What role should pharmacy play in travel medicine?

It’s highly likely that as professional services like vaccinations are increasingly provided by pharmacists, they will also have a more significant role to play in the area of travel medicine.

But travel medicine itself is about much more than advising holiday-makers on preventive health strategies such as not drinking local water. It’s also about recognising that more and more Australians travel frequently for business, including often taking long-haul flights to isolated areas where infectious diseases may be endemic, say stakeholders.

Frequent work-related travel takes a toll on workers, particularly those in fly-in, fly-out (FIFO) situations.

 

The trouble with FIFO

In 2015, a West Australian parliamentary committee investigated the impact of FIFO work arrangements on mental health in the resources industry.

It found that the typical FIFO worker comes from the highest risk demographic (men aged 18 to 44) for mental illness and suicide.

“FIFO takes such an individual regularly away from home, puts him in isolation from his family and other social supports, subjects him to fatigue and then controls his life within the camp environment,” wrote chairman Dr Graham Jacobs.

“Understandably, this can have a significant impact on his emotional health and wellbeing.”

The investigation found FIFO work could lead to a greater risk of mental health issues.

2010 Pharmacist of the Year Karalyn Huxhagen told the AJP that a significant proportion of these workers are at risk of physical and mental illness, and that frequent flying, as well as some of the barriers to a healthy lifestyle created by being away from home, only exacerbate this risk.

“In my area of practice in the mining areas, we found people were flying in and out of country and not really thinking about how these long-haul flights affect their cardiovascular health, their risk of stroke or DVT,” Huxhagen says.

“These guys aren’t always getting a great deal of screening in terms of their cardiovascular risk.

“Some of these guys are big, their BMIs are high, they’d be high-risk even if they weren’t doing that work. They live on planes, they’re grabbing quick food that’s not good for them.”

She cited UK research which concluded that the incidence of cardiovascular events on long-haul flights was increasing.

“You’ve got to get your FIFOs healthy,” Huxhagen says.

Dr Ian Heslop, Associate Professor – Pharmacy at James Cook University, says FIFO workers aren’t only going to rural and remote parts of Australia, but areas where they may need to consider preventive measures against diseases like malaria.

“As part of my doctorate, we looked at Cairns International Airport and found that there’s a significant number of mainly mine workers, but also other workers, commuting from Cairns to various mine sites in Papua New Guinea,” he says. “And we did notice some trends among those travellers.

“Some were going to areas that would be classed as malarial endemic areas, and the uptake and use of antimalarials in that group were low.

“There were reasons for that: generally on a mine site in a malarial endemic area, the companies do tend to use vector eradication programs, to keep the level of mosquitos relatively low; and they supply [the workers] with insect repellent.

“If you’ve got people frequently travelling from Australia to working destinations in these types of areas, they may not want to take antimalarials for long periods of time, and often rely more on other preventive measures. And if they do get symptoms, they get treatment for those symptoms.”

 

Business travel

Dr Monique Beedles, pharmacist and CEO and founder of business advisory Teak Yew, says that with a lot of companies cutting back on business class travel, and many white-collar work travellers expected to fly economy anyway, workers may be more at risk of cardiovascular problems in flight.

“Some companies have policies that if you fly for over a certain number of hours, such as seven or eight, you need to fly business class,” she says.

“That’s a health and safety issue, because the added room means you have less risk of DVTs and that sort of thing. It’s not just about comfort, and when you arrive, being more prepared to go into a work situation.

“But it’s something that’s often adjusted as companies cut back, so it’s something to be aware of, especially if a person flies often.”

Dr Beedles says that most people have low awareness about DVT and their personal risk.

“A lot of people will think that it’s only older people at risk, for example: they’ll think, ‘I’m only 40, it won’t happen to me.

“Well, I had a cousin who was 41 and died from a DVT after a long flight.

“I think it’s a risk you’ve got to be aware of, and a pharmacist is in a good position to advise on that risk and how to reduce it: moving around the cabin, doing some exercise, perhaps taking some sort of preventive anticoagulant which could be low dose aspirin.

“Pharmacists can also talk to people about risk factors such as being a woman and taking an oral contraceptive pill, which increases your risk. You don’t have to be elderly to be at risk of DVT.”

Dr Beedles says that hydration in flight is particularly important.

“People will say, ‘I don’t want to have to go to the toilet on this long flight, so I won’t drink much’. Or they might drink a lot of alcohol, which makes matters worse. But if you do drink more water, you get the benefits of hydration and you also get to move about on the way to the toilet!

“That’s the sort of basic thing that people need to understand, and that fatigue and dehydration can affect your mental performance.”

Dr Beedles says that mental health is another neglected area of travel health, particularly for frequent travellers – whether they’re blue-collar mine workers or senior executives.

“It’s not just the physical aspect. It’s being away from your family, being in a stressful work situation, maybe stuck in your hotel room alone in the evening… so there’s things you can do to proactively help yourself,” she says.

“For example, some simple exercises, even if it’s just doing Pilates or stretching in your hotel room, or taking advantage of the gym or pool facilities in your hotel.”

 

The role of pharmacists

The International Society of Travel Medicine has a professional group for pharmacists, aimed at promoting their role in travel medicine, as well as serving as a resource for them.

Dr Heslop, a Group Steering Council member, told the AJP that he thinks pharmacists have a key role to play in travel medicine.

“Studies show that up to 50% of international travellers don’t get any travel health advice prior to going overseas,” he says.

“I think this is a niche area for pharmacists, and that is the lower-risk traveller who may not automatically get travel advice. Certainly studies have shown that pharmacists can adequately give the standard public health messages to those travellers, and refer them onto prescribers if there’s services they can’t provide, such as prescribing antimalarials and giving vaccinations.

“If you look at the role of pharmacists in travel health in other countries, for example the US and the UK, the enabling factor for pharmacists to become increasingly more involved was the ability to vaccinate.

“So when pharmacists became able to do influenza jabs in the US and the UK, that was shown to be effective, so therefore they gained the ability to extend the number of vaccinations that could be given, including some travel vaccinations. It should be said that this is not all pharmacists, but pharmacists who have a specific interest in travel health.

“Pharmacists who do travel health vaccinations do need to have some additional training in this area.”

Travel health specialist Dr Sarah Chu says that pharmacists are “accessible and trusted healthcare professionals and ideally suited to provide high-quality travel services in the community”.

“My personal opinion is that travel medicine offers pharmacists a chance at expanding their scope of practice and also explore untapped business opportunities,” she says, also citing data that shows many travellers do not seek health information from their GP.

“A 2015 report showed that one in four Australians travelling to at-risk destinations fell ill on their last trip, while 51% of Australian at-risk travellers didn’t think about vaccinations or a pre-travel health-check before leaving for their last trip,” Dr Chu says.

“In fact, 46% of Australian travellers didn’t visit their GP for pre-travel health advice before leaving for their trip, which is when they would receive tailored travel health advice for their destination.”

Huxhagen says that it’s often pharmacists who see the red flags when frequent travellers present in store.

“These workers will often come in saying, ‘I’ve flown three times in the last week and my back’s playing up’,” says Huxhagen.

“So we have a role to play in raising awareness of the danger of these lifestyles. So many people will get only a couple of days’ notice that they’ve got to jump on a plane, so they need to think long-term about their health.

“You can’t live on airplane food forever.”

 

Infectious diseases

Whether travelling for business or pleasure, Australians have very little understanding about infectious diseases, says travel health specialist Dr Sarah Chu.

And when we do think about infection, it’s likely to be about a high-profile disease which we’re less likely to get, rather than diseases which are actually more prevalent.

“Travelling to at-risk destinations is a favourite pastime for most Australians,” Dr Chu says.

“Of the top 10 countries Australians are travelling to, seven are considered at-risk: Indonesia, Thailand, India, China, Fiji to name a few.

“Unfortunately, many Australians are simply unaware of infectious diseases in regions like South East Asia, because they don’t exist in Australia. Many Australians don’t realise that simple, everyday activities like eating lunch at restaurants, drinking a cocktail or brushing their teeth can expose them to infectious diseases.”

Australians are more likely to be worried about an outbreak of something like Zika, Ebola or SARS, rather than the much more frequently occurring malaria or typhoid.

“In 2014, West Africa experienced the largest outbreak of Ebola in history with the total number of deaths reported at greater than 12,000, with a lot of corresponding media attention,” Dr Chu says.

“Contrast this with an estimated 214 million cases of malaria worldwide, and 438,000 people died—mostly children in the African Region in 2015; or over 250 million people around the world living with chronic hepatitis B—most in areas with little or no healthcare or where services are difficult to access.”

Typhoid fever is another good case in point, she says: at one time almost universally prevalent, it has been largely forgotten in Australia, but still plagues other parts of the world to which Australians travel.

“Typhoid fever is caused by Salmonella enterica serotype Typhi,” she says. “It is spread through the ingestion of food or drink contaminated by the faeces of an infected person or from an asymptomatic carrier. 

“Typhoid is a severe systemic illness characterised by high fever, headache, tiredness, anorexia, abdominal pain, non-productive cough and constipation (more often than diarrhoea).

“High risk destinations include Asian destinations particularly the Indian subcontinent. For travellers visiting these regions where sanitation is likely to be poor, safe food and water advice in combination with hygiene measures is important as typhoid immunisation does not afford complete protection.”

Dr Chu cited the words of Dr David Shlim, the immediate past president of the International Society of Travel Medicine, who stated that “the ideal form of travel medicine would be the kind that makes travel medicine unnecessary”.

Dr Chu says this is a concept “which reminds us of the fact that many ‘travel-related’ diseases were once endemic in developed countries, and have since been eliminated through hygiene measures, vaccination, treatment, and vector control.

“Having eliminated the risk of malaria where we live in developed countries, why do we think it is okay to continue to allow people to live with the constant risk of malaria in other countries?” she asks.

 

Common sense advice

  • “Pharmacists can provide advice on precautions to take with food and drinks: drinking bottled or boiled water, avoiding ice; cook it, boil it, peel it, wash it or forget it regarding food,” says Dr Chu. This should include avoiding raw or undercooked seafoods or meats, raw fruits or vegetables, runny eggs, pink poultry, unpasteurised dairy products, washing hands regularly and using alcohol based hand sanitiser.
  • Wear light-coloured long-sleeved clothing, insect repellent on exposed skin, and sleep in screened accommodation or netted beds.
  • Pharmacists can advise on bringing a travel essentials kit: “aspirin/paracetamol/ibuprofen, anti-emetics, thermometers, steroid cream, antihistamines, thrush treatments, sunscreen, lubricant eye drops, below knee compression flight socks, rehydration ORS, creams for bites/stings/itch, condoms, antidiarrhoeal medications, cold and flu medications including decongestant (especially for air travel with hayfever or cold), water purification tablets, motion sickness preventive advice and over the counter remedies,” says Dr Chu.
  • “In some countries it’s illegal to carry, say, codeine, so the customer may need to talk to their doctor about what they’re planning to take with them,” says Dr Beedles. “They may need to ask their doctor to write a letter to show to Customs or another authority, to say that this person is taking the medication on the authority of a doctor. This can be the case even for OTCs, so pharmacists should advise on this – different countries have different regulations, and you don’t want to get yourself in trouble.”