The recentE.colioutbreak in Germany and sharp rise in measles cases on the continent proves that advance holiday health planning and preparation is essential.Dr Caroline Hirdfrom the Health Protection Agency (HPA) offers some timely advice for travellers
_ When planning an overseas trip, particularly to tropical destinations, a visit should be made to a health advisor well in advance1 (at least a month)
_ Vaccinations depend on the travel destination and length of trip and can include: the MMR (in light of the measles outbreak in France), hepatitis A vaccination, yellow fever vaccination, meningococcal ACWY vaccination, rabies vaccination (especially if handling animals) and BCG (if under 16 and visiting an high prevalence area for more than 3 months). Recommendations by country are given on the NaTHNaC website
_ Get malaria prophylaxis if travelling to an endemic region
_ Buy medicines and first-aid kits in advance and ensure you carry a letter from your doctor explaining why you need to carry any emergency medicines with you (such as adrenaline pens and asthma medication)
_ Find out where your nearest hospital will be to you on your holiday prior to travelling, especially if you're with children or one of your party is pregnant
_ Get adequate health insurance
Recent events have proven a "laissez-faire" approach to holiday planning is potentially risky health-wise. Sensible families are increasingly relying on health professionals to provide them with topical advice and information on potential risks, such as diseases transmitted by the faecal-oral route, contaminated food and water, animals and insect bites.
Gastrointestinal infections Gastrointestinal infections range from a mild, short lived and self-limiting illness to life-threatening disease requiring prolonged hospitalisation. Even when mild, they can ruin a holiday and typically occur when eating inadequately prepared food, or from poor hand hygiene
- there are simple steps you can take to avoid infection, and limit its spread if someone develops symptoms.
E.coli contamination from animals
Visiting a farm, or camping in a farmer's field, can be a very enjoyable and educational experience for adults and children alike. However, visitors need to be aware that animals act as reservoirs for a number of infectious organisms including E. coli O157 and cryptosporidia. While E. coli O157 doesn't cause illness in animals, it can cause severe disease in humans2. Young children are particularly susceptible to haemolytic uraemic syndrome, the serious complication of E. coli O157, which leads to renal failure, so particular care should be taken to prevent them from putting anything in their mouth that could be contaminated with animal faeces, including their thumbs.
Soap and water should be used to wash hands after contact with animals, or touching surfaces on a farm, and always before eating. Hands should then be thoroughly dried. Alcoholic hand gels are not effective in killing organisms such as E. coli O157 and cryptosporidia and should not be used as an alternative to handwashing3. They may, however, provide extra benefit if used after handwashing with soap and water. There is specific guidance available for nursery nurses and schools planning trips to open farms included in the advice to farmers produced by the Health and Safety Executive4. The HPA has also produced advice for the public on avoiding infection from animals when visiting farms5.
E.coli contamination from food
Undercooked foods, such as beef burgers, can be contaminated with E. coli O157. Although the meat is not intrinsically infected, as is the case in campylobacter, the carcass can become contaminated with faecal matter after slaughter. Mincing and mixing beef can lead to infectious organisms being present in the interior of foods such as beef burgers, where they will survive inadequate cooking6.
Campylobacter contamination from food
Campylobacter is the most common bacterial cause of gastrointestinal infection reported to the HPA. Each year there is a sharp increase in cases in late spring, the reason for this is not fully understood7. This organism is present in raw poultry and is common in other raw meat8. Cooking kills campylobacter, rendering it harmless to humans. This is the reason that chicken must be cooked properly before consumption and checking, either by cutting and direct inspection or by using a temperature probe, is essential. Barbequed food also poses a risk as the heat is not usually uniform across the cooking surface, so cooking times may vary considerably. Cross-contamination during food storage and preparation can also lead to infection. Cooked foods should be kept away from raw foods and raw foods should be stored below cooked and ready to eat foods in the fridge. Implements such as knives that have been used to cut raw chicken must be washed and dried adequately before being used to prepare foods, such as salads, that are not cooked before consumption.
Tap water is not safe to drink in all parts of the world and travellers should not assume that it is. If water is not considered safe, travellers should not add ice to drinks or brush their teeth using tap water; boiled, bottled or chemically filtered water should be used instead. However travellers should be alert to fake bottled water and avoid products that may have been tampered with. Water from rivers or steams should not be drunk. Further guidance on water purification is available from the NaTHNaC website9.
Insect and animal bites
There are many serious diseases transmitted by biting insects, including malaria and Lyme disease. Avoiding bites is important; less bites means lower likelihood of exposure to insect-born diseases17. Bites can be avoided by wearing appropriate clothing, which is a loose fitting long-sleeved shirt and long trousers, tucked into socks in tick-infested areas. Insect repellants containing DEET are the most effective, and are very safe if manufacturers' instructions are followed. Several strengths are available, up to 50 per cent DEET are recommended and can be used by pregnant or breastfeeding women and for babies over two months. In tropical destinations, effective air conditioning usually reduces the number of insects in your room. If air conditioning is not available insecticide impregnated mosquito nets should be used. Many insects bite between dusk and dawn, so staying indoors during this time will help to reduce the number of bites.
Lyme disease is an infection caused by spiral shaped bacteria called Borrelia burgdorferi and is transmitted to humans by bites from infected ticks. It causes a distinctive rash which spreads from the site of the tick bite, and if untreated nervous system, joint or cardiac complications can develop15. There are estimated to be between 2,000 and 3,000 cases of Lyme disease each year and in 2010 there were 953 laboratory confirmed cases reported to the HPA16. The majority of these were acquired in the UK rather than abroad.
Ticks are tiny spider-like creatures, the size of a poppy seed, commonly found in woodland and heathland areas. Cases of Lyme disease are often acquired through recreational activities including walking, hiking and mountain-biking. Areas where the infection has been acquired in the UK include popular holiday destination such as Exmoor, the New Forest, the South Downs, parts of Wiltshire and Berkshire, Thetford Forest, the Lake District, the Yorkshire Moors and the Scottish Highlands15. Studies of ticks in the UK show that only a small proportion carry Borrelia burgdorferi, so tick bites do not necessarily lead to illness.
Ticks attached to the skin should be promptly removed with tweezers or special tick removers to reduce the risk of infection17. Frequent inspection for ticks should be carried out while in high-risk areas, taking care to check in skin folds. Particular care should be taken with children's head and neck areas, including the scalp. To remove any attached ticks, grasp the tick near to the skin and steadily pull it out, taking care not to crush its body or squeeze its stomach contents into the bite site.
Malaria is a serious and potentially life threatening illness caused by the protozoal parasite, Plasmodium. It is transmitted by the bite of the female Anopheles mosquito18. The number of cases in the UK has increased by almost 30 per cent since 2008, with 1,761 cases reported in 201019. Around 40 per cent of these cases had visited Nigeria or Ghana, while 10 per cent had visited India. Malaria is an almost entirely preventable disease when precautions are taken. Advice should be sought prior to travel regarding the risk of malaria, precautions taken to avoid bites (see above) and appropriate chemoprophylaxis. People living in Britain who are making a return visit to the country in which they were born or grew up in are not immune from malaria and should take precautions. The same clearly applies to children born and living in Britain who visit friends or relatives in malarial areas. More advice on malarial prevention is available from the HPA and NaTHNaC.
Rabies is an acute viral infection that causes progressive viral encephalitis, and once clinical symptoms develop it is nearly always fatal18. Transmission to humans occurs through exposure to saliva of an infected animal via bites, scratches, licks or other contact with saliva (ie: feeding animals). Dogs are the main transmitter to humans, but all mammals are susceptible. Rabies is preventable by vaccination, so a course of rabies vaccination may be recommended for visits of more than a month to some countries. If bitten or scratched in a country where rabies is present, clean the wound thoroughly with soap and plenty of water and seek medical advice immediately . If a person returns to the UK without having received treatment, they should still seek medical advice, even if the bite was weeks before. Advice regarding postexposure treatment is available in the Immunisation Handbook21 or from the HPA.
Health Protection Agency (HPA):www.hpa.org.ukThe HPA was established in 2003 to protect the public from threats to their health from infectious diseases and environmental hazards.Under the proposed changes contained in the Health and Social Care Bill, the HPA will become part of Public Health England in 2012.The HPA website provides a valuable source of information to health professionals and the public. National Travel Health Network and Centre (NaTHNaC)www.nathnac.org/travel/index.htmThe National Travel Health Network and Centre (NaTHNaC) is funded by the HPA to provide up-to-date advice for the travel health information for the public and health professionals.
1.HPA.Travel health advice http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733830852 [Accessed May 2011]
2.HPA.Vero cytotoxin-producing Escherichia coli (VTEC) http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/EscherichiaColiO157 [Accessed May 2011]
3.Gormley FJ, Little CL, Chalmers RM et al. Zoonotic Cryptosporidiosis from petting farms, England and Wales, 1992-2009 [letter]. Emerg Infect Dis. 2001 Jan; [Epub ahead of print]
4. Health and Safety Executive.Agriculture Information Sheet No 23(rev2): Preventing or controlling ill health from animal contact at visitor attractions (includes teachers' supplement). 2011 http://www.hse.gov.uk/pubns/ais23.pdf Accessed May 2011]
5.HPA.Avoiding infection on farm visits. 2011 http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1270122184581 [Accessed May 2011]
6.Hawker J, Begg N, Blair I et al.Communicable disease control handbook (2nd edn.) Blackwell Publishing, 2005
7.HPA.Campylobacter infections reported by month, England and Wales, 1989-2008.http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Campylobacter/EpidemiologicalData/ campyDataEwMonth1989to2008/ [Accessed May 2011]
8.HPA.Campylobacter - frequently asked questions. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Campylobacter/GeneralInformation/ campyCampylobacterFAQs/ [Accessed May 2011]
9. NaTHNaC. Food and water hygiene. 2011 http://www.nathnac.org/travel/misc/travellers_food.htm [Accessed May 2011]
10.HPA.Advice if you are a patient or care for a patient. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/EscherichiaColiO157/PatientCarer/ [Accessed May 2011]
11.HPA. Guidance on infection control in schools and other childcare settings. 2010 http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1203496946639 [Accessed May 2011]
12.World Health Organization Regional Office for Europe.Vaccines and Immunization Measles outbreaks across Europe show no sign of slowing. 2011 http://www.euro.who.int/en/what-we-do/healthtopics/ disease-prevention/vaccines-and-immunization/news/news/2011/04/measles-outbreaks-acrosseurope- show-no-sign-of-slowing [Accessed 14 April 2011]
13.Department of Health. Chapter 11 Immunisation schedule - updated 11 January 2011 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_079917 [Accessed May 2011]
14.HPA.Going to Camp this summer? Avoid the misery of the three Ms: measles, mumps and meningitis. 2009 http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1271257097761 [Accessed May 2011]
15.HPA. Frequently asked questions about Lyme borreliosis http://www.hpa.org.uk/Topics/Infectious/Diseases/InfectionsAZ/LymeDisease/GeneralInformation/lym010FAQ [Accessed May 2011]
16.HPA. Lyme disease. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/LymeDisease/ EpidemiologicalData/ [Accessed May 2011]
17. NaTHNaC. Insect and tick bite avoidance. 2010 http://www.nathnac.org/travel/misc/travellers_ mos.htm [Accessed May 2011]
18.Hayman DL (Editor).Control of communicable disease manual (19th edn) American Public Health Association, 2008
19.HPA.Malaria cases up almost 30 per cent in two years as it's revealed most cases haven't taken antimalaria tablets. 2011 http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2011PressReleases/ 110425Malaria/ [Accessed May 2011]
20.HPA. Rabies: Frequently asked questions. 2011 http://www.hpa.org.uk/Topics/InfectiousDiseases/ InfectionsAZ/Rabies/GeneralInformation/ClassicalRabiesFAQs/ [Accessed May 2011] 21.Department of Health. Chapter 27 Rabies in Immunisation against Infectious Disease. 2006 (Updated chapter available online) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_079917 [Accessed May 2011]