Travel Health: What to Arrange Before You Go
Most travel illness is preventable, and most of the prevention has to happen weeks before departure rather than at the airport.
Start six to eight weeks out
This is the single most useful piece of travel health advice. Several vaccines need multiple doses spaced over weeks, and some need time to become protective.
A travel health consultation should consider your destination, rural versus urban, season, duration, planned activities, accommodation, your age, pregnancy status, medical conditions and existing vaccination history.
Vaccines to discuss
Routine, worth being up to date regardless: measles-mumps-rubella, tetanus-diphtheria-pertussis, polio, influenza, COVID-19.
Measles deserves specific mention, since outbreaks occur in many destinations and travel is a common route of importation.
Destination-dependent:
- Hepatitis A. Food and water transmitted. Recommended for most of Asia, Africa, Latin America and parts of eastern Europe
- Typhoid. Recommended for the Indian subcontinent, parts of Africa, Latin America and Southeast Asia
- Hepatitis B. For longer stays, medical work, possible medical treatment abroad, tattoos or piercings, or new sexual partners
- Yellow fever. Required by law for entry to some countries, and proof of vaccination on an international certificate may be demanded at the border. Must be given at least 10 days before arrival. Parts of Africa and South America
- Rabies pre-exposure. For long stays, rural travel, cycling, caving, work with animals, or travel to areas with poor access to post-exposure treatment. Pre-exposure vaccination does not remove the need for treatment after a bite, but it simplifies it considerably and removes the need for rabies immunoglobulin, which is scarce in many places
- Japanese encephalitis. Rural Asia, particularly rice-growing and pig-farming areas, longer stays or monsoon season
- Meningococcal ACWY. Required for Hajj and Umrah pilgrims, and recommended for the African meningitis belt
- Cholera, in specific circumstances
- Tick-borne encephalitis for forested parts of central and eastern Europe with outdoor activity
Malaria
Vaccines are not a substitute for prophylaxis for travellers. Prevention has two parts.
Bite avoidance, which is non-negotiable:
- Repellent with DEET 20 to 50 per cent, picaridin, or oil of lemon eucalyptus
- Long sleeves and trousers after dusk, since the malaria mosquito bites at night
- Insecticide-treated bed nets
- Air conditioning or screened rooms
- Permethrin-treated clothing for high-risk travel
Chemoprophylaxis, chosen by destination resistance pattern:
- Atovaquone-proguanil: daily, started 1 to 2 days before, continued 7 days after leaving
- Doxycycline: daily, started 1 to 2 days before, continued 4 weeks after. Causes sun sensitivity and can cause oesophageal irritation if taken without water and lying down
- Mefloquine: weekly, started 2 to 3 weeks before, continued 4 weeks after. Neuropsychiatric side effects in some people, avoided with a history of depression, anxiety or seizures
The most common failure is stopping too early. The post-travel period is part of the course, because the parasite can emerge from the liver after return. Any fever within a year of travel to a malaria area, and especially within three months, needs malaria excluded.
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Traveller’s diarrhoea
The most common travel illness.
Prevention: bottled, boiled or properly treated water; no ice; avoid raw salads and cut fruit from street vendors; fruit you peel yourself; hot, freshly cooked food; hand hygiene; caution with dairy and shellfish.
Treatment:
- Oral rehydration solution is the mainstay. The volume lost is what matters, not the number of episodes
- Loperamide for symptom control in adults, but not if there is fever or blood in the stool
- A standby antibiotic prescribed before travel can be considered for moderate to severe illness, though routine use is discouraged because of resistance and the effect on gut flora
- Seek care for blood in stool, high fever, severe dehydration, or symptoms beyond 72 hours
Flights
- Clot risk rises with journeys over about four hours. Move every two to three hours, do calf exercises, stay hydrated, limit alcohol. Compression stockings for higher-risk travellers
- Jet lag: adjust sleep timing a few days before, get morning daylight at the destination when travelling east, evening light when travelling west, and consider low-dose melatonin timed appropriately
- Ear pain: swallow, yawn, or use a decongestant beforehand if congested. Avoid flying with acute ear infection where possible
- Recent surgery, pneumothorax, severe anaemia, or recent heart attack may require medical clearance before flying
Altitude
Above roughly 2,500 m, altitude sickness becomes relevant: headache, nausea, fatigue, poor sleep, dizziness.
- Ascend gradually. Above 3,000 m, increase sleeping altitude by no more than 300 to 500 m a day, with a rest day every 3 to 4 days
- Climb high, sleep low
- Acetazolamide can aid acclimatisation and is worth discussing
- Descend immediately for confusion, loss of coordination, breathlessness at rest, or cough with frothy sputum, which indicate high altitude cerebral or pulmonary oedema and are life-threatening
- Fitness does not protect against altitude sickness
Insurance, and the clause people miss
Buy travel insurance that explicitly covers medical evacuation and repatriation, which is where the enormous costs sit. An air ambulance can cost more than most people’s annual income.
Two things that invalidate claims routinely:
- Undeclared pre-existing conditions. Declare everything, even if it raises the premium
- Excluded activities. Trekking above a stated altitude, diving, motorcycling, skiing and many adventure sports are often excluded unless specifically added
Check whether the policy pays providers directly or requires you to pay and claim back, because some hospitals require payment upfront.
The medical kit
- Your regular medicines in original labelled packaging, enough for the trip plus extra, in hand luggage, split across bags
- A doctor’s letter for controlled or injectable medicines, since some are restricted or illegal in certain countries
- Oral rehydration salts
- Paracetamol
- Antihistamine
- Loperamide
- Antiseptic, plasters, bandage, tape
- Thermometer
- Sunscreen and insect repellent
- Rehydration-friendly items for long journeys
- Any standby antibiotic prescribed for you
- Condoms
- A copy of prescriptions and vaccination records, on paper and on your phone
Check medicine legality at your destination. Some common medicines, including certain painkillers, sleep aids, ADHD medicines and strong cough preparations, are controlled or prohibited in some countries, with serious consequences.
After you return
Tell any doctor you see in the following year where you have travelled. Several travel-related infections present weeks to months later, and the travel history is what points to the diagnosis.
Seek care for fever, persistent diarrhoea, unexplained weight loss, skin lesions that are not healing, or jaundice after travel.
The short version
Book a travel consultation six to eight weeks ahead, because vaccines need lead time and yellow fever needs ten days before arrival. Finish malaria tablets after you get home, not when you land. And read the insurance policy for pre-existing conditions and excluded activities before you need it rather than afterwards.