TRAVEL PACK.

Which medicines might you wants to take with you?

The Travel Doctor will offer you a prescription for a travel pack. You simply take the script the the pharmacy of your choice.

Here’s our ABC approach to travel scripts:

A for Antibiotics.
B for Basic Medicines.
C for Comprehensive written advice.

The Travel Pack is tailored to your requirements. These are the sorts of things that are taken into account:

Your destination
The type of holiday or experience
How self-sufficient you want to be

THE SCRIPT.

The following prescribed medications may be prescribed by the travel doctor when required:

Loperamide (eg. Gastrostop).
Azithromycin 500mg tablets (Comes in a pack of 3).
Tinidazole 500mg tablets (Comes in a pack of 4) – for higher-risk travel.
Acetazolmide – consider for altitude sickness
Antimalarials – very important!

Melatonin may be helpful for Jeg lag.

PREVENTING TRAVELLER’S DIARRHOEA.

Good food hygiene is important anywhere, especially in less developed countries. At-risk destinations include our close neighbours such as Bali, Thailand, Fiji, China and India. Unfortunately, Gastro is really extremely common and can upset your holiday. So try to be sensible! The tradition advice is pretty useless – ‘Boil it, cook it, peel it or forget it…. easy to remember, impossible to do.”

What can you do to stay healthy?

Hand hygiene is important. Wash your hands with soap and water. Use an alcohol-based sanitiser
Do not drink tap water. Brush your teeth with clean water from a bottle. Ice in drinks is another source of infection.
Hot drinks that are made with tap water should be very hot. Ask for your tea or coffee to be made “with boiling water.” Check the drink is steaming before you drink it.
Food should be hot. Avoid eating salads, uncooked veg, fresh fruit juice & milk. Eating fruit that you have yourself peeled is fine. Don’t eat under-cooked meat or shellfish.

Surveys show that most travellers break these rules within a few days of arrival.

Holidays are about trying out new experiences. But at least try to avoid street vendors, and use bottled water!

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TREATING TRAVELLER’S DIARRHOEA.

Mild diarrhoea is one or two unformed bowel motions without any other symptoms over 24 hrs. Take two loperamide tablets straight away, and then one tablet after each loose bowel motion – up to a maximum of 8 in 24 hours.

Antibiotics have been proven to be effective for traveller’s diarrhoea.

However, a study of antibiotic use in traveller’s diarrhoea published in 2015 showed the potentially “bad” effect of antibiotics on bowel bacteria. Of 430 random travellers from Finland , 21% returned with resistant bacteria in their faeces. However, 37% of those who returned after a course of antibiotics for traveller’s diarrhoea were colonised with the same resistant bacteria.

Therefore, it is reasonable to hold off antibiotics until you need them. When diarrhoea persists more than 24 hrs, you may wish to start the antibiotic. Start antibiotics earlier if there are cramps, mucus or blood.

Azithromycin is the main antibiotic used for traveller’s diarrhoea. Take one tablet each day for up to 3 days. Stop the Azithromycin early if the diarrhoea has gone away. You may continue to take Loperamide during this time, but stop loperamide if you have a high fever with bloody diarrhoea.

When diarrhoea is moderate to severe to start with then you can start the Azithromycin straight away. As a guide, you can start the antibiotic after having at least 2 unformed bowel motions in 24 hrs with another symptom such as nausea, cramps, vomiting, or blood in the bowel motions.

A second-line antibiotic occasionally used is Tinidazole which covers less common causes of diarrhoea such as Giardia. Tinidazole is taken as four tablets in a single dose (in one go). You’d normally want to get a stool test done to identify the cause but this isn’t always possible.

Please read the information sheet that comes with the medication to check for any interactions or other issues such as children & Pregnancy.

Rifaximin (®Xifaxan) is another option for travellers. The dose is 200mg three times per day for three days. This antibiotic was approved in Australia in 2016 for Traveller’s diarrhoea.

Rifaximin is an attractive option because the antibiotic is not absorbed into the body. The downside is that Rifaximin is unlikely to be as effective against full-blown bacterial gastroenteritis as other antibiotics. For example, Rifaximin is not effective against Salmonella, Campylobacter or Shigella. Therefore, Rifaximin should not be used when there is severe illness, fever, or blood in the bowel motions.

Finally, don’t forget about rehydration. A recent study of gastroenteritis in young children showed that “Dilute apple juice is a good alternative to electrolytes for children with gastroenteritis.” The children in the study presented to an emergency department with gastroenteritis and had “minimal rehydration.” The children were age 6 months to 5 years and given either half strength apple juice or standard electrolytes.

TRAVELLER’S DIARRHOEA ON RETURN TO AUSTRALIA.

By the time you get back, you’ll likely to need a stool test arranged by your doctor. The sample is tested for bacteria such as Campylobater, Salmonella, Shigella, and parasites such as Giardia and Amoebic Dysentery. Modern DNA testing has a rapid turnaround, and often results are available by the next day

Giardia may cause prolonged diarrhoea, smelly bowel motions, bloating or excessive wind. Amoeba tends to cause more in the way of abdominal pain, fever and bloody stools.

Diarrhoea can persist even after the infection has gone and other causes have been excluded. This is called “post-infectious gastroenteritis” and occurs in up to 30% of people after an episode of traveller’s diarrhoea. It might be worth excluding lactose in the diet, or trying a low FODMAP diet that’s used in IBS.

A review of 65 returned travellers who returned to Australia with prolonged diarrrhoea found that:

47% were caused by a parasite
8% were caused by bacteria or virus
12% were post-infectious gastroenteritis
10% were caued by other pathology such as inflammatory bowel disease and 1 case of bowel cancer

This confirms that parasites are a common cause of prolonged diarrhoea. However, bowel diseases unrelated to travel also need to be considered.

JET LAG & MELATONIN.

“East is Least, West is Best”

Travelling East:

Is harder because the clock is “ahead” of you.
Bedtime at the destination will effectively be earlier than normal.
So a 6 hour time difference is like suddenly going to bed early at 4pm!
You may therefore have trouble falling asleep.
Seeking bright light in the morning may help.
Melatonin may help when taken a little before bedtime.

Travelling West:

Is easier because the clock is “behind” you.
Bedtime at the destination will effectively be later than normal.
So a 6 hour time difference is like going to bed late at 4am!
You may therefore go to sleep quickly, and probably lie in – That’s what travelling West is like.
However, you may have trouble staying asleep on arrival and will wake early.
Seeking bright light in the evening helps.
Melatonin may help shift the body clock when taken in the later part of the night.

TRAVEL MEDICATION FAQS.

How Can I get Melatonin?

In Australia Melatonin requires a prescription.

The most widely available formulation in Australia is 2mg modified release (MR). The travel doctor will most likely prescribe this formulation.

Doses up to 5mg appear to be similarly effective but sleep onset may possibly be quicker with the higher dose. The MR version will last throughout the night.

How do I take Acetazolamide to prevent Altitude Sickness?

Acetazolamide is not licensed for the prevention of altitude sickness although it can be helpful.

The usual dose recommended by the travel doctor is 1 x 250mg tablet taken twice per day.

It’s generally a good idea to try it out for a couple of days before you leave to check for side effects such as tingling or numbness.

You may be advised to start 2 days before before ascent, continuing for 1- 2 days after you’ve reached your highest altitude.

Altitude sickness may be fatal. You will need to descend immediately if you are experiencing significant symptoms.

Are The Scripts prescribed under Medicare?

The prescriptions are non-medicare.

However, most people will pay the same for non-medicare or private scripts.

What is The cost of The travel Scripts?

Let’s take an example script. This gives you an idea of typical pharmacy costs:

Pack of 3 x Azithromycin: Around $15
Pack of Imodium: Under $10
Tinidazole: Under $20

What advice do you have for carrying my own prescription medication?

Take sufficient quantities! Most repeat scripts last just one month. For longer term travel you may be eligible for a “regulation 24” prescription from your doctor.
Carry medication in your hand luggage.
Check the medication is legal for the country you are travelling to! For example, some cough and cold medicine, opiates, and stimulants used to treat ADHD may be restricted.

You may need to ask for a letter from your doctor, and bring the original prescription.

Can I use the Antibiotic for something like a chest infection?

You should see a doctor before considering taking Azithromycin for anything other than traveller’s diarrhoea. Most infections of the respiratory tract are viral and will not respond to antibiotics.

What else should I carry?

Here are some ideas to jog your memory:

Simple painkillers
Antifungal cream
Compact first aid kit
Insect Repellant
Sunscreen
Disinfectant handwash
Water purification tablets for at-risk travel
Oral rehydration salts

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