Travel consultation essentials: for departures and arrivals

The pre-travel checklist

The objectives of the first travel consultation are to:¹

1. Establish the traveller’s itinerary and assess any risks that they may be exposed to
2. Provide education to minimise risk and self-manage transient illness
3. Determine any need for vaccinations, malaria prophylaxis and as-required medicines

The following factors determine what should be addressed in a travel consultation:¹

• Date of departure, length of stay and areas to be visited, e.g. rural or urban
• Activities likely to be undertaken
• Accommodation, e.g. hotel, backpackers, camping, staying with locals, cruise ship
• Immunisation history
• Relevant medical history, including previous and current conditions, medicines and allergies
• Any safety or security issues, e.g. weather or conflict
• Prior travel experience, e.g. previous high altitude exposure

Remind travellers that their insurance needs to cover pre-existing conditions and any activities that may be planned, e.g. riding a motor scooter. Policies should be checked for exclusions and to ensure they contain a medical evacuation clause if repatriation to New Zealand is required. Supplementary insurance will be required to cover pregnancy-related complications, including pre-term birth (See: “Travelling during pregnancy”).¹ Online access to medical records via a patient portal can be beneficial if patients do require medical attention while overseas.

Safetravel is a government website that provides up-to-date information for travellers leaving New Zealand, available from: www.safetravel.govt.nz

Assessing a person’s fitness to fly

As a rule, people with unstable medical conditions should not fly,² and caution is required when considering travel to destinations at altitude. A person with a condition such as cardiopulmonary disease may experience an exacerbation due to decreased barometric pressure and partial pressure of oxygen.² The duration of the flight is also relevant when assessing a person’s fitness to fly.²

International airlines have medical units that can be contacted to determine if a passenger requires a medical certificate to travel.² Conditions where this may be appropriate include:

• Cardiovascular disease, e.g. unstable angina or congestive heart failure, recent myocardial infarction or a history of venous thromboembolism (VTE)
• Respiratory conditions, e.g. unstable asthma or advanced chronic obstructive pulmonary disease
• Neurological conditions, e.g. recent transient ischemic attack, seizure or neurosurgery
• Unstable psychiatric illness

People with communicable diseases, such as measles and varicella, are not permitted to fly while they are infectious.²

Air New Zealand may require a medical fitness for air travel form (MEDA) to be submitted to their Aviation Medicine Unit for passengers with a major health condition. A MEDA is required to take medical equipment such as oxygen or continuous positive airway pressure (CPAP) machines on board a plane.

Air New Zealand provides guidance on the submission of MEDA forms, available from: www.airnewzealand.co.nz/assets/PDFs/meda-part-3-doctor-guidelines.pdf

Travelling during pregnancy

Most airlines will allow women with an uncomplicated pregnancy to fly until 36 weeks gestation; later travel may be possible with medical clearance.¹ Evidence of the expected date of delivery may be required.¹ Women with a multiple pregnancy are advised not to fly after 32 weeks gestation.² Most cruise ships restrict travel for passengers beyond 28 weeks gestation, some as early as 24 weeks.¹ Pregnant women travelling by sea may be asked to provide a letter indicating that they are fit to sail and their expected date of delivery.

Precautions for people with insulin-dependent diabetes

People with insulin-dependent diabetes should have a letter stating their need to carry pens or syringes, and carry sufficient quantities of insulin and blood glucose test strips.³ Individual urine ketone testing kits and several glucagon hypokits are recommended; these can be prescribed or purchased from pharmacies.³

Travelling across time zones may affect insulin dosing; discussion with the patient’s medical advisor or an diabetologist or diabetes nurse prior to travel is helpful if there is uncertainty. Mild hypoglycaemic symptoms may be masked by disrupted sleep; testing blood glucose levels every four to six hours assists in the timing of meals and insulin administration.¹ Advise patients that their blood glucose levels may run higher than usual while travelling, but that this is acceptable provided these elevated levels (e.g. up to 16-20 mmol/L) do not persist for more than 24 hours;³ this will also help to prevent hypoglycaemia.⁴ Those with insulin-dependent diabetes should wear an alert bracelet and learn how to say key phrases, such as “I have diabetes”, in the language(s) of the countries they will be visiting.³

Recommendations for travellers taking insulin include:^{3, 4}

• Try to maintain regular meal times and medicine dosing while travelling
• Carry an accessible supply of carbohydrates (e.g. jelly beans, glucose tablets and muesli bars) to cover gaps in food service on the plane or delays in airports
• In-flight meals provided for people with diabetes can be low in carbohydrates and may not be appropriate for those at risk of hypoglycaemia
• After arrival, switch to local time. The next dose of intermediate-acting or pre-mixed insulin may need to be adjusted depending on the amount of time since the last dose. When flying to the east, a reduced dose may be appropriate to account for a shorter day and when flying to the west, more insulin may be needed.
• Basal-bolus insulin regimens, i.e. once daily long-acting insulin and post-prandial short-acting insulin, do not need adjustment and patients can keep taking long-acting insulin every 24 hours and bolus insulin after meals
• Insulin pumps only need to have the time on the pump changed to the local time.⁴ Ensure the safety plug (used to waterproof the pump) is not in the pump during flight as this can lead to incorrect dosing following changes in air pressure.

Information for travellers with insulin-dependent diabetes is available from: www.diabetes.org.nz/living_well_with_diabetes/living_with_type_1_diabetes/travelling

People taking warfarin may need to adjust their doses

People taking warfarin need to adjust the timing of their dosing if they are travelling across six or more time zones, i.e. six or more hours difference in time from their departure city.⁵ The dose can be delayed by two hours per day after arrival until warfarin is being taken at a more convenient time.⁵

Travel causes changes to routines which may mean INR monitoring needs to be more frequent. Point-of-care INR testing may be available from a pharmacy in the country of destination or a health provider could be contacted in advance to arrange testing. Self-monitoring of INR levels is an option for people who are able to purchase a device and testing strips. Patients taking warfarin should be advised to seek medical assistance if they experience unusual bleeding or bruising.

Contraception advice while travelling

Travel can cause disruption to oral contraceptive dosing; if pills are missed the routine advice applies (see below) and an alternative method of contraception should be used if there are concerns. If a woman taking a combined oral contraceptive misses two or more active pills in the first or last week of her cycle or more than eight active pills during other weeks, she will need to use the seven-day rule to maintain contraceptive coverage.⁶ Progesterone-only contraceptive pills need to be taken within the same three-hour window (12 hours for desogestrel) to be effective.⁷

Women taking contraceptives pills may wish to adjust their dosing regimen prior to departure to account for the new time zone. For example, after finishing her placebo pills a woman may begin the next active cycle of pills at the time in New Zealand that corresponds to the time she plans to be taking each dose when she arrives at her destination, e.g. 10 am in New Zealand and 10 pm in England. Alternatively in this example, she may begin taking the pill an hour earlier each day, 12 days before departure (one day for every hour of time difference).⁸ The usual schedule (at the destination time) can then be recommenced on arrival.

Family planning provides information on how to manage missed contraceptive pills, available from: www.familyplanning.org.nz/media/172505/instruction-pad-coc-pill-sept-2014.pdf

Travelling with opioids and other controlled medicines

International law allows people prescribed narcotics (e.g. opioids) or psychotropic medicines, i.e. medicines which act on the central nervous system (e.g. antipsychotics, antidepressants, anxiolytics, sedatives), to carry one month’s supply across international borders for personal use.⁹ However, there are substantial differences between how countries enforce this policy. Some countries have stricter controls and others are more lenient; Japan and the United Arab Emirates are known to be stricter than most.⁹ People needing to carry more than one month’s supply of these medicines into another country can contact the Ministry of Foreign Affairs to determine if they are able to do so. A consultation with a health professional at the patient’s destination may need to be arranged to ensure a continuing supply of medicines.

The dispensing rules for medicines in New Zealand do not necessarily match the laws governing transportation of medicines between countries. For example, zopiclone can be dispensed in 90-day lots in New Zealand, but some countries may only allow travellers to enter with one month’s supply.

The transportation of opioids and their derivatives, e.g. codeine and morphine, is controlled by the 1961 Narcotics Convention and travellers carrying these medicines should always have a letter from a doctor.⁹ The person’s name on their passport must match the name on any documentation provided by a doctor.

The International Narcotics Control Board has information on international agreements governing the transportation of medicines across borders, available from: www.incb.org/incb/index.html

When travelling to a country with strict drug laws, e.g. Indonesia or Thailand, or if there is uncertainty regarding the legality of a medicine in another country, further information can be requested via the Ministry of Foreign Affairs’ website: www.mfat.govt.nz/Embassies/2-Foreign-representatives-to-NZ/Diplomatic-and-Consular-List.php

Guidance on vaccination depends on the region the person will be travelling in, their immunisation status, general health and the length of time until departure. Six to eight weeks may be required to complete some vaccination schedules. When discussing vaccinations the lifetime risk of disease exposure should be considered, rather than the risk due to a single trip. Travel consultations are an opportunity to ensure that all routine vaccinations are up to date, e.g. the MMR vaccine. Vaccinations given to reduce the risk of travel-associated illnesses are not subsidised in New Zealand. Table 1 provides a summary of key vaccination recommendations for travellers prior to departure.

The United States Centers for Disease Control and Prevention (CDC) provides destination-specific vaccination advice for travellers and health professionals, available from: www.cdc.gov/travel/destinations/list

Booster vaccinations may be appropriate for some patients

A combined tetanus and diphtheria (Td) booster is recommended for most travellers if it is more than ten years since their last dose.¹¹ Following immunisation with the tetanus, diphtheria and pertussis (Tdap) vaccine at age 11 years, combined tetanus and diphtheria booster doses are recommended and subsidised at ages 45 and 65 years¹¹ Diphtheria is endemic in Africa, Latin America, Asia the Middle East and parts of Europe.¹¹ A single dose of Tdap to boost pertussis immunity may be preferable to the Td booster for travellers to areas where pertussis incidence is high, particularly healthcare workers with regular exposure to infants, if it is more than ten years since their last dose.¹¹ Pregnant women are eligible for a subsidised Tdap vaccine between 28 – 38 weeks gestation.

A one-off IPV booster vaccination to increase immunity against poliomyelitis is recommended for adult travellers to countries where poliomyelitis is endemic, if more than ten years have passed since their adolescent dose.¹¹ The spread of poliomyelitis has been declared a Public Health Emergency of International Concern by the World Health Organisation (WHO).¹⁴ The fluctuating spread of poliomyelitis is closely monitored and recent outbreaks have been reported in Afghanistan and Pakistan.¹⁴ Some authorities may require proof of vaccination against poliomyelitis from travellers who have visited these countries.¹⁴

The latest international recommendations regarding poliomyelitis are available from: www.polioeradication.org/Keycountries.aspx

Additional vaccinations that may be recommended

Consultation with a travel medicine clinician is recommended for people with a high risk of infection, e.g. disaster relief workers or those who will be living for extended periods in areas with reduced sanitation. Additional recommended vaccinations may include: Japanese encephalitis, yellow fever and Bacille Calmette-Guérin (BCG) vaccine to protect against tuberculosis.

Table 1: Summary of vaccination recommendations prior to international travel^{7, 10–13}

Avoiding insect-borne infection

The best way to prevent insect-borne infectious diseases, e.g. malaria, zika, chikungunya or dengue fever, is to avoid insect bites. Areas with stagnant water are a risk factor for mosquito bites. Recommendations for travellers in regions with high levels of insect-borne disease include:⁷

• Wear trousers and long-sleeves
• Hang mosquito nets infused with permethrin
• Use sprays containing 20–50% diethyltoluamide (DEET); apply after sunscreen
• Take malaria prophylaxis; recommendations vary depending on destination

The New Zealand Formulary provides country-specific recommendations for malaria prophylaxis, available from: http://nzf.org.nz/nzf_70212

The risk of venous thromboembolism is increased during air travel

All forms of travel involving immobility lasting more than four hours are associated with an increased risk of VTE.² This is because popliteal venous return is reduced by approximately 40% due to compression of the lower leg veins.¹⁵ Risk factors for VTE for airplane passengers are shown in Table 3.

Periodic walking and calf muscle stretching during travel is recommended as it may reduce the likelihood of VTE in people with risk factors.¹⁶ Graduated compression stockings providing 15 to 30 mmHg of pressure at the ankle are recommended for people with risk factors for VTE who are flying long distances;¹⁶ leg measurements should be taken to ensure that the stocking is correctly fitted and providing the right amount of pressure. There is no evidence that aspirin protects against VTE,¹⁵ and anticoagulants are generally not recommended.¹⁶ People with a previous history of VTE, active cancer or recent surgery (especially orthopaedic surgery of the lower limbs), may benefit from low molecular weight heparin,¹⁵ e.g. enoxaparin, 40 mg subcutaneously, on the morning of the flight and the following day.⁷ In other countries, newer anticoagulants, e.g. rivaroxaban and apixaban, are taken by travellers for the prevention of VTE, although this is not currently a licensed indication for these medicines in New Zealand.

Reducing the symptoms of jetlag

People with jetlag often experience daytime fatigue and sleep disturbance, as well as reduced cognitive function, dizziness, weakness and irritability.¹⁷ Adequate fluid intake and avoidance of caffeine and alcohol are recommended for travellers in transit.

There is evidence that immediate-release melatonin (unsubsidised) can reduce jetlag.¹⁷ Melatonin appears to provide greater benefit for patients travelling across five or more time zones, particularly in an easterly direction.¹⁷ Doses should be taken in the late afternoon or evening at the destination,¹⁷ and are often repeated for several days. Exposure to bright light in the morning may help adjustment to the new time zone.¹⁷ Taking melatonin prior to departure is not recommended.

For further information see: “Melatonin: is it worth losing any sleep over?”, BPJ 69 (Aug, 2015).

Self-managing traveller’s diarrhoea

Diarrhoea may affect up to half of all travellers,¹⁰ depending on the time of year and destination. An unclean water supply, eating from street stalls and activities such as camping during summer are risk factors. Immunisation has a very limited role in protecting against traveller’s diarrhoea. An oral cholera vaccine is available that provides 80 – 85% protection for at least six months for the small number of travellers who may be at risk.¹²

Fluid and electrolyte replacement is essential for treating gastrointestinal infections.¹⁸ An oral rehydration solution can be made by adding six level teaspoons of sugar and half a level teaspoon of salt to one litre of bottled water.¹⁹ Antibiotics and loperamide can be prescribed for travellers likely to be at an increased risk to take with them, although for this purpose they are unsubsidised. Advise patients to only use antibiotics if absolutely necessary and not to use them to treat mild diarrhoea, as this can result in infections of multi-drug resistant bacteria.²⁰

For mild watery diarrhoea, oral rehydration is the key management strategy. Treatment with loperamide may be considered for the short-term control of symptoms,¹⁰ e.g. loperamide, initially 4 mg, followed by 2 mg after each loose stool, to a maximum of 16 mg, daily.⁷ However, there is a theoretical risk that this may increase the length of time that the pathogen is present and therefore the duration of the illness. Loperamide is contraindicated in children aged under 12 years.⁷

For moderate to severe diarrhoea or mild diarrhoea that does not improve after 24 hours, oral rehydration should be continued, and loperamide considered in combination with antibiotics to provide more rapid relief and shorten the symptom duration.¹⁰ Ciprofloxacin, 1000 mg taken immediately, is likely to improve symptoms.¹⁸ Azithromycin is an alternative in areas with high rates of fluoroquinolone resistance, e.g. 500 – 1000 mg, immediately.¹⁰

Table 2: A summary of considerations for travellers with specific health conditions^{1, 3}

Table 3: Risk factors for venous thromboembolism (VTE) in airplane passengers^{15, 16}

All visitors to New Zealand will receive essential acute care

In New Zealand, anyone who requires acute treatment will receive it.²⁹ Individual DHBs are responsible for determining which services are acute and which are elective.²⁹ In general, acute care is treatment without which:²⁹

• The patient will die
• The patient’s condition could deteriorate and become life threatening or significantly debilitating
• It is not possible to tell if a patient’s condition is potentially life threatening or significantly debilitating

Citizens of Australia and the United Kingdom are provided with the same funded access to urgent healthcare (but not primary care consultations) as New Zealand citizens; as are New Zealand citizens travelling to Australia or the United Kingdom.

ACC covers citizens, residents and visitors

The Accident Compensation Corporation (ACC) covers treatment due to accidents for all visitors to New Zealand, if their claim is accepted.²⁹ New Zealand residents injured overseas, who have been overseas for six months or less, are covered for treatment received upon return to New Zealand, if their claim is accepted.

Further information about ACC eligibility is available from: www.acc.co.nz

Access to funded primary care consultations

In general, most visitors to New Zealand will not meet Primary Health Organisations (PHO) enrolment requirements and will be required to pay the “casual” rate for primary care consultations. Visitors to New Zealand will also be charged a non-PHO co-payment when medicines are dispensed.

A PHO enrolment checklist is available from: www.health.govt.nz/system/files/documents/pages/pho-enrolment-checklist.pdf

Prescribing to patients who are visiting New Zealand

Visitors to New Zealand may run out of medicines or lose them while travelling. When this occurs it can be difficult for practitioners to comply with good prescribing practice if they do not have access to the patient’s medical records or a letter from their clinician, and investigations are limited by time and cost.

Follow-up visits are not always possible. Practical steps should be taken to ensure there is continuity of care. For example, give the patient a printed copy of their consultation notes or organise a follow-up consultation in another centre if their itinerary is known.

If the medicine that the patient normally takes is available in New Zealand it can be prescribed in the usual manner, and when the prescription is dispensed they will pay either the non-subsidised cost of the medicine or a co-payment if they are eligible for subsidised care. If the medicine that the patient normally takes is unavailable a similar medicine can be prescribed or the doctor treating the patient in their home country contacted to discuss an alternative. The cost of unsubsidised medicines can be discussed with a pharmacist; costs may vary between pharmacies.

A database containing information on medicines used in 185 countries is available from: www.drugs.com/international

For further reading about travel medicine, see: Providing medical advice to travellers, BPJ 41 (Dec, 2011).