Travel health: Beyond the booking

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Summer is nearly upon us and for many it is time to start looking forward to a holiday — an opportunity to de-stress and enjoy spending quality time with loved ones. But booking a holiday is just the beginning.

When preparing to travel, there is a lot more to think about than just summer attire, especially if the holiday involves a flight. Community pharmacy teams can make a real difference here, by helping customers to become ‘holiday ready’ from a health point of view. This article provides an overview of some of the health issues people should be thinking about before jetting off into the sun. 

Taking medicines abroad

It is essential that patients who are prescribed regular medication take sufficient supplies for the duration of their holiday, plus extra for any delays, damage or losses. All medicines should be kept in their original packs with the attached dispensed labels, and these should be carried in hand luggage with extras stored in a suitcase.

Travellers need to recognise that the legal status of some medicines, including OTCs, can vary between countries. Additionally, some items, such as insulin, require careful storage during travel and may freeze in the aircraft hold or overheat during a long hot car or bus journey. Pharmacists should stock travel accessory bags that are specifically designed to carry insulin.

The Government allows patients to carry essential medicines and equipment (including needles, syringes, insulins and inhalers) through airport security in hand luggage.

This applies to liquids greater than the normal 100ml restriction, provided the patient has the necessary documentation (usually a letter) from their doctor or specialist. It is recommended that travellers contact the airline in advance of travel to make appropriate arrangements if they need to fly with oxygen, insulin or other injectable medicines.

A further consideration is that regulations are likely to be different in other countries when patients travel with controlled drugs. The Home Office provides a list of recognised controlled drugs, which includes schedule 2 and 3 drugs (see Travel Health Resources).

If an individual is going abroad for three months or longer, they will need an export licence prior to transporting set quantities into or out of the UK. Patients do require proof that the drugs have been prescribed for them, either a letter from their GP or their repeat prescription slip. Further details on the requirements for different countries are available from the International Narcotics Control Board (incb.org).

In general, it is definitely worth checking with the relevant embassy prior to travel to understand which restrictions apply. Failure to provide the necessary details may result in a fine or, even worse, potential imprisonment.

Vaccinations

Prior to travel, holidaymakers should check with their local GP surgery that they are up to date with the vaccines and boosters they may need.

As most vaccinations should be administered four to six weeks before travel, this is worth discussing with patients who are planning a trip abroad. The vaccinations required will vary depending on the destination and websites such as travelhealthpro.org.uk provide current advice. Pregnant women from 16 weeks’ gestation should have a booster of pertussis vaccine, even if they are not travelling.

Malaria prevention

Although malaria is uncommon in the UK, in 2023 there were 2,106 imported cases, which was 26 per cent higher than in 2022. In most cases, the malaria was due to inadequate adherence to chemoprevention. Pharmacists should therefore emphasise the importance of prophylactic treatment to those travelling to a country in which there is a risk of contracting malaria.

Insect bites and stings

In addition to malaria, mosquitoes can transmit dengue and yellow fever, chikungunya and the Zika virus. Insect repellents minimise the risk of being bitten and help to reduce the transmission of these diseases. The most effective repellents contain DEET (diethyltoluamide), which is available in concentrations ranging from 20 to 50 per cent, with the higher concentrations providing longer protection.

DEET can be used from two months of age and by pregnant women. Some people may prefer to avoid it in favour of products containing picaridin, which is odourless, or natural ingredients such as lemon eucalyptus extract, which contains PDM (p-menthane-3,8-diol). Alternatively, sprays containing permethrin can be used to provide a long-lasting insect repellent effect on clothing. Pharmacies might also want to consider stocking mosquito nets.

Despite the best prevention intentions, bites and stings are often an unavoidable consequence of travelling. Customers might like to purchase treatments such as antihistamines or crotamiton and hydrocortisone cream before they travel.

Sun protective clothing

Clothing can have a sun protective effect. The Ultraviolet Protection Factor (UPF) is a measure that indicates how much UV radiation (both UVB and UVA) a particular fabric allows to reach the skin. The higher the UPF, the greater the degree of protection. For example, a UPF50 fabric blocks 98 per cent of the sun’s rays. The UPF of clothing depends on a range of factors, such as the colour and type of the fabric.

For instance, darker and brighter colours are better at absorbing UV radiation. Similarly, densely woven cloth like denim and canvas is more protective than thin or loosely woven cloth. It is easy to get some idea of a fabric’s sun protective value by just holding it up to the light.

If you can see through it, it is more likely to allow UV radiation to penetrate through and reach the skin and is therefore less protective. Using a wide brimmed hat can also protect against the sun.

Motion sickness

Motion sickness tends to occur due to repeated movement when travelling in cars, boats or planes, leading to nausea and vomiting. Although general advice such as sitting in the front of a car or the middle of a boat can help, drug treatment in the form of antihistamines and travel bands is preferred by many.

Antihistamine use for travel sickness has been recommended for decades, although evidence has been conflicting regarding efficacy. A 2022 Cochrane review concluded that the drugs were superior to placebo, although there was an increased risk of sedation. There is much less evidence of effectiveness for antihistamines in children and even weaker evidence for other treatments, such as scopolamine.

Eye protection

Protecting the eyes from the sun is just as important as protecting the skin. Exposure to sunlight can cause photokeratitis. This painful condition is essentially ‘sunburn’ of the eyes and is the same problem encountered by welding arcs or ‘welder’s flash’.

An extreme form of photokeratitis is snow blindness, which can occur during skiing holidays because of intense reflection of sunlight from snow and ice. Fortunately, photokeratitis normally resolves within a few days.

The risk of photokeratitis can be significantly reduced by using adequate protection in the form of sunglasses that protect against UVA and UVB. Check that sunglasses have a CE mark that complies with EU safety and environmental requirements.

Flight socks

Prolonged immobility, dehydration and cabin pressure changes during a flight will contribute towards venous stasis, hypoxia and hypercoagulability. Together, these factors increase the risk of a venous thromboembolism (VTE).

It has long been recognised that there is an association between extended travel and VTE.

A review of studies in 2022 concluded that there was a 26 per cent higher risk of a VTE for every two hours of air travel; this relationship really becomes significant after four hours of air travel.

However, it is important to recognise that the absolute risk of a VTE is quite low in the general population. It will depend on the duration of the flight as well as the presence of specific risk factors, such as a previous VTE, thrombophilia (increased risk of blood clots), pregnancy and oral contraceptive use.

Flight socks (essentially graduated compression stockings) are often recommended as a preventative strategy. While the quality of evidence demonstrating a benefit from these socks is generally low, there does seem to be a prophylactic effect, as long as the compression is between 15 and 30mmHg.

Other simple measures, such as performing leg exercises, walking, avoiding alcohol and staying hydrated, can all help to reduce VTE risk.