Your guide to healthy travel
It was supposed to be the trip of a lifetime: a two-month yoga pilgrimage that Madeleine Cahill hoped would provide some much-needed respite from her frenetic life in Melbourne.
Instead, the 29-year-old director of a busy communications agency found herself in an Indian hospital, seriously ill with typhoid fever, a vaccine-preventable disease caused by the bacterium Salmonella typhi and spread through contaminated food and water.
“I wasn’t keen on getting too many injections and I thought that if I was careful and ate in decent places and maintained high levels of cleanliness, it would be enough,” says Cahill, who fell ill in 2009. “I carried antibacterial hand wash everywhere and was always careful with the water I drank. But unfortunately, as I later learned, typhoid can be contracted from accommodation and cutlery, among other things.”
Cahill had struggled with the symptoms of the disease — which include fevers, headaches, a red rash, a cough, stomach pain and constipation or diarrhoea — for two weeks before seeking medical treatment.
“I thought I had the flu and tried to fight it off naturally but all of a sudden I was struck with fever and bedridden,” she recalls. “Before I knew it, I was in my hotel room and my body was telling me, ‘If I don’t get help, I am going to die.’”
According to researchers from the University of Sydney’s Family Medicine Research Centre, Australians are today travelling in record numbers. We take almost eight million short-term overseas trips every year — more than double the number of jaunts of a decade ago. Our favourite destinations include Thailand, Indonesia, Vietnam, India and Africa.
While around 50 per cent of Australian travellers will suffer a travel-related illness, a shocking two-thirds do not seek any pre-travel health advice, either from their GP or a specialist travellers’ medical clinic. In fact, in most of the developing countries Australian travellers flock to, standards of cleanliness and food hygiene are generally far below “First World” standards — and this can have serious consequences for holidaymakers.
Food and water-borne diseases
We’ve all heard horror stories of “Delhi belly” or “Bali belly”, so it’s no surprise to learn that gastrointestinal illnesses strike Australians overseas more frequently than any other type.
The most common of these is “traveller’s diarrhoea”, which is contracted through consumption of food or water contaminated with bacteria, usually E. coli. As well as frequent loose or watery stools, symptoms of traveller’s diarrhoea can include abdominal pain and bloating, nausea, a mild fever and a feeling of general malaise.
If promptly treated with antibiotics, the illness can subside within hours. If untreated, the sufferer may be sick for a week or more and can become dangerously dehydrated.
A pre-travel oral vaccine can provide immunity to E. coli. While this may not prevent traveller’s diarrhoea — because there are other bugs that may cause the condition — it can reduce the risk by up to 40 per cent. Being vigilant about food and water hygiene is also crucial, says Dr Tony Gherardin, national medical advisor at The Travel Doctor (TMVC) (traveldoctor.com.au).
“Largely it’s about care with food selection and avoiding poorly cooked food, dirty water, dirty plates and unwashed hands. Don’t drink the local water; stick to bottled or boiled,” Gherardin advises.
“Travellers should embrace the local culture, and that means the food and the environment, but that shouldn’t be without thought for their own protection. If people are aware of the risk, they can help to manage it.”
Specialist travel medicine clinics sell kits containing anti-diarrhoeal medication and rehydration salts. GPs are generally also happy to prescribe a course of antibiotics before departure for travellers to take with them.
Also spread via contaminated food and water, as well as through bodily fluids, is the hepatitis A virus. The most common vaccine-preventable illness in travellers, it attacks the liver and can cause fever, stomach discomfort, fatigue and jaundice. There is no specific treatment for hepatitis A and recovery can take weeks or even months. It is common throughout the developing world.
“Adults are usually sick enough to be off work for three months,” says Dr Colleen Lau, a Fellow of the Australasian College of Tropical Medicine (tropmed.org). “Usually, travellers recover completely but in older travellers — especially people over 70 — the chance of dying from hepatitis A increases dramatically. Once you’re vaccinated you are immune for life, so if you’re a frequent traveller it is worthwhile.”
The typhoid vaccine, however, provides immunity for around three years only and can be “overridden” depending on the severity of bacterial infection. According to Gherardin, the Indian subcontinent — countries including India, Sri Lanka and Nepal — is the highest risk zone for typhoid.
“It is treated with antibiotics, but there are concerns about the emergence of antibiotic-resistant strains,” he explains. “Therefore there’s more imperative for people to consider being vaccinated before they travel.”
When she contracted typhoid, Madeleine Cahill spent a month in an Indian hospital. “Travellers need to take precautions,” she says. “Our bodies are just not ready for the bacteria that are in some of these countries. Immunisations are there for a reason.”
Less common but equally severe is the acute diarrhoeal disease cholera. While it’s rarely seen in short-term travellers, Australians who spend longer periods in rural or remote parts of countries with poor sanitation are at increased risk. The disease can be fatal but, with prompt rehydration, fewer than one per cent of cholera patients die. There is an effective cholera vaccine.
Notes Dr Lau, “Cholera is most common in places where there’s severe environmental disruption such as flood zones, refugee camps and after earthquakes when the sanitation and water supplies are disrupted.”
They’re annoying at the best of times, but when it comes to travel diseases, mosquitoes can be deadly.
According to Dr Deborah Mills, a travel health specialist based in Brisbane (thetraveldoctor.com.au), around one per cent of Australian travellers contract dengue fever, a virus spread by the dengue and Asian tiger mosquitoes. Endemic throughout Asia, the Pacific, sub-Saharan Africa and the Middle East, it is also found in north Queensland.
Symptoms include sudden fever, chills, severe headache with pain behind the eyes, muscle and joint pain, extreme fatigue and a faint red rash.
There are four separate strains of dengue fever. Travellers who contract the disease will become immune to the strain they’ve had but may still be reinfected by the other three strains. Subsequent dengue infections carry around a two per cent higher risk of the condition developing into dengue haemorrhagic fever, which causes internal bleeding and can be fatal.
There is no vaccine for dengue fever and no specific treatment; sufferers are advised to rest, take pain relief and drink plenty of fluids. The best prevention is avoiding mosquito bites by wearing appropriate clothing and using DEET-based repellents at all times, as dengue mosquitoes are daytime feeders.
“The key thing with dengue fever is that it is increasing and it is a problem around popular resorts because mosquitoes breed where people are,” says Gherardin. “It’s a huge issue and a major problem for Australian travellers, but there’s no reason not to go to [regions such as] Asia as long as you take proper precautions.”
Malaria, perhaps the most notorious mosquito-borne disease, is in fact five diseases. There are four human species and one monkey species that can also affect humans. A parasite spread by the female Anopheles mosquito, malaria affects the liver and red blood cells.
“Malaria is not just one thing; we’re talking about some complexity,” Gherardin says. “Forms such as vivax and ovale can cause relapsing malaria; they sleep in your liver and come out weeks, months or even years later. There is also a severe type called falciparum that can cause cerebral malaria, which can kill quite quickly.”
Symptoms of malaria include sudden fever, chills, headache, sweating, nausea, vomiting and pain in joints and muscles. In cases of cerebral malaria, symptoms can include seizures, confusion, kidney failure, breathing difficulty and coma. Australians can contract malaria in tropical and subtropical areas of Asia, Africa, Central and South America, the Pacific Islands and parts of the Middle East. Around 500 cases are diagnosed in Australia each year, almost all in people who travelled to malaria-affected countries and didn’t take anti-malarial medications. The Anopheles mosquito feeds at night, so the risk in malaria-affected areas is greatest between dusk and dawn.
While there is no malaria vaccine, there is a range of anti-malarial drugs that will kill the parasite. These can be taken before departure and for the duration of the trip; however, no anti-malaria drug is 100 per cent effective and travellers also need to protect themselves against mosquito bites. Malaria is treated with specific drugs called ACTs (artemisinin combination therapies). As Gherardin says, “Treatment is required for malaria and in general it needs to be very quick.”
A more recently identified and increasingly common mosquito-borne viral infection is chikungunya, found mostly in Asia and Africa. There has been an epidemic throughout the Indian Ocean region since 2004 and symptoms include fever, chills, muscle pain and headache, severe joint pain, a rash and fatigue.
There is no vaccine; avoiding mosquito bites is the most effective prevention. There is also no specific treatment, though anti-inflammatory drugs can provide some relief.
Mills says travellers often become sicker than they need to because they’re reluctant to seek medical treatment abroad: “People who are outside their normal environment tend not to seek medical treatment. They’re resistant to seeing doctors because they’ve heard terrible stories about doctors being ‘dodgy’. Ignorance is a very big problem.”
Statistics show that a traveller who spends a month in Thailand has around a four per cent chance of being bitten by an animal. Bites are also common in parts of Indonesia, especially Bali. But a recent study of more than 7000 international travellers departing Bangkok Airport found that a third of those who had sustained an animal bite had done nothing about it.
Rabies is a form of lyssavirus spread by mammals through bites and scratches and is almost always fatal. It is found in most countries around the world but is more common in the developing world. Symptoms include headache, fever, malaise, sensory changes around the site of the bite or scratch, excitability, an aversion to fresh air and water, weakness, delirium, convulsions and coma.
“The first thing is to be aware that animals are all dangerous in the developing world and really need to be avoided,” Gherardin says. “For people travelling for a long time in higher-risk countries like India, Africa and Asia, they need to be pre-vaccinated.”
Pre-vaccination involves a series of injections before departure. However, travellers who are bitten while away will also need post-exposure rabies treatment as quickly as possible.
“Pre-vaccination gives you a much bigger safety margin because you’re creating the immunity before you get bitten,” says Gherardin. “There have been post-exposure treatment failures in people who were not pre-vaccinated but there have never been failures of post-exposure treatment in people who were pre-vaccinated.”
For all the exotic illnesses Australians risk when they travel, it’s the more commonplace conditions that often do the greatest damage. The most common preventable disease in travellers worldwide is garden-variety influenza.
Explains Lau, “When you’re on a plane with hundreds of people or you’re transiting through big airports, it really doesn’t matter what time of year it is — you’ll be exposed to people coming from wintry climates and bringing their diseases with them. A simple flu shot before you go can make a big difference.”
Travellers are also at risk of sexually transmitted infections (STIs) including Hepatitis B and C and HIV. There is a vaccine for Hepatitis B but not for C or HIV.
Sadly, the most common cause of death for Australian travellers is accidents and injuries. Driving on unfamiliar roads, looking the wrong way before crossing the street or riding a motorcycle without a helmet can have dire consequences. Ultimately, says Mills, Australian travellers need to be more aware that they are susceptible to health risks overseas, whether trekking in the desert or enjoying five-star luxury.
The natural perspective
According to Gherardin, only the use of orthodox vaccines can guarantee immunity to potentially life-threatening diseases like malaria and hepatitis A. He strongly discourages the use of so-called natural vaccines: “We butt up against travellers all the time who say they’re doing ‘natural vaccination’ with homeopathy or similar, but they have zero immunity. There’s no evidence that any of those things work.”
Not only are pharmaceutical vaccines very effective, they are also more convenient than maintaining an alternative medical regime while travelling, says Gherardin. “Things like probiotics and prebiotics may help to improve immunity in your gut but that’s a lot of effort to go to while you’re travelling. It’s hard work.”
Of course, the fact that it’s hard doesn’t mean it’s not worth doing. However, where natural remedies are really effective is in assisting the recovery of people who have contracted and been treated for a travel disease. Olwen Anderson, a nutritionist and naturopath from Murwillumbah in northern NSW (olwenanderson.com.au), says working with a qualified complementary therapist can be the difference between a protracted or a speedy recovery.
“For as long as we’ve lived amongst parasites and bacteria, including mosquito-borne diseases, herbs have been growing alongside us to beat them,” she says. “If you’re unfortunate enough to be infected, your herbalist can select the right herbs and the right dosage to help fight the infection and support your immune system.”
This rings true for Madeleine Cahill: “The doctors in India put me on a range of drugs, which really knocked me out, but then they treated me with Ayurvedic herbs. To be honest, after them, I felt more healthy and alive than I had before getting sick. I recovered really well.”
Carrying natural remedies and seeking out alternative Health practitioners overseas can also help if illness strikes while travelling.
“At the very least, take with you some probiotic capsules that don’t require refrigeration,” Anderson advises. “Before you go, make a note of Australian-trained natural therapists in the country you’re visiting. Most countries also have associations that register properly-trained practitioners. Do your research before you go and keep a list with you in case you need assistance for mild problems.”
Download or bookmark these handy sites and you’re good to go:
Travel Health Guide app, for iPhone and iPad
Vaccine Record for Travellers app, for iPhone and iPad
Travel Medicine Alliance, travelmedicine.com.au
Travel Health Advisory Group (THAG), welltogo.com.au
Travel Medicine Centre Perth, travelmed.com.au
Laura Greaves is an award-winning freelance writer who specialises in health and wellbeing. Find out more at lauragreaves.com.