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2017 HCHB_digital

Travel Health (including

Travel Health (including Vaccinations) With some forward planning and sensible precautions, New Zealanders can reduce their risk of getting sick while overseas. Medicines Medicines should only be taken overseas if they are for a customer’s personal use, or the personal use of someone travelling with them. All medicines should be left in their original packaging, and a note from the prescriber explaining what the medicine is for, together with a copy of the prescription (if applicable) should be carried. Since some medicines may not be legal in certain countries, customers should check with the Embassy or High Commission of that country before departing. Customers should also be wary of purchasing prescription medicines over the counter overseas since counterfeit or substandard products are rife. Mosquito-borne illnesses Several life-threatening illnesses are transmitted by mosquitoes and travellers need to be aware of which ones they may be at risk from during their trip. Malaria is more common in Central and South America, Africa, Asia, Indonesia and Eastern Europe. Symptoms occur anywhere from seven days to one year after infection and include fever and flu-like illness, chills, headache, muscle aches and tiredness. Customers should consult with a doctor aware of current, country-specific, anti-malarial recommendations, as these are always changing. If anti-malarial tablets are prescribed, these need to be taken exactly as directed, and precautions also taken to avoid getting bitten (see also Bites and Stings). Dengue fever is a mosquito-borne viral illness that has seen a dramatic rise in incidence in tropical and subtropical parts of the world in the past few decades. Outbreaks have been reported in Burkina Faso, Egypt, Fiji, Hawaii, Queensland, Samoa, Tonga, and Uruguay in the past three years. Symptoms of dengue fever are usually mild and flu-like and include a high temperature, headache, pain behind the eyes, joint pain, muscle and bone pain, rash and mild bleeding such as nose bleeds. Some people are at risk of developing severe dengue which can be fatal without immediate medical attention. Symptoms of severe dengue include a decrease in temperature (below 38°C), severe abdominal pain and persistent vomiting, rapid breathing, bleeding gums and blood in vomit, fatigue, and restlessness. Several dengue fever vaccines are in development. The first, Dengvaxia is approved for use in Brazil, Mexico and the Philippines but has limited availability elsewhere. Travellers must still protect themselves from mosquito bites during the day and night as the vaccine is only 60% effective against dengue; however, it does prevent more than 80%–90% of severe cases. Zika is another mosquito-borne viral illness that is becoming more prevalent. The 2016 outbreak that started in Brazil rapidly spread to other tropical and sub-tropical countries. Zika is typically a mild disease; four out of five people experience no symptoms. The remainder develop a low-grade fever, headache, a rash, joint pain and conjunctivitis. Hospitalisation is uncommon and symptoms usually resolve within a week. Significantly, outbreaks have been associated with an increase in the number of cases of Guillain-Barré syndrome, and a twentytimes higher rate of microcephaly (abnormally small head, incomplete brain development) in babies born to mothers infected with Zika. Other mosquitoborne illnesses include chikungunya and Japanese encephalitis. Vaccinations Advise customers to see their doctor or travel vaccination clinic ideally eight to 12 weeks before departure to discuss what vaccines they will need and to allow time to begin the course before their departure. Whether vaccinations are required or not depends on age and: • duration of visit and planned activities (eg, cycling, caving, trekking) • how the person plans to travel (eg, car, bus, safari truck, on foot) • if they are a woman who is pregnant or breastfeeding • long-term health conditions (eg, asthma, diabetes) or regular medicines • possible contact with animals and type of accommodation • previous vaccinations (including completion of childhood immunisations). Most travel vaccinations are not free and can cost from $20 to over $250 per dose. Yellow fever vaccinations can only be given by an approved vaccination centre which will issue an International Certificate of Vaccination, which certain countries require before entry is granted. Commonly encountered diseases for which vaccinations are available, are summarised in the table. Because no vaccine guarantees complete immunity, good hygiene and self-protection measures (eg, applying insect repellent, safe-sex) should still be practised. Traveller’s diarrhoea Diarrhoea affects over half of all travellers. Causes are numerous including changes in food or drinking water, bacteria, viruses or other microbes (eg, E. coli, rotavirus, Giardia). Treat with electrolyte solutions to replace fluids lost through PHARMACY TRAVEL ESSENTIALS Category Examples Comments Vaccines Other products [PRESCRIPTION MEDICINE] – except in the form of an oral liquid when sold in a pharmacy by a registered pharmacist eg, Dukoral eg, MicroCleanz eg, 1Above, No Jet Lag eg, Blis K12 Travel Guard, Colloidal Silver Oral vaccine. Provides approximately 85% protection against Vibrio cholerae and at least 50% protection against enterotoxigenic E. coli. Follow recommended algorithm to assess customer suitability. Hand sanitisers may be used if hygienic hand washing facilities are unavailable. Products are available that may help alleviate the symptoms associated with jet lag. Other products may help support our body's natural immune defence system. @PharmacyToday. A part of your everyday. New Zealand’s only e-newsletter designed specifically to provide a news snack for pharmacy. With links to PharmacyToday.co.nz you’re only a click away from the full story. Page 152 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Vaccinations to Consider for Travellers Disease Transmission Illness effects Protective effect Countries where prevalent (not all inclusive) Chickenpox (varicella) a Virus transmitted through airborne droplets Generally mild, with a rash. Serious complications rare 10–20+ years Common in countries with low vaccination rates Cholera Bacteria transmitted through contaminated Acute, profuse, watery diarrhoea and dehydration 6 months–2 years Endemic in much of the developing world water and food Dengue b Mosquito-borne virus Generally mild and flu-like but severe dengue can be fatal Unknown (2+ years) Common throughout tropical and subtropical countries Influenza Virus transmitted through infectious airborne droplets Flu symptoms which can be fatal in certain groups of people 1 year (since virus changes) Worldwide Hepatitis A Hepatitis B a Japanese B encephalitis Measles, Mumps, Rubella a Exposure to sewerage-contaminated water, ice, shellfish, or uncooked, unpeelable fruits, vegetables or other foods Contact with blood or blood-derived fluids, contaminated needles, unprotected sex Viral infection of the liver – fever, anorexia, abdominal discomfort, jaundice. Not associated with chronic or long-term infection Viral infection of the liver – fever, anorexia, abdominal discomfort, jaundice. Can become chronic Vaccine: 20+ years Lifelong Common throughout the developing world South-East Asia, Africa, Carribean Mosquito-borne virus Only 1:250 infected people develop encephalitis symptoms 2–3 years Most of Asia especially rural agricultural regions where flooding irrigation is used Direct contact with infectious droplets, sometimes airborne Measles: Rash, fever, cough, sometimes severe complications Mumps: Swelling of salivary glands, sometimes severe complications and infertility Rubella: Can cause birth defects in pregnant women 15+ years Common in countries with low vaccination rates Meningococcal disease Direct contact Fever, headache, nausea, vomiting. Can be fatal 2–3 years Sub-Saharan Africa, Haj pilgrims Epidemic in New Zealand 1991–2004 Poliomyelitis a Virus transmitted by faecal–oral or oral route Most infections asymptomatic, but in some people acute paralysis, respiratory failure, and rarely death can result 10+ years Low incidence worldwide due to vaccination Rabies Animal bite that inoculates virus into wound Incubation period of 1–3 months after which no treatment is effective. Delirium and convulsions followed by coma and death Tetanus/Diphtheria/ Pertussis a Tuberculosis (BCG) Traveller’s diarrhoea Tetanus: Bacteria transmitted usually through contaminated wounds though has occurred during clean surgical procedures Diphtheria: Raw milk or dairy products Pertussis: Contact with respiratory droplets Usually airborne spread of bacilli through coughing or prolonged sharing of same air space. Can be transmitted through unpasteurised milk from infected cattle Can be due to changes in food or water or microbes (eg, bacteria, virus, protozoa) Tetanus: Muscle rigidity and painful spasms, sometimes fatal Diphtheria: Bacteria causes membrane to form over mucous membranes. Can be fatal Pertussis: Severe cough, sometimes serious complications Latent TB is asymptomatic. Active pulmonary TB causes cough, fever and weight loss Dehydration caused by excessive diarrhoea and vomiting can be very debilitating and even fatal 1–10+ years Found in many parts of the world. Risk highest with unprotected outdoor exposure 10–20+ years Common in countries with low vaccination rates Long for miliary and meningeal forms. Variable for pulmonary disease Vaccination unreliable in adults. Not generally recommended since treatment is usually effective 3+ months Although traveller’s diarrhoea is common, routine vaccination is not considered necessary unless under the advice of a health professional Typhoid Bacteria transmitted through unboiled water, or Persistent very high fever, sometimes rash, can be fatal 2–3 years South-Asia, Central America uncooked or poorly reheated foods Yellow fever c Virus transmitted through mosquito bites Can cause severe hepatitis and haemorrhagic fever 10 years Parts of Sub-Saharan Africa (eg, Guinea, Kenya) and South America (eg, Columbia, Brazil). Some countries require International Certificate of Vaccination for entry Protective effect of vaccination varies according to information source. a. Included in NZ immunisation schedule; b. Limited availability internationally (not currently New Zealand); c. Must be given at an authorised yellow fever vaccination centre. diarrhoea and vomiting; with antidiarrhoeal medicines (eg, loperamide); and if necessary, antibiotics (but only under medical supervision). See Diarrhoea for OTC product information. Initial assessment If you know or suspect a customer may be travelling overseas, offer to help them put together a first-aid kit and recommend other OTC travel-related essentials (such as flight pillows, sunscreen and insect repellent). Check they have had a recent dental check-up and sought advice about which vaccines they may need. Encourage travellers going to less developed parts of the world to use self-purified or properly sealed bottled water for drinking and cleaning teeth, and to avoid ice. Hands should also be washed thoroughly before eating and after toileting or hand sanitiser used if washing facilities are unavailable or suspect. Foods should be cooked thoroughly and served piping hot. Avoid vegetables or fruits that cannot be peeled and raw seafood and shellfish. Customers should also be directed to the New Zealand Government’s official source of advice for New Zealanders travelling or living overseas (www. safetravel.govt.nz) which contains information on everything from passports and visas to weather warnings and recommendations about what countries NOT to visit. Travellers can also register their travel plans on the site. Information about the association between venous thromboembolism (blood clots) and air travel can be found in the Varicose Veins and Support Stockings chapter). Page 153

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