three some will waive the excess charge if an EHIC has been and five years. used. In many countries part or all of the cost will An EHIC only covers the same standard of health have to be paid when presenting an EHIC, with a care that a resident of the country would experience refund claimed later. Each person needs their own e.g. EHIC. In Portugal basic hospital treatment might be free, EHIC 0845 606 2030 (applications), 0845 605 0707 but you will have to pay for secondary examinations (inquiries) www.ehic.org.uk such as x-rays and laboratory tests and only applies to 44 Journal of BTHA, Volume VIII, 2006

Flight or Fright: How was it for you? Elaine Iljon Foreman

patient presents with symptoms including Rather than focusing on a typical case history, the chest pain, palpitations, and extreme distress. clearest way to understand the nature of the problem, AThe request is for a letter permitting cancella- and the process of change, can come from the experi- tion of a flight “on medical grounds.” The flight in ence of patients. Two different perspectives follow on question may be an interview at Head Office abroad, what it means to have a fear of flying, and the ramifi- an eagerly awaited family holiday, or even a honey- cations of conquering the phobia. moon. Examination reveals no physical problems. Clearly the patient is terrified by the prospect of the flight. It can be hard for those not sharing this fear to understand it. A familiar adage is “flying is the safest form of transport”,yet estimates indicate nine million people in the UK suffer from a fear of flying. The fear can affect both those who have never trav- elled by air, as well as highly experienced travellers, including aircrew. Children and adults can suffer from this problem. Research indicates two primary fears behind a reluctance to travel by air. One is of an “internal loss of control,” for instance panic attacks, claustrophobia, agoraphobia and social phobia, or alternatively, worries of an “external loss of control”, including obsessional ruminative worries of a catas- trophe to the plane. Heights, turbulence and terrorism photo by Iain McIntosh fall into this latter group. Air travel is the worst imag- inable situation for most patients suffering from the Personal perspectives above, given the increased arousal, fears of imminent Case History One catastrophe, terror, a strong desire to escape, and “Are you scared of flying? I was, but it was much more knowledge that one really is trapped. than that. I even refused to get myself a passport, as with- Understanding the cause of the fear may make it out one I was definitely unable to go abroad. Flying was possible for the Travel Health Professional to help the only one aspect of my fears. During my early years it did person to overcome it. However, some patients may not matter, as I had neither the time inclination or money to be unable to express their true reason for not wanting go abroad on holiday.. However as time progressed some of to fly. Extensive research indicates that treatments the reasons for not flying began to wear thin, and were no developed from Cognitive Behaviour Therapy (CBT) longer valid for not venturing broad. give the greatest long-term success for many different Friends tried to encourage me, telling me about exciting anxiety problems, including that of fear of flying. places I could go to and experience, instead of merely watch- From a Cognitive Behavioural perspective a GP or ing them on TV., I didn’t even really enjoy seeing those Practice Nurse would try to ascertain whether the travel programmes, nor listening to friends who assured me patient had previously experienced a traumatic flight. that real life was far better! Then my nephew and family Clearly a patient having a panic attack on a plane and thought they might emigrate, “Only to Australia!” he said, interpreting the symptoms as a heart attack would be “You’ll be able to visit me!” No passport! Scared of Flying! deterred from taking risking further flights. Likewise The other end of the earth? “No way!”, I thought.because an actual catastrophe or a near miss can be a deterrent. flying was only one aspect of my fears. I was unable to drive When patients can understand why they are doing a car up higher than the third floor of a multi-storey car something it becomes possible to learn ways to park. I was unable to go down the escalators in modern change that behaviour. Patients frequently report that shopping centres. I did not like lifts, and so it continued. they have successfully applied CBT principles to a Then a number of things happened. I told friends to stop number of other fears such as travelling by train, tube, hassling me to go aboard-a pressure I did not need. I ‘made lifts, social anxiety, public speaking, heights, spiders, enquiries about professional help in overcoming fear of fly- water . ing having made the momentous decision to seek help,. I Specialist help from a qualified CBT practitioner very much liked the description of Elaine’s course. In a tele- may however be required, if the Travel Professional’s phone assessment, she asked about my other difficulties and advice proves insufficient, and the problem persists. suggested she could help with these. as well. I therefore Subtle avoidance behaviour can maintain the problem decided to join the course in May 1996. and vividly recall despite the patient flying frequently – practice does standing holding the ‘phone and shaking – what had I done! not always make perfect – it all depends on what and Until then I had only confessed my problems to a very few how one practices! friends. Now I was really terrified! What had I undertak- Flight or Fright: How was it for you? 45

en?I was in my fifties a difficult time of life to let people and think about those 50 flights that have taken me all over know you are scared!! the world and amassed over a hundred thousand miles in Treatment was in a small group of four, - I have the air. The Empire State Building, Raffles, Ayres Rock, The since seen programmes which show a class room of Sahara desert, For me the world had truly become a smaller maybe over 100 people all suffering the same prob- place. lem. The course was two sessions. The first was in the I think about, the person I was, the person I have become. consulting room, where we talked and discussed our How could one fear have so utterly affected my life? I con- fears. We learned how we could each deal with our sidered myself to be well balanced, but this irrational fear own difficulties. I was amazed to find I could talk had destroyed my self-confidence in everything I did and about my problem, as previously I couldn’t even go wrenched me between jealousy and confusion. into a travel agent, or to the airport, without breaking Where had it come from? How had I allowed it to creep out in a sweat. I had a whole week before we were to up on me? fly. and can see why the course isn’t completed on one I had flown infrequently before the bad times. I had day - there’s normally time between booking the always had a child’s passion for aircraft and had wanted to ticket and flying, and we were taught how to deal join the air force. with our worries during the waiting period... I ponder the questions but I can’t find answers. I glance Would we all turn up? What would it be like? Were we up at the statue of Christopher Columbus, I know at that going to be scared? Yes!!!! We arrived at Heathrow. All moment the fear will never return. of us. We got our tickets,passed through passport con- I look to the future. Hawaii next, but that will be seven trol – all new experiences for me!! Some of the others months away, the longest period I have gone without flying had flown many times, but at the start of the course since I sought help. I finish my coffee, it is time for me to go were just as scared as me. We got onto the plane and and rejoin my new friends. All from different walks of life were off.Going along the run way was very much like we are part of a unique circle who has each faced the Tiger being in a bus! “Look around you. No one knows how that stalked us; and the Tiger backed down. “ you feel – and you look just like everyone else”. I looked around and it was true! We arrived at our des- Elaine Iljon Foreman BA(Hons) MSc AFBPS, is a Chartered Clinical Psychologist specialising in the treatment of fear of flying tination! We had flown! We got off the plane – in a for- and other anxiety related problems. eign country and the return ws just as successful Since the course I have managed successfully to go to the top of buildings in many parts of the world and References I’ve flown to many parts of the world... Il Beck, A.T. Cognitive Approaches to Panic Disorder: Theory and I’ve actually enjoyed flying most of the time. There Therapy – In S. Rachman and J.D. Masser, (Eds). Panic: can be moments of doubt. but then, one can have such Psychological Perspectives (1988) Lawrence Erlbaum, Assa, moments on a bus, train or ferry. Most of all I wish I Hillside N.J. Borrill J., Iljon Foreman E., Understanding Cognitive change: A had sought treatment it years ago “ qualitative study of the impact of CBT on fear of flying. Clinical Psychology and Psychotherapy 1996, 3(1): 62-74. Case History Two British Association of Behavioural and Cognitive Psychotherapy “I walk slowly down La Rambla until I find a café with BABCP Publications, Accrington, UK. Self Help Leaflet of Fear of Flying 2003. tables outside. A waiter is wiping down tables and chairs Clark D.A.M., Salkovkis P.M., and Ost L. (1997) Misinterpretation after the recent rain. I claim one and order coffee. of bodily sensations in panic disorder. Journal of Consulting The sun has brought shoppers and the trinket market is and Clinical Psychology, 65, 203-13. in action. Business in the market becomes brisk as it has on Iljon Foreman E. Bor R. and Van Gerwen L. Flight or Flight? Psychological Approaches to the Treatment of Fear of Flying. In the café terrace. Barcelona, capital city of the Catalans has R. Bor and T. Hubbard (Eds) Aviation Mental Health, Ashgate, come alive and for a little while, I’m part of it. London 2006. Two weeks ago it was Dubai. Three weeks ago I was Iljon Foreman E., Borrill J., Plane scared: Brief Cognitive therapy standing in beautiful Kings Park overlooking the city of for fear of flying. Scottish Medicine, 1993, 13(4) 6-8. Iljon Foreman E. “Freedom to Fly”. I.A.T.A., Review, 3/91, 19-20. Perth, Western Australia. Two months ago my wife and I McFadyen M. (1989) The Cognitive invalidation approach to had celebrated our wedding anniversary in the medieval panic. In R. Baker (Ed) Panic Disorder: Theory Research and city of Prague. Therapy. John Wiley and Sons Ltd. 17-34. Six years ago I had stood in the car park at Heathrow Waring H., Iljon Foreman E., “The aetiology of panic attacks”. Chapter in Cognitive Therapy for Anxiety. Baker R. (Ed). Wiley Airport and cried out of sheer terror at the thought of board- and Sons, London 1992. ing an aeroplane. Twelve years ago I had got as far as the Williams S. Lloyd (1990). Giuded mastery treatment of agorapho aircraft door before I turned around and walked away. bia: Beyond stimulus exposure, Progress in behaviour modifica- tion, 26, 89-121. Leaving my poor wife uttering apologies to the cabin crew. Zane G. and Williams S. Floyd (1993). Performance related anxiety Barcelona: I am part of a fear of flying reunion and it was in agoraphobia: Treatment procedures and Cognitive mecha- flight number 50 that had brought me here. I sip my coffee nisms for change, Behaviour Therapy, 24, 625-643. 46 Journal of BTHA, Volume VIII, 2006

Scenarios from the NaTHNaC Telephone Advice Line Alexandra Jordan

he National Travel Health Network and Centre Doxycycline has a long license and can be used for up (NaTHNaC) is a Government funded initiative, to two years or more. Further advice can be found in Tdeveloped by the London School of Hygiene the ACMP Guidelines.1, 2 The traveller would be rec- and Tropical Medicine, the Hospital for Tropical ommended to seek further advice for South America Diseases, Communicable Disease Surveillance Centre in Australia. Pre-travel health services there are of a (now part of the Health Protection Agency), the good standard and widely available. The traveller Liverpool School of Tropical Medicine and the should exercise vigilance against biting insects & Defence Medical Services. report any unusual symptoms. The telephone advice line service provides detailed advice for health professionals advising travellers Vaccines with special needs or complex itineraries, between the Hepatitis A: a second dose can be given to complete hours of 9am – 12pm and 2pm – 4.30pm, Monday – the course. Even though it is now 4 years since the first Friday. Queries are answered by the team of specialist dose, evidence seems to show that a second dose now nurses, with medical cover provided. For more infor- will still provide good immunity for up to and possi- mation on NaTHNaC refer to the website at bly more that 20 years.3, 4 www.nathnac.org Rabies: A single booster dose of rabies would be Scenarios from the calls may prove informative to recommended, even though more than 2 years has health professionals. A selection has been included elapsed since the previous dose. It is recognised that below. With all travellers it is essential the immune system has memory and not usually con- to complete a risk assessment. This involves finding sidered necessary to re-start the course. It is essential out some details about a) the traveller, includ- that travellers who may have been exposed to rabies ing; past/current medical history, previous vac- perform immediate first aid on the wound and report cines/malaria chemoprophylaxis and b) the trip, to hospital as soon as possible for further treatment.5 including; date of departure, length of time away, the Hepatitis B: Research seems to show that lifelong countries to be visited and the areas within those cover is achieved if the traveller received a full course countries (i.e. urban, rural, coastal, altitude), type of at the recommended intervals. Measuring titres lev- accommodation and any planned activities. els is not routinely recommended in travellers, but can be done if required.6, 7 Scenario 1 Japanese encephalitis: The risks & recommenda- tions for Japanese encephalitis need to be discussed A 22 yr old male is going backpacking in one week with the traveller. The itinerary should be scrutinised to urban & rural areas in Thailand, Vietnam, Laos & for the type of travel he his doing. The vaccine is nor- Cambodia for 3 months, Australia for about 6 months mally recommended for long trips into rural areas or and then South America (details unknown). where the traveller’s activities put them at high risk. In 2002 he received boosters of diphtheria, tetanus Vigilance against biting insects may be the only and polio and full courses of hep B and rabies, method of prevention that is necessary.8 typhoid and the 1st dose of hep A. He did not return General advice; recommendations for food and for the 2nd dose of hep A. He is worried about water hygiene9 insect bite avoidance10 and the risks of Japanese Encephalitis. sexually transmitted infections should be discussed He took mefloquine for prophylaxis in 2002, but he with the traveller.11, 12 had strange dreams when he was taking it. Scenario 2 What would you advise? Malaria: Mefloquine (Lariam™) should be avoided A 29 yr old lady is travelling to Dubai in the United due to the history of sleep disturbance. Doxycycline Arab Emirates to visit her family for two months. or atovaquone/proguanil (Malarone™) are both suit- She is travelling with her 3 month old baby, who is able for areas visited, but atovaquone/proguanil breast fed. She has had no vaccines since the child- is only licensed for 28 days, plus for 2 days before and hood routine schedule. 7 days after the trip. The Malaria Reference The baby is up to date with UK routine schedule so Laboratory (MRL) advise that they are confident ato- far. vaquone/proguanil (Malarone™) can be taken for up to 3 months for travel and up to 6 months with cau- What is recommended for this lady and her baby? tion, but this would be extremely expensive. Mother; following a risk assessment it may be nec- Scenarios from the NaTHaC Telephone Advice Line 47

essary to recommend tetanus, polio, hepatitis A & tective immunity from the vaccine may last longer typhoid despite the fact that she is breast feeding her than 10 years.15 It would be considered extremely baby. This would be a clinical decision to vaccinate on unwise to travel to the Amazon Basin without the pro- a risk/benefit basis and an out-of-licence use of the tection of yellow fever vaccine and this should be vaccines. There is no evidence to show the possible strongly discouraged. The traveller needs to make an adverse events, however these are anecdotally informed decision on whether or not to change his described as rare events. She needs to make an itinerary and not go to the Amazon Basin and whether informed decision about whether or not to receive or not to receive vaccine. If he decides not to receive vaccine. vaccine a letter of exemption will be required as the Baby; cannot receive hepatitis A and typhoid vac- countries subsequent to Brazil require a certificate, cines as the licensed ages are 1 year and 18 months even if he decides not to travel to the Amazon Basin. respectively. The risk of hepatitis A disease in small A template for how to write a letter of exemption is children is lower, as they usually (not always) get a available.16 sub-clinical illness. Research has shown that 50% - Malaria; there is a high risk of malaria in the 90% of infections acquired before the age of 5 are Amazon Basin and Dominican Republic, and so he asymptomatic; 70% - 90% of infected adults will have may decide to avoid these areas. If not any expected symptoms.13 Mother needs to be aware of course that contra-indications, drug interactions and adverse the baby can still transmit hepatitis A disease to events need to be considered with relation to his adults, so it is necessary to take care when dealing current condition and medication,17 the use of meflo- with faeces etc. The baby is at a high risk of food and quine is contra-indicated due to his current cardiac water borne illnesses generally i.e. traveller’s diar- medication. Malarone™ (atovoquone/proguanil) rhoea. The health professional should promote breast may be the best option due to no known interactions feeding which can reduce the risk. Advice on precau- and its short course which may increase compliance tions against biting insects could also be relevant.8 if the time in the risk area is only a few days. Avoidance of mosquito bites and reporting any Scenario 3 unusual symptoms would be an important part of malaria prevention/management. A 62 yr old male is travelling on a 4 week cruise to General advice; this gentleman is a generally high South America, Dutch Antilles and the Caribbean. risk from infections due to his immunosuppressed Destinations include French Guiana, Brazil (includ- state. It would be recommended that he take some self ing 14 days down the Amazon River) Barbados, treatment antibiotics for travellers diarrhoea e.g. Curacao, Tobago, Dominican Republic, Cuba, St ciprofloxacin 500mg twice daily for a maximum of Lucia and Antigua. three days, after which time he would be advised to His past medical history includes Hodgkin’s dis- seek medical advice if the diarrhoea had not resolved. ease diagnosed in 2003. He had radiotherapy and He should also consider skin infections, sun protec- chemotherapy in 2003, but has only been in remission tion, risk of diseases transmitted by mosquitoes other since October 2005 i.e. for 4 months. His medication is than malaria e.g. dengue fever. Accidents in the Aspirin, Omeprazole, Atenolol, Atorvastatin, GTN elderly are a significant cause of death and injury in spray, Monomax SR and Amlodipine. the elderly and sensible precautions should be taken.18 Travel insurance is important and he would be His routine travel vaccines have been given. The strongly recommended to read the policy document query was on whether or not he should have yellow carefully to see what conditions are covered.18 fever vaccine and what malaria tablets would be rec- He would be recommended to take a medical letter ommended. giving details of his condition and medications in case Yellow Fever; It would be necessary for the health he needs to seek medical advice abroad and to pack professional to find out if the hospital consultant is medication in their original containers, in the hand aware of the trip and confident that this gentleman is luggage rather than the suitcase in case of loss.18 fit to travel. The consultant’s opinion should be sought on whether this gentleman can receive a live Scenario 4 virus vaccine in view of a very recent remission date from Hodgkin’s disease. It is also necessary for the A 13 year old girl is going to visit relatives in India health professional to consider the gentleman’s age with her family. They are of a high social caste and when discussing yellow fever vaccine. Evidence will stay in top quality family accommodation. seems to show that first time recipients of the vaccine, She had a heart transplant done approximately 3 who are over the age of 60yrs, are at more risk of years ago and is immunosuppressed. Drugs include severe adverse events.14 The traveller should be ques- Tacrolimus, Azathiaprine and Pravastatin. Her con- tioned about any previous history of vaccine, even of dition is stable and she is well in herself. She has had many years ago. Evidence seems to show that the pro- a routine influenza vaccination. 48 Journal of BTHA, Volume VIII, 2006

Scenarios from the NaTHaC Telephone Advice Line continued

What else is advised? Question; Caller is enquiring about which malaria As with the previous scenario this girl is at a high prophylaxis to recommend for this lady. Questioning risk because of her past medical history when she is the use of malarone because of anti-folate properties travelling. The same advice applies regarding travel and the risk of hypertension with doxycycline. Blood insurance, a medical letter and transporting medica- test results show low iron deficiency anaemia, white tion. The cardiac consultant in charge of her care cell count, thyroid, liver function and urea and elec- should be involved in the planning of this trip. trolytes are all normal. Blood pressure readings are Malaria; complications from the disease may be normal and stable. more severe due to her immunocompromised condi- Answer; This lady has iron-deficiency anaemia not tion, although the predominant form of malaria in a folate deficiency so the anti-folate properties of India is P.vivax which is less likely to cause serious malarone would not be relevant. There is a small fatal disease. It is important that the preventive meas- chance of hypertension with doxycycline so the pre- ures against the disease are adhered to and to stress to ferred options would be atovoquone/proguanil or her parents that assuming they have lived in the UK mefloquine. for a long period of time they may no longer be natu- rally immune to malaria because it is not known how Scenario 6 long it takes for partial immunity to wane.18 If she was born and brought up in the UK so far she may well 79 yr old male and 76 yr old female are travelling on have never been immune. The standard malaria pro- a cruise in three months. They fly to Mombassa where phylaxis of chloroquine and proguanil would be rec- they spend one night in a hotel and then depart on the ommended. No known interactions exist with her cur- ship and spend 14 days cruising to Mauritius, rent medication, however the prescriber has responsi- Reunion, Comoros, Zanzibar, Madagascar and bility to confirm that is the case as medications may Mayotte before going back to Mombassa for one change. Paediatric doses are worked out according night. Many years ago they lived in tropical Africa to the child’s body weight. A chart showing the and they are certain that they have previously had weight ranges and doses is provided in the ACMP yellow fever vaccine, but the caller has not seen docu- Guidelines.1 Avoidance of mosquito bites and report- mented evidence. The gentleman has past medical his- ing any unusual symptoms would be an important tory of ischaemic heart disease but declines to take part of malaria prevention/management.10 medication. Vaccines; the routine schedule of paediatric inacti- vated vaccines should be up to date; hepatitis A and Question; Caller is enquiring about whether to give typhoid are also recommended. Special recommenda- yellow fever vaccine to this couple due to the recent tions are made due to her immunosuppressed condi- evidence that seems to demonstrate that people over tion; pneumococcal vaccine is recommended, inacti- the age of 60 yrs are at increased risk of serious vated vaccines may provide a sub-optimal response of adverse events. shorter duration and live vaccines e.g. MMR are con- Answer; The risk of yellow fever on this trip is rel- traindicated.19 atively low, but there is a requirement for an General advice; she is at a high risk of complica- International Certificate of Vaccination for yellow tions from food and water borne illnesses due to her fever for the islands as they are travelling from a yel- immunosuppressed condition. Ciprofloxacin is not low fever endemic country. However vaccine would routinely recommended for self treatment of trav- not be recommended if they were primary vaccinees eller’s diarrhoea in children.20 However in this case it as the risks of the vaccine to them possibly outweigh could be considered with the permission of the con- the risks of disease. In this case they should be offered sultant as it is used within the transplant unit. The a Letter of Medical Exemption. However this advice dosage would need to be checked and she and her would be negated if they have previously had vaccine parents instructed in its use. in which case the vaccine would be recommended, as Hopefully access to medical care will be good as the the risks are not felt to be present in those who have family are wealthy and know the area well. previously received vaccine with no adverse events. The gentleman is a high risk traveller due to his past Scenario 5 medical history of ischaemic heart disease and should be advised to ensure that he carries a medical letter 18 yr old female is travelling to Ghana in one month and has comprehensive travel health insurance. The for 8 weeks to visit family. Past medical history of cruise company should be pre-warned about the past phaemochromocytoma (a tumour in the adrenal medical history. Elderly travellers should ensure that gland). Only current medication is ferrous sulphate routine influenza and pneumococcal vaccines are up 200mg bd. Currently under investigation by genetics to date as there is a risk of outbreak of these on board specialists, but they have so far found no genetic rea- ship. Accidents on cruises are also known to be a risk son for the tumour. to the elderly and so this couple should be warned to Scenarios from the NaTHaC Telephone Advice Line 49

take care on the deck and also when transferring to would be recommended. and from launches to the mainland. Answer; MMR – The caller was referred to the NaTHNaC Clinical Update of the 24th May 2006, Scenario 7 available on www.nathnac.org which reads as follows; “An outbreak of measles in Caracas, Venezuela in 81 yr old male and 75 yr old female travelling on a March 2006 has been reported to the Pan American cruise in five months time for six weeks. They will Health Organization (PAHO) [1]. The index case was visit the following places Madeira, Barbados, in an airline pilot who may have contracted the illness Martinique, Tobago, St Lucia, Grenada, Dominican during a trip to Spain in February 2006. A small num- Republic, Dominica, Marguerita Island, Venezuela ber of cases have been reported in persons who had (Caracas), Brazil where they will sail down the been in direct contact with this index case. Amazon River (stopping at Santarem, Parintins and In response to this outbreak, authorities in Manaus and back again), and then back to the Venezuela have implemented control measures which Caribbean Islands and Virgin Islands. include increased surveillance and vaccination of peo- ple living and working in affected areas. In addition, The male’s past medical history includes chronic the Venezuelan Ministry of Health has decreed that all obstructive pulmonary disease, diabetes, atrial fibril- Venezuelan nationals and foreign residents living in lation, ischaemic heart disease and intermittent clau- Venezuela require proof of measles and rubella vacci- dication. He has previously had a cardiac bypass nation if leaving the country through international air- operation. Medication includes warfarin, allopurinol, ports or ports to travel outside the Americas [2]. aspirin atrovent & salbutamol inhalers, digoxin, doxa- Anyone who does not have a certificate of measles zosin, flecainide, insulin & metformin, lisinopril, and rubella vaccination will be vaccinated at the point mefanamic acid, simvastatin, carbocisteine and O2 of departure. cylinder at home. The female has irritable bowel syn- While this resolution applies specifically to drome and multiple allergies. Her medication Venezuelan nationals and foreign residents, there includes desloratidine, lorazepam, moduretic and appears to be some confusion in its interpretation at mebeverine. Both of them have previously had yel- Venezuelan points of departure [3, 4]. Until the situa- low fever vaccination within the last ten years. tion is clarified it would be advisable for travellers to Question; The caller is enquiring about the risk of Venezuela to carry documentation of vaccination malaria on this trip and which prophylaxis would be against measles and rubella. recommended. Measles vaccination with MMR should be consid- Answer; There is a high risk of malaria in the ered for travellers who have no history of natural Amazon basin and so for this part of the trip they infection or who have not received two doses of a would be recommended to take prophylaxis, possibly measles containing vaccine. Those who have been malarone would be the best option. This could be tar- born before 1970 are likely to have had natural geted to the specific risk areas of the trip and would measles infection and will not need to be vaccinated. not be needed all of the time. They should be advised Travellers who have had measles may carry a note to ensure they carry their International Certificate of from their physician documenting a history of illness, Vaccination for yellow fever. This couple are extreme- however, it is not known whether this will be accept- ly high risk travellers with extensive past medical his- ed by the Venezuelan authorities. As the situation tories. They would both be advised to see their con- becomes clarified, new information will be posted.” sultant specialists for review well before the trip. A Yellow Fever – Vaccine is not currently recom- medical letter explaining the different diagnoses and mended for travellers who are only visiting listing the medication may be of use in case they need Marguerita Island as the risk is felt to be low. medical attention whilst away. Other advice similar to Precautions against biting insects are recommended. the previous scenario may also be of use. Alexandra Jordan is a Travel Health Specialist Advisor and Nurse Trainer at The National Travel Health Network and Centre Scenario 8 (NaTHNaC). A 63 year old female is travelling to Marguerita Island off Venezuela in one month for two weeks References beach holiday in a resort. There is no current medical 1 Advisory Committee for Malaria Prophylaxis (ACMP) Guidelines for malaria prevention in travellers from the United history of note. Kingdom for 2003. Commun Dis Public Health 2003;6 (3): 180- 99 Question; The caller is enquiring as to whether or not www.hpa.org.uk/cdph/issues/CDPHvol6/No3/ the traveller should receive MMR vaccine as she has 6(3)p180-99.pdf 2 Advisory Committee for Malaria Prophylaxis (ACMP) heard that it is now compulsory for travel to Guidelines for long term use of malaria prophylaxis. Commun Dis Venezuela and whether or not yellow fever vaccine Public Health 2003; 6 (3): 200-208 50 Journal of BTHA, Volume VIII, 2006

Scenarios from the NaTHaC Telephone Advice Line continued

6(3)p200-208.pdf 17 British National Formulary (BNF) 3 NaTHNaC Frequently Asked Question (FAQ); Hepatitis A www.bnf.org/bnf/ www.nathnac.org/pro/misc/hepA.htm 18 Keystone J.S., Kozarsky P.E., Freedman D.O. et al Editors. Travel 4 NaTHNaC Health Information Sheet; Hepatitis A Medicine. 2004. Philadelphia: Mosby. www.nathnac.org/pro/factsheets/hep_a.htm 19 Department of Health. Immunisation against Infectious Disease. 5 NaTHNaC Health Information Sheet; Rabies Chapter 7 Contraindications and special considerations. 2006 www.nathnac.org/pro/factsheets/rabies.htm The Stationery Office. 6 NaTHNaC Information Sheet; Hepatitis B www.dh.gov.uk/assetRoot/04/12/86/07/ www.nathnac.org/pro/factsheets/hep_b.htm 04128607.pdf 7 European Consensus Group on Hepatitis B Immunity Are 20 Medicine Guides booster immunisations needed for lifelong Hepatitis B immunity? www.medicines.org.uk/searchresult.aspx?search= 2000 The Lancet volume 355 issue 9203 page 561. ciprofloxacin 8 NaTHNaC Information Sheet; Japanese encephalitis www.nathnac.org/pro/factsheets/japanese_enc.htm 9 NaTHNaC Health Information Sheet; Food and water hygiene www.nathnac.org/pro/factsheets/food.htm 10 NaTHNaC Health Information Sheet; Insect bite avoidance www.nathnac.org/pro/factsheets/iba.htm 11 WHO. Sexually transmitted infections. International Travel and Health 2005 http://whqlibdoc.who.int/publications/2005/ 9241580364_chap5.pdf 12 Sexually transmitted infections Health Protection Agency www.hpa.org.uk/infections/topics_az/hiv_and_sti/ default.htm 13 Bell, B.P. & Feinstone S.M. In: Plotkin SA & Orenstein WA, Editors. 2004. Philadelphia: Saunders. 14 NaTHNaC Health Information Sheet; Yellow fever www.nathnac.org/pro/factsheets/yellow.htm 15 Monath T.P. Yellow fever vaccine. In: Plotkin SA & Orenstein WA, Editors. 2004. Philadelphia: Saunders. 16 Department of Health. Exemption from the Requirement for an International Certificate of Vaccination. Health Information for Overseas Travel (2001). The Stationery Office. www.nathnac.org/yellow_book/pdfs/appendix1.pdf

Disabled Travellers’ Disability Discrimination Rights Commission says that a voluntary code, Access The Disability Discrimination Act (DDA) has been a to Air Travel for Disabled People, which was brought giant leap forward in improving the rights of disabled in a few years ago, has not been effective. Recent people in this country. It requires those who provide problems included airlines ejecting deaf, blind and services not to discriminate against disabled people, partially sighted passengers from aircraft. and to make ”reasonable adjustments” to ensure that Legislation agreed by the European Parliament due what they offer is accessible to the disabled. during 2007 will ban airlines from refusing to carry But in its present form, the act has a serious short- people because of a disability, except on safety coming: it doesn’t cover public transport. Recent grounds. Assistance to disabled passengers will no amendments will rectify this and come into force in longer be a courtesy but a right of the passengers. December 2006 and they will extend the provisions of Assistance will have to be seamless, from arrival at the the act to trains, buses, coaches, taxis and trams. airport to departure, and to avoid confusion, it will be Transport providers will be expected to take rea- the airports responsibility. Assistance will have to be sonable steps to make it easier for disabled people to provided free, with the costs shared by all passengers. get on or off vehicles and to use the services on board (such as a train’s buffet car). They will also have to Website Information provide reasonable extra help – such as staff guiding The Disability Rights Commission’s website (www.drc-gb.org) has information on the DDA, including a visually impaired passengers to their seats. detailed document explaining the provisions relating to transport. Companies will not be obliged to adapt old vehi- The European Disability Forum’s website, (www.edf-feph.org) cles. Rail companies have until 2020 to ensure all reveals the new rights for airline passengers with disabilities. trains are accessible. The date set for buses is 2017. The Disabled Persons Transport Advisory Committee’s website Air travel, which has long been difficult for the dis- is (www.dptac.gov.uk/door-to-door) abled, is outside the scope of the act. The disability Letter from Honduras 51

Letter from Honduras Nigel Potter

bout a mile down the road from my house the family managed to get it together and the father, lives a large family. The mother, Dona Elsa, is Mario took him to the nearest hospital in La Paz, Aa very somewhat sad and careworn looking which sent them on to the capital where the lad was woman who, it is said, is physically and verbally diagnosed with acute lymphoblastic leukaemia. abused by her husband, Don Mario. He is a “respon- There is a cancer hospital for kids in Tegucigalpa sible” husband and father though, in that he sets forth run by a private (American) charity where expensive every day to go to work and earn his two daily dollars treatment is free. The bad news is that it is catastroph- and I have never seen him drunk. What always ically expensive just to stay around to get the free amazes me about them is they never look me or any- treatment. Elsa is left at home with the other kids and one else in the eye. His face has a nervous twitch too Mario, the big earner of the daily two dollars, is away and she sometimes turns her back on you and speaks for weeks at a time with their son at the hospital, so he over her shoulder. can receive his treatment. This has been very intensive For the last three or four years she has brought her but has now settled into a certain routine, a week on many (10 of them) smaller children to me for treat- and a week off at home rather than away for several ment, mostly run of the mill stuff, diarrhoea and vom- weeks as at the beginning. There were a couple of set- iting and chest infections which usually quickly backs but basically the kid has and is responding well cleared up without any trouble. One son she brought to treatment and it is good to know he can return to me in 2002 with a sty was easily treated and then home to his mother from time to time. It all costs: again the same boy in June last year came with burns about $20 round trip for the father and son ($2 a day to his mouth and an arm(an accident heating up sugar remember). The treatment itself is an atomic cocktail cane juice at a sugar cane mill), which also healed bomb, a mixture of powerful chemotherapy and quickly. I was not surprised when she came once steroid drugs which Francisco Antonio seems to be again with the same lad, Francisco Antonio, now 11, in tolerating well. I have been giving him supportive July of this year. Neither surprised nor overjoyed. I treatment to help him survive this onslaught. His hair sometimes feel Dona Elsa takes advantage of my serv- loss has so far been minimal and so have the nausea ices since, I think, that until now her total contribution and vomiting associated with such treatment. His to my practice finances has been two eggs! Then I face, however, is developing the bloated, steroid- know she has many mouths to feed, is very poor and induced “moon face”. leads a hard life (but yes, income does matter.) It The whole experience has been devastating for the would be hypocritical to pretend otherwise. family. Not only the possible imminent death of one This time round, young Francisco Antonio, had had small boy and the economic side-effects and father a fever for a week, his glands were swollen as in and son, country folk, suddenly plunged into the big mumps and there was a swelling behind an ear. His city and the sophisticated world of white coats and hi- tongue was a dirty yellow and teeth unbelievably rot- tech medicine. Still they seem to be coping well. ten (nothing unusual in that in Honduras). He was Mario is well organized – he has a plastic folder for all eating and drinking fine, had been going to school the endless medical documents: test results, appoint- and playing with his pals, but it was hurting him to ments and the full, long-lasting, complicated drug swallow and speak, he had a cough and found it hard regimes which he produces every time he visits me. to bring up any spit. He also complained of tiredness, When the boy is at home either his mother or father went to bed to sleep on his return from school, had bring him round to see me. On all such visits he has diarrhoea and a stomach pain in his right side, a looked remarkably well though, at first, he was some- buzzing in one ear and a bruise on the inside of one what withdrawn and rather morose. On the last few thigh, which he could not remember how he had got visits he has been much brighter, more active and gen- in the first place. I prescribed a remedy believing he erally more cheerful. had an infection which would settle in a few days And so to finish with a few one-liners: (then was away from home for some time) and I heard At the end of a consultation I usually ask the patient he was desperately ill in Tegucigalpa. Apparently he if there is anything else they want to tell me or think had taken a turn for the worse. His mother had come that I should know. One elderly man said. searching for me and when I was nowhere to be “Yes, they (the Salvadoran military) murdered my found, taken him to a health centre where he was son and tortured me. He was 18.” advised to go to a hospital. Easier said than done! One Another; a very beautiful, sophisticated and com- has to catch a bus, in itself not always as practicable as posed 30 year old woman who had answered all my it sounds, for the service is patchy, unscheduled and questions in a polite, friendly and open manner, sud- may not run because of bad weather and appallingly denly crumpled before me and burst into anguished, bad roads, or hire a pick-up. All this involves instant grievous tears, money, not so easily found on a wage of $2 a day. Still, “Yes, I never had a childhood! I was never a child!” 52 Journal of BTHA, Volume VIII, 2006

Letter from Honduras continued

She revealed she was mother to a family of five, “I for 14 years and with whom I worked for several: was raped, you see.” “Well, my medicines don’t seem to have done you “You want to tell me about it?” much good”, I said. “He hurt me very much, I was bleeding badly and She replied, “Don’t you worry, Nayo, they have bruised, I told no one ever.” done just fine. I don’t feel I am dying of any disease. I “But didn’t you go to the doctor to bind your feel I am just fading away through weakness.” wounds?” “It was the doctor who did it.”! Nigel Potter is a Scottish RGN and Health Visitor who emigrated to Honduras to work in a remote rural village helping destitute Finally, I was commiserating with a patient, a local peasants. He sends this note of one of his patient contacts woman of 50 with a large family, dying of stomach which highlights the problems of family health care in his locale. cancer, and something of a friend who I have known

BOOK REVIEWS

Bioterrorism preparedness medicine,and reference books that are directed specifically at can- didates preparing for academic and professional examinations. Edited by Nancy Khardori John Wiley, Chichester Meeting the acute need for a book determining the crucial ele- Third World Health: Hostage to First World ments of bioterrorism preparedness, this is a global perspective on Wealth the history and current concepts on bioterrorism, integrating the Theodore H MacDonald, Radcliffe ISBN 1857757696 scientific, medicinal, public health and health policy strategies. MacDonald emphasises the point that good health isn’t just The first three chapters provide a historical perspective and an about health care. International trading relationships are grossly overview of management of all categories of potential bioterrorism distorted in favour of the rich nations, and cause appalling health agents including special issues related to the care of children. conditions. Chapters four to nine provide a thorough discussion on all He believes that the World Bank and IMF structural adjustment Category A bioterrorism agents. The last two chapters are devoted policies which have cut health expenditure in poor indebted coun- to priorities, policies and legal issues. The book discusses the role tries are illegal and immoral. These policies, designed in the 1980s, of the World Health Organization and International Health regula- address four maladies assumed to underlie all economic ills: poor tions for bioterrorism preparedness. It contains information rele- governance, excessive government spending, excessive govern- vant to healthcare providers including Infection Control practi- ment intervention in the markets and too much state ownership. tioners, microbiologists, epidemiologists, biotechnologists, public Unfortunately, the outcome for poor countries has been savage cuts health agencies and pharmaceutical agencies. in health and education for 20 years. MacDonald’s answer is that, unless health workers transcend Understanding Clinical Papers – national interests and add their voices to these injustices, and Second Edition unless their words are heeded, the human race doesn’t have much chance of surviving long-term. He is objective in is outlook. To David Bowers, Allan House, David Owens arouse greater commitment within the medical profession. John Wiley, Chichester A useful overview for someone looking at international health Now in its second edition this book helps to unravel the process problems and their connections with the environment. of evidence based practice which requires clinicians to evaluate and collate information from the journals they read. It uses actual papers to illustrate how to understand and evalu- ate published research, but goes beyond this to provide an expla- nation of a range of important research-related topics and included FROM THE JOURNALS a chapter on measurement scales, it will appeal to its target audi- ence of practitioners and clinicians. Do enforced bicycle helmet laws improve Is an essential addition to libraries of all health care workers who need to use articles in journals and all physicians, nurses and public health? other health professionals endeavouring to publish their personal While many public health specialists believe this argument has data. been settled in the affirmative, it remains hotly contested in some quarters. No clear evidence from countries that have enforced the MCQs in Travel and Tropical Medicine wearing of helmets. Before and after data show enforced helmet laws discourage cycling but produce no obvious response in per- Don Colbert, Universe, New York centage of head injuries. Governments should focus on factors This is a primer of Tropical Medicine which basically contains such as speeding, drink-driving, failure to obey road rules, poor 500 multiple choice questions (MCQ) and 25 test questions. Each road design, and cycling without lights at night. At least six inde- MCQ involves selecting one correct response from four possible pendent studies have reported a protective association between responses. Each of the 500 nontest MCQs has the answer and an wearing bicycle helmets and head injuries. Reduction in head explanation of the answer, usually with a reference. The answers to injuries after legislation was enacted. the 25 test MCQs have also been given. BMJ 2006 332 722-5 Few of the 500 MCQs sampled are sufficiently valid in their design for the purposes of designing professional examination papers. Nonetheless they challenge the reader in interpreting these Sport utility vehicles and older pedestrians questions to improve their understanding of travel medicine and People over 60 are more than four times as likely to die if injured provide an opportunity to test readers’ knowledge of this area. by a car than younger people. Older people in Ireland account for The publication is a useful adjunct to core textbooks on travel 30% of pedestrian deaths but only 11% of the population. From the Journals 53

Pedestrian protection is an even more pressing problem in the Death and injury on roads developing world. Pedestrian injuries and deaths from collisions with vehicles represent about 20% of automotive casualties in the Jackson R., Norton R. European Union, but they rise to nearly 50% of casualties in devel- Lowering the road toll will take much more than altering road oping countries, which have poorer roads and more travel by foot. users’ behaviour. At the same collision speed, the likelihood of a pedestrian fatal- There is an unacceptable and largely neglected global toll of ity is nearly doubled in the event of a collision with a large SUV road traffic crashes. Low and middle income countries bear the compared with a passenger car. Primarily due to the geometry of brunt of this burden, accounting for more than 85% of the deaths the front end structure. SUV bonnets are higher than those of cars and 90% of disability adjusted life years lost from road crashes. and this results in more severe primary impact on the critical cen- High income countries (including the United Kingdom) have tral body regions of the upper leg and pelvis. sharply reduced their rates of road crashes in recent decades. There BMJ 2005 787-8 is a strong association between sleepiness and the risk of road traf- fic crashes. French drivers report that they drove when sleepy once a month or more over 12 months had almost three times the risk of Malaria: an update on treatment of adults in serious injury in the subsequent three years compared with those non-endemic countries who did not drive when sleepy. Strategies to prevent driving while Whitty C., Lalloo D., Ustianowski A. acutely sleepy could prevent almost 20% of car crashes that cause Every year people die from malaria in Britain and other indus- serious injury. trialised countries. Most of these deaths are avoidable: they occur People need to be convinced, to stop driving when they are because a patient or doctor has underestimated the severity of the sleepy. disease or has not considered the diagnosis early enough. This arti- BMJ 2006 333, 54-55 cle provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence. Diarrhea and Respiratory Symptoms Among Summary Travelers to Asia, Africa, and South and Central Assume that patients who are unwell on returning from tropical America From Scotland areas, especially Africa, have malaria until proved otherwise. They do not have to have a fever, although most will have history of Redman C., MacLennan A., Wilson E., Walker E. fever. Falciparum malaria – admit patients to hospital for initial Results. From 2006 returned questionnaires (response rate = treatment. Patients with non-falciparum malaria seldom need 41.3%), diarrhea and respiratory symptoms were reported by 44.2 admission. Patients with a mild or moderate attack of falciparum and 16.8% of respondents, respectively; the incidence was signifi- malaria , consider oral quinine (followed by a second drug), ato- cantly greater among travelers to Asia for both diarrheal (55.5%) vaquone-proguanil, or artemether-lumefantrine. For a patient with and respiratory (23.7%) symptoms than among travellers to Africa severe or potentially complicated disease, use parenteral quinine (36.6 and 12.2%, respectively) or South and Central America. For or artesunate. Loading dose of quinine. diarrhea, age was a highly significant risk factor for travelers to BMJ 2006 242-5 Asia, South and Central America and Africa. Self-organised tourist/backpacker, traveling to Asia was associated with increased risk. Diarrhea and respiratory conditions being especially common despite attending a travel clinic for advice prior to departure. Journal Travel Med., 2006 203-11 I.B.M IN THE NEWS

Walkers and Climbers Because the sport is self-regulated, there is no stan- dardised training. Travel insurance may have to be acquired from spe- Diving qualifications gained abroad are not neces- cialists such as the British Mountaineering Council. sarily relevant for diving here because of completely Try Direct Insurance (01903 812345, different conditions including currents, swells and www.direct-travel.co.uk), which will cover up to any poor visibility. Extra training should be required. altitude as long as climbing ropes or other specialised Likewise, learning here does not prepare for possible equipment is not being used. Travel health policies problems abroad. from Tesco and the Post Office also cover hill walking Novices are being misled by being able to secure up to 4,500 metres. “advanced diver” status “over a weekend” after as few as nine dives. Dr Bryson, the head of the Diving Diseases Research Centre, in Plymouth, said that Scuba Divers many divers became over confident. Some organisa- A day scuba diving abroad could risk death or tions abroad did not even check for medical problems serious injury or qualifications. “People have a few dives, think they The British Diving Safety Group and British Sub are advanced because they are told they are, yet are Aqua Club said that 17 divers died last year. totally unprepared for some of the very real dangers A record 441 incidents were reported. they might come across,”. Last year more safety incidents than ever before It is a great lure for people to go scuba diving on were reported in British waters. holiday, especially when they are abroad. About two 54 Journal of BTHA, Volume VIII, 2006

In the News continued million dives a year take place in Britain and thou- In-flight Support System sands more people go abroad to learn. While it is still Emirates has installed a sophisticated new medical largely a safe sport, three recent deaths highlighted system on its aircraft in an attempt to tackle in-flight the problems of divers failing to follow basic require- health problems related to long-haul journeys. The ments while overseas. system, known as Tempus, enables cabin crew with minimal medical expertise to diagnose a raft of med- ical conditions, including potentially fatal Deep Vein Air Travel Thrombosis (DVT). The results are then transmitted Facts and Figures via satellite to a team of medical experts on the ground Air travel to the rest of the world except USA con- who directly inform cabin crew of their diagnosis and tinues to grow. The International Air Transport advice. The system enables medical teams on the Association reported a 6.4 per cent rise in passengers ground to differentiate between a serious and a minor for the first seven months of 2006. medical condition. The number of Britons flying to the US has not now returned to pre-September 11 levels. Flip Seats Regarding the top 10 fastest growing long-haul air Cinema-Style “flip seats” could be introduced on routes over the past decade. Of the 10, 6 are routes to aircraft to speed boarding and help cut the risk of and from London. Deep Vein Thrombosis (DVT). The largest growth has been in the London-Dubai The aviation industry has been experimenting with route, going from 405,433 seats sold in the first half of ways of maximising the space for passengers and 1996 to more than 1.2m this year. London-Mumbai has developing materials which would make seats slim- gone from 225,100 seats in 1996 to 616,000 this year mer. The flip seat designs were displayed recently at while London-Hong Kong has gone from 576,568 to a trade fair in Hamburg. 1.06m. (Ascend Consulting). Passengers will have three times as much room as on a conventional seat, and it gives opportunity to Plane crash deaths double stretch legs. People killed in air crashes worldwide doubled last year. Thirty-four fatal accidents, 1,050 deaths. 28 fatal accidents and 466 deaths in 2004 – Flight Cruise Travel International magazine. Cruise Ship Virus Infection None of the major world airlines suffered a fatal On a recent cruise on ‘Black Prince’. 100 of the 393 crash. passengers fell ill with a vomiting bug. The same liner was hit by an outbreak of vomiting and diarrhoea that Professional responsibility in the air, Governance affected 136 passengers during a cruise to the of behaviour in commercial flights Norwegian fjords previously and a small number of A doctor, nurse or paramedic is obliged by law to passengers were also affected during a recent Baltic give medical assistance to another passenger in a US cruise. The problem was identified as the norovirus . plane flying over France. Even more stringent disinfection processes now take A doctor, nurse or paramedic is obliged by law to place on board. People were confined to their cabins give medical assistance to another passenger in a with gastroenteritis. (48 hours isolation is the best pro- French plane on the tarmac in the USA. cedure to avoid spreading the virus). In a medical emergency a doctor may be legitimate- ly sued for damages when attending a fellow passen- Ship Trauma ger in an area outside ones own special competence More than 100 passengers were injured, 20 of them e.g. a public health doctor attending a cardiac arrest. seriously, when a new cruise ship listed sharply to one When flying the law of the land where the plane is side shortly after leaving Port Canaveral in Florida. registered is in force. When on the ground it is the law Travellers and furniture were hurled against the of that country which takes precedence. In the US the decks and walls and swimming pools emptied on the Good Samaritan law governs ones actions but no pay- ‘Crown Princess’, a 3,000-passenger ocean liner. The ment is allowed and in many countries e.g. the UK, lurching of the 113,000-ton vessel was blamed on a the Medical Protection Societies cover such acts even steering problem. for non emergencies, provided there is no payment. In some countries e.g. France, it is mandatory to ren- Ship Fires der assistance to a fellow passenger or crew member if Two cruise ships have recently had fires on board, so asked in an emergency Bagshaw M. in Travel several cabins were burned out and passengers suf- Medicine. Mosby, 2004 416-430. fered inhalation effects. In the News 55

Ferry Passengers Deaths from malaria Last year nearly 24 million passengers travelled on ferries between the UK and northern European ports. Latest figures from the Association of British Travel This was eight per cent fewer than in 2004 and almost Agents show that all UK visitors to high risk malaria a third less than the 34 million passengers who used regions such as India and Sri Lanka peaked last year the route in 1995. at 4.7 million compared with the 1.9 million visits Dover was again the most popular port, accounting made in 1995. This has coincided with a rise in the for over half of international ferry passengers. The UK most deadly strain of the disease, falciparum malaria, cruise industry has more than trebled in size in eight which can cause death within 24 hours. It has years. increased from 17 to 74 per cent in Britain in the last 30 years. QE2 Medical Staff There has been an increase in travel to popular Include a trained anaesthetist, a second doctor, malaria-risk destinations in the past 10 years. three nursing sisters and a medical petty officer. There is also a dental clinic. The ship has ten beds in five wards, two for men, two for women and a two-bed Holiday Fears intensive care ward geared up mainly for cardiac Terrorist attacks were highlighted as the main con- patients. It is the only liner making six-day cern when choosing a holiday destination by trav- Transatlantic trips. The main areas of work on most ellers from England, Germany and Austria, according cruise ships are acute cardiac and respiratory ills. to a new survey. “European travellers are very resilient, but safety is now more of a consideration for countries such as Train Travel England and Germany,” said Charles Walckenaer, managing director of the insurance company Europ The journey from Golmud in China’s remote western Assistance UK and Ireland, which questioned 3,535 Quinhai province to Lhasa, the capital of Tibet is on a people. train on the world’s highest railway. The train zigzags A YouGov survey suggests that the great majority through perilous mountains to climb more than three of Britons will continue to fly despite terrorist attacks. miles (16,633ft) above sea level, 1,000ft higher than The poll reveals a degree of heightened nervous- Mont Blanc and half the cruising height of an average ness among potential airline passengers. passenger plane. Its 700 miles of track cross nearly 400 42 per cent of YouGov’s respondents say they are miles of permanently frozen earth. The highest point either “a lot more nervous” about flying now than is, 650ft higher than the previous record holder in the they used to be (11 per cent) or “a little more nervous” Peruvian Andes. The line opened on July 1. The train (31 per cent). is pulled to the top of the Tibetan plateau by three Only a tiny minority, six per cent , say they are “not diesel powered, American made, 3,800-horsepower going to fly again if they can avoid it”. engines, to reach the highest railway station in the Eighty-five per cent say they still intend to fly, in world (at 3.17 miles above sea level). The line passes some cases even if they have never flown before. through seven tunnels and across 286 bridges, with Only one respondent in 20 has never flown and never the longest tunnel spanning two miles and its longest means to. bridge 7.2 miles. The highest point of the journey is Six months after a series of terrorist attacks record more than three miles above sea level and in first- numbers of British holidaymakers are travelling to class, four people share sleeper compartments fitted Egypt. with televisions, oxygen canisters and face masks for Nearly 838,000 Britons visited the country last year, travellers to use at their leisure. Extra oxygen is a 53 per cent increase on 2004. Visitor numbers last pumped out through the air conditioning. At Lhasa, month were up almost 50 per cent on January last up to 900 businessmen, officials and tourists disem- year. bark to live for a few days at high altitude Americans going abroad fell sharply following the terrorist attacks of September 11, 2001, Britons contin- ued to travel in sizeable numbers. 94 per cent said that Ski Holidays terrorism had not changed their plans. According to the operator Crystal holidays, more than 1.15 million ski holidays were bought in Britain last season, a rise of seven per cent on the previous New GP travel medicine tool year and 40 per cent more than in the mid-1980s. GPs gain a valuable new tool for use in travel med- icine consultations with the launch of an innovative new web-based guide. The Pulse Travel Clinic is designed so GPs can provide patients with person- 56 Journal of BTHA, Volume VIII, 2006

In the News continued alised advice and calculate a schedule of recommend- Edinburgh Sleep Centre. He urged airlines to alter the ed vaccinations. With free access through the pulse light on planes to help passengers to adjust their body website, the clinic is designed for easy and instant clocks when jumping time zones. For example cabins use. should be flooded with blue light halfway through an overnight New York to London flight. Dr Idzikowski, who carried out a study of more than 1,000 British Tourist Medicine in India Airways passengers, found that traditional methods Taj Hotels, resorts and palaces are working along- of fighting jet lag – shifting one’s watch to the desti- side Apollo Hospitals in a partnership that reflects a nation time – were largely ineffective. He has already surge in medical tourism to India. The major hotel drawn up a jet lag ready reckoner, which is available chain has tied up with a big hospital group- 6,400 beds on the internet (www.ba.com/jetlag). For example, in 32 hospitals across India and confirmed that it was someone flying to New York who normally rises at in talks about a medical tourism partnership. The hos- 7am should expose themselves to light between 9pm pital chain already has six international patient cen- and 11.30pm. They should avoid it between 11.30pm tres in cities across India and claims to treat 10 million and 2am. patients from 55 countries. The study also found that while women had more 150,000 tourists visit India every year seeking non- trouble sleeping after they had landed than men, they emergency treatment in both conventional hospitals fared rather better on board with 18.1 per cent saying and traditional ayurvedic centres. Last year the Indian they were bothered by aircraft noise, compared with government announced plans to introduce medical 31.1 per cent of male passengers. visas for tourists seeking treatment during their visits. Anyone flying a long distance for a business meet- ing should make sure it did not take place when they were at their lowest ebb – normally three hours before Bird flu their normal waking up time. Fear of the virus is making people reluctant to visit Asia and the Far East, South East Asia, Thailand, ECDC China,Bangkok. Turkey tourism was however up by more than 50 per cent until recent bombings. The main scientific voice of ECDC is the scientific journal Eurosurveillance, published in a weekly elec- Table 1 tronic edition with short, timely information on out- Total Number of Confirmed Cases breaks and other important events of European rele- Cases Deaths vance, a monthly electronic edition with longer fully Cambodia 4 4 peer-reviewed scientific articles, and a quarterly print China 8 5 compilation. This free-of-charge journal is a must for Indonesia 16 11 anyone interested in travel medicine, and it is very Thailand 22 14 easy to register for a subscription on the journal web- Turkey 4 2 site www.eurosurveillance.org ECDC will fully take Vietnam 93 42 the responsibility for the journal by March 2007, with Total 147 78 a joint editorial office in Stockholm.

Table 2 The Spread of the Disease Year by Year 2003 – 3 Cases, 3 deaths in Vietnam 2004 – 46 Cases, 32 deaths in Thailand & Vietnam 2005 – 93 Cases, 41 deaths in Cambodia, China, Indonesia, Thailand & Vietnam 2006, Total so far – 5 Cases, 2 deaths in China & Turkey

Sunglass Wear Long-distance air travellers should wear sunglasses during the latter stages of an overnight flight to beat jet lag according to one of the country’s leading sleep experts. “Not only should they be worn on the air- craft, but also for the first couple of hours on the ground”, said Chris Idzikowski, the director of the