Dr Goodyer is director of pharmacy practice research at King's College London, and superintendent of Nomad Travel Pharmacy
This is the first in a series of articles designed to prepare the community pharmacist to play an active, and in some circumstances leading, role in the important area of travel medicine. The aims of the series are to provide the necessary background information to enable pharmacists to provide effective health promotion to the travelling public, to raise awareness of the important issues in travel medicine, to discuss the provision of pharmaceutical and related supplies to various types of traveller, and to define areas where pharmacists can work with other health professionals. This first article provides an introduction to the subject
The discipline of travel medicine has grown in recent years, in parallel with the general rise in tourist travel, to the extent that in the United States it has been given its own name of "Emporiatrics." The history of travel related disease is a long one and can be traced back to ancient times. For instance, it is recorded that the Athenian plague of 430 BC was probably spread via the trade routes. The first attempts at public health to contain travel related epidemics date back to the plagues of the middle ages, where the practice was to detain ships and crews for 40 days, the word quarantine being derived from the Latin for forty. The roots of the study of travel medicine date back to the late 19th century when morbidity and mortality among explorers and missionaries was extremely high. In one study at the time it was revealed that over a quarter of workers had to return due to their own or their families' ill health.1
The risk to an individual's health may have two sources: the presence or increased incidence of diseases at the country of destination (eg, tropical disease) or the hazards of travel and travel related pursuits (eg, travel sickness, environmental problems and accidents). In some cases the absence or poor quality of the local medical facilities can also present a hazard to health. Not to be underestimated is the likely impact of tourists on an over-stretched health system. More recently, travel medicine has tended to include a study of the health implications related to movement of displaced peoples, ie, refugees, into host nations. The general range of health problems related to travel is shown below.
Much in the field of travel health involves preventive medicine, that is, education of the travelling public in ways of minimising the various hazards. For instance, appreciation that many tropical diseases are transmitted by insect vectors encourages the use of methods for bite prevention. Similarly, knowing the ways in which diarrhoeal diseases are contracted will help to define the various steps to be taken regarding food and water hygiene. Pharmaceutical and related supplies would also tend to be "preventive" in nature - these include vaccines, antimalarial tablets, sun blocks, kits containing sterile equipment and chemicals for water purification. The management of medical problems once they occur should also be considered. Certain medicines may be in short supply or of poor quality in the country to be visited and so should usually be purchased before travel.
For many people, the first consideration given to travel health is the planning of any recommended vaccinations, although, as will be discussed later, this does not necessarily represent the group of diseases posing the greatest risk. However, it does bring the traveller into contact with a health professional, usually the practice nurse. The nurse may only have a limited time for screening and advice and, as in other general areas of health promotion, the community pharmacist has an important role to play.
International travel has undoubtedly increased over recent years. For instance, total visits abroad by UK residents rose from 11.8 million per year in 1970 to 31m by 1989. There is also a trend for increased travel to the tropics, with a 15 per cent average annual growth rate (1960-1993) in travel to South East Asia and a 10 per cent growth in journeys to Africa.
That compares with a growth of travel to Europe and the US of just 5 per cent, although these destinations still have by far the largest market share.2
The size and extent of the problem of travel related illnesses has been quite well defined by a number of studies, the largest being carried out in Scotland,3 Finland4 and Switzerland.5 The results are summarised in Table 1.
A number of factors have been shown to increase risk, including the area to be visited, age of the traveller and length of time away. The Swiss study found that 75 per cent of travellers to the tropics had at least one health related problem, although only 5 per cent of these were serious enough to warrant medical attention. The Finnish and Scottish studies mainly consisted of travellers to Spain or North Africa and reported a lower level of health related complaints. Generally, the further south, and in Europe the further east, you go the greater the chances of health related problems. Both the Scottish and Swiss studies confirmed the highest number of problems to be in the 20-29 age group.
A number of studies6-9 have established that the largest cause of death among travellers is related to cardiovascular disease, usually myocardial infarction, and this has been placed at between 35 per cent and 70 per cent of reported deaths. This trend may be partly due an increase in travel by elderly people, although these deaths are not necessarily related to travel per se. Accidental deaths, mostly from motor accidents or drowning, are next most common, accounting for around 20 per cent of deaths. This may be a reflection of the tendency for individuals to undertake activities which are more adventurous and dangerous than they would consider doing at home. Infectious disease accounts for just 1-3 per cent of deaths.
The level of service that a particular pharmacy wishes to provide to the travelling public will vary, depending on the profile of the travellers using that pharmacy, as classified in Table 2. Each category of traveller may have different requirements. Holidaymakers on short trips to westernised destinations, eg, southern Europe, form the greatest proportion of customers to most pharmacies. In this group, advice regarding sun awareness and gastrointestinal infections might be the main areas of concern. Some individuals may also need help with problems connected to air travel or travel sickness. Reactions to bites or stings may also cause problems. Holidaymakers to developing countries, in particular the tropics, eg, sub-Saharan African or south east Asia, will need additional advice relating to disease contracted from biting insects, particularly malaria. Also, for these destinations a vaccination schedule will need to be planned, ideally two or three months before travel. Travellers and backpackers on longer trips tend to be of a younger age group and may be travelling independently or with one of the "Overland" companies. An example of the latter would be a group of 10-20 individuals in trucks on a six month trans-African tour. This type of traveller would be well advised to carry a fairly comprehensive medical kit, perhaps including antibiotics. The overland truck may well have an extensive kit, but individuals are always recommended to have their own supplies. For certain destinations, eg, the Himalayas and the Andes, altitude problems may also need to be considered. Providing a service to an expedition - scientific or exploratory - would probably be outside the remit of most pharmacies. Special considerations regarding medical supplies and climatic conditions are needed in such cases.
The community pharmacist will be involved with three types of activity: