#257      34 min 23 sec
Setting forth safely: Travel health before, during, and after the journey

Infectious diseases specialist Assoc Prof Tilman Ruff explains the myriad health risks to today’s travellers, including what to consider before the journey and post-trip follow-up and care. Presented by Dr Dyani Lewis.

"It distresses me to see travelers taking risks while they're away that they would never contemplate taking at home." -- Assoc Prof Tilman Ruff




Assoc Prof Tilman Ruff
Assoc Prof Tilman Ruff

Tilman Ruff is Associate Professor in the Nossal Institute for Global Health, University of Melbourne; and international medical advisor for Australian Red Cross. He serves as Co-President of International Physicians for the Prevention of Nuclear War (Nobel Peace Prize 1985) and International Councillor for Australia; Co-Chair of the International Steering Group and an Australian Board member of the International Campaign to Abolish Nuclear Weapons (ICAN).

A public health and infectious diseases physician, Tilman contributed to travel medicine; worked on hepatitis B control, immunisation and maternal and child health in Indonesia and Pacific island countries, and is a member of the WHO Western Pacific Region Hepatitis B Expert Resource Panel. He is an author of Manual of Travel Medicine (3rd edition, IP Communications).

Tilman’s work has included ciguatera fish poisoning and its relationship with nuclear testing in the Pacific, removing highly-enriched uranium from medical isotope production, and public health evidence and advocacy for eradicating nuclear weapons. He was a civil society advisor to the co-chairs of the International Commission on Nuclear Non-proliferation and Disarmament.

In June 2012, Tilman was appointed a Member of the Order of Australia “for service to the promotion of peace as an advocate for the abolition of nuclear weapons, and to public health through the promotion of immunisation programs in the South-East Asia – Pacific region”.

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Host: Dr Dyani Lewis
Producers: Eric van Bemmel, Kelvin Param, Dyani Lewis
Audio Engineer: Gavin Nebauer
Voiceover: Nerissa Hannink
Series Creators: Kelvin Param & Eric van Bemmel

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VOICEOVER 
Welcome to Up Close, the research talk show from the University of Melbourne, Australia. 

DYANI LEWIS
I'm Dyani Lewis, thanks for joining us. The world's airports, seaports and other border check points now see the arrival of over one billion international travellers each year. Compare this to the paltry 25 million international arrivals that took place in 1950 and you can begin to appreciate just how much international travel has grown over the last few decades. Tourists are now able to visit exotic destinations that their parents and grandparents may only have read about; migrants are able to make regular visits back to their homeland; and millions of students travel to foreign countries every year for university and college education. But what impact does all of this global movement of people have on health and disease control? Does travel present particular health risks for the individual traveller? What about the consequences at the community level?
To help travellers understand the health issues they may face on the road, at their destination and even when they return home, I am joined in the studio by infectious disease and public health physician Associate Professor Tilman Ruff. Tilman is from the Disease Prevention and Health Promotion Unit of the Nossal Institute for Global Health at the University of Melbourne. Welcome to Up Close, Tilman.

TILMAN RUFF:
Thanks very much, Dyani.

DYANI LEWIS:
Tilman, often when we think about getting sick when we travel we think about infectious diseases. For a typical traveller who might be heading overseas for a couple of weeks on a holiday, what are the most common infectious diseases that they're likely to come into contact with?

TILMAN RUFF:
It depends obviously a lot on where they're going. It's not just about travel outside one's own country, but travel within one's own country too in large countries like the US, Australia, China or India, there are huge differences within countries. But the most common infections are diarrhoeal infections, things that you acquire from eating contaminated food, or drinking contaminated water. These are really common. Mostly not serious, generally rather brief, but certainly can have important sequelae and consequences, occasionally be severe, occasionally they are severe infections. Insect-borne infections are another important group, malaria being the commonest, serious potentially life-threatening infection in travellers, but dengue and other insect-borne diseases are really common. 
Skin and blood and sexually submitted infections are a really important group. I forget respiratory tract infections which are, of course, are really probably number two to diarrhoeal disease. Flu is, in fact, the most common vaccine preventable infection in travellers.

DYANI LEWIS:
So things like malaria and dengue fever are tropic diseases. Are tropical and exotic locations more risky in terms of infectious diseases?

TILMAN RUFF:
Yes, the risks tend to be higher in unfamiliar settings where hygiene and sanitation may be poor and the infectious disease pressure, the likelihood of being exposed is high. So generally developing country settings with poor infrastructure, poor hygiene and sanitation, intense crowding, are often the settings where the infectious disease risks are higher. But I think it's important to treat this as really a global issue and it's not just an issue that's confined to particular countries or regions. For example, at present there's a substantial outbreak of rubella in Japan and also across Europe. Outbreaks on cruise ships, particularly of influenza, but sometimes of other respiratory infections like Legionnaires' disease are also quite common.
There's no area of the world that's immune from the movement of people and bugs, exposing people to things that they're not already immune to. 

DYANI LEWIS:
So really there's no place that's immune to illness or there's no safe place to travel is what I'm asking?

TILMAN RUFF:
Well, I think it's all relative. Life is a dangerous business and there are risks everywhere, but being informed about those risks, and understanding them and taking the appropriate measures to minimise them is appropriate in every place. Even if you're going to a place that seems safe, or you're not aware of any particular risks, particularly if it's isolated long term travel, or if there are people travelling who have chronic illness, who are very old, or very young or pregnant, those people in particular need the best possible advice. But if you're going to, say, the fiords of Norway, or doing a trek in the Central Asian mountains, there are issues: vaccine issues, infectious disease issues that you may not be aware of. Lyme disease, for example, is a disease of ticks that's common along much of the forested areas of the northern hemisphere. 
Tick-borne encephalitis is another insect borne disease spread by ticks present through much of central and northern Europe and Asia and a vaccine preventable illness that is important to be aware of that people in Australia, for example, or areas where there isn't tick-borne encephalitis would not be aware of. Influenza is the opposite in the hemispheres obviously, so people in Australia who have holidays in summer who are heading to a northern winter, may not be aware that they're heading straight into the middle of the flu season and should be thinking about that, especially if they're in - have any chronic illness or are travelling in large groups, where their exposure is likely to be high. In the tropics flu is not seasonal, so flu is a risk any time of year. So there are issues in every place and I think getting travel health advice, preferably at least six weeks before travel if possible. It's never too late, even if it's the day before, it may still be useful.

DYANI LEWIS:
Now, you mentioned travellers' diarrhoea which is definitely the bane of many travellers. Why are travellers so susceptible to getting diarrhoea when local communities apparently seem to be resistant?

TILMAN RUFF:
Diarrhoeal disease is obviously a really common global problem and it's a very major cause of illness and death in young children. Travellers in a sense are like young children immunologically, so the spectrum of bacteria mainly – but viruses and other bugs, protozoa and more complex larger organisms – the spectrum of organisms that can cause diarrhoea differs a little bit, different strains in different places. So if you're born and live there then over time you will become immune, at least partially, to many of those local strains. That immunity comes at a price of some illness and occasionally some death, but by and large most adults in developing country settings will generally be immune to most of the local bacterial flora. Of course it changes; it's not static, so one is never immune to whatever's around.But a traveller going in who has very different and typically much lower immunological experience from gut flora, gut bugs, will be like the child. The spectrum of organisms that infects travellers is actually surprisingly - maybe not so surprisingly - similar to the bugs that infect children in those areas – with some differences. So Rotavirus is a virus that causes by far the majority of severe childhood gastroenteritis everywhere in the world, completely democratic, ubiquitous virus that everybody - every child essentially born gets eventually infected with. For travellers it's mostly bacteria, because all of us essentially have had Rotavirus infections in early childhood. So that's one bug that's much more common in children than adults. But in general the main causes of travellers' diarrhoea in adults are bacteria that they're not used to.

DYANI LEWIS:
Is there any way that travellers can protect themselves against being infected?

TILMAN RUFF:
Yes, there is. The main root of infection is from contaminated food and water, so there are simple rules about food hygiene and about personal hygiene that can significantly reduce the risk. Eating foods that are freshly and thoroughly cooked, that are served steaming hot, that haven't been sitting around at room temperature and on a buffet or somewhere for an unknown number of hours growing bacteria, being sat on by flies that carry more bacteria onto them. Things that you can peel yourself; fruit that you can peel and drinks that are either commercially prepared that come out of a sealed container and carbonated drinks, is the simplest way of making sure that it's not simply a refilled and resealed container, or that are made with boiling water. Those will help reduce the risk of travellers' diarrhoea very dramatically. Also hand washing, simple hand washing is really important before you eat and prepare food. It reduces the risk not just of diarrhoeal and gastrointestinal infections, but also is actually a very important way of reducing the risk of respiratory infections, because most respiratory viruses, including influenza, hand-to-mouth contact is actually a really important route of transmission. But the problem with that is that often being adventurous about what you're eating, trying the local cuisine and doing whatever the group is doing, are part of the sort of adventure and interest of travel. All of the studies show that people follow those simple hygiene rules very, very poorly. Even in studies of cultures that are, perhaps, better at following rules than most, like Germans and Swiss, when you educate travellers about how to reduce the risks and you follow them up a few days later, almost all of them have broken one or more rules.So it's really hard to avoid consistently, the risk can certainly be reduced, but because it's so common travellers who are travelling for any length of time at significant risk, particularly in isolated areas, would generally be advised to take something with them to manage diarrhoea. 

DYANI LEWIS:
So what sort of things can manage diarrhoea if you do get infected then?

TILMAN RUFF:
There are a couple of things that would typically be advised. A thermometer is really useful; knowing whether you've got fever or not is a really useful thing, not just in the setting of diarrhoea, but for all sorts of other illnesses. People often feel hot and sweaty in the tropics and whether you've actually got a fever or not is a really important thing. If you haven't got a fever you don't have malaria, for example. So a thermometer is really useful. There's a number of medications that can just reduce the contractions of the bowel that result in cramps and pain. And particularly if you're having to travel in a bus or a plane, or doing something important where it's really important that you avoid or try and minimise having diarrhoea or i tt's incredibly disruptive,  those medications like Loperamide - is the most typically widely used one available over the counter in pretty much all of the world - is a very useful way in the short term to relieve symptoms and really shouldn't be used just in a couple of limited settings, in young children or in settings of dysentery, where there's actually ulceration of the lining of the bowel, which can produce blood in the stool and high fever and a lot of pain.In other settings, except in dysentery, so blood or high fever, because most travellers' diarrhoea is due to bacteria, antibiotics that are active against those common bacteria can be very useful. Usually just single dose treatment suffices, 90 per cent of people respond to just a single dose. However, the problem with that is that antibiotic resistance is a really growing problem in much of the world. That's not for every episode of diarrhoea, that's just if it's severe or not getting better.

DYANI LEWIS:
Sure, but certainly prevention is the key thing.

TILMAN RUFF:
But certainly prevention is the main thing and for people who travel for longer periods, then we might add something else to treat Giardia, the commonest parasite that causes more persistent diarrhoea, so most people can manage the vast majority of episodes of travellers' diarrhoea safely and effectively themselves by being adequately prepared.

DYANI LEWIS:
I'm Dyani Lewis and you're listening to Up Close. In this episode we're talking about staying healthy when travelling with public health physician, Tilman Ruff. Tilman, if we turn to some of the other infectious diseases that you talked about, things like dengue fever, malaria or the flu, can people get vaccinations for these before they go, or are there other measures that they should be taking?

TILMAN RUFF:
There are certainly a number of important vaccines that travellers should be availing themselves of and these come in a number of sort of categories. The diseases that are part of the routine immunisation programs that are recommended are generally ubiquitous diseases that are everywhere and being protected against them is an important part of being prepared for travel. So measles, polio, pertussis - whooping cough – tetanus, diphtheria, all of those common vaccine-preventable diseases are globally important and it's - travel is often a good opportunity to update those routine immunisations as well as ones that are specific to the traveller. If a woman, for example, in child-bearing years is travelling, it's a good opportunity to think about is she immune to rubella? 
For somebody who's working in first aid settings or healthcare settings, are they sure that they're immune to chickenpox, Hepatitis B and the other things thatare important for health workers. So updating routine vaccines is an important thing. Then there's a range of vaccines that are indicated for travel, some that virtually all travellers probably should have like Hepatitis A – food and water borne, very common – extraordinarily effective and safe vaccine that probably provides protection for life. Virtually nobody who's going to settings of poor or uncertain hygiene should be going out without Hepatitis A protection.

DYANI LEWIS:
But things like malaria and dengue fever, there isn't any vaccination for those, is there?

TILMAN RUFF:
No, there isn't at this point. There are promising trials of malaria vaccines, but they're still a way to go. We've just had some disappointing results with the most advanced dengue vaccine candidate, so for both of those vaccines will probably be some time hence. So for dengue, which is the most common mosquito-borne infection globally and can cause severe illness, as well as a lot of discomfort acutely, really protecting yourself from mosquito bites with covering up, effective repellents on bare skin and sleeping somewhere that's adequately screened, preferably in a building that's screened, if not then under an insecticide-treated bed net, dramatically reduces the exposure to mosquitoes at night, which for malaria is when the important exposures occur. The malaria-transmitting mosquitoes bite almost exclusively at night, whereas the dengue-transmitting mosquitoes tend to live in and around human habitation, breed in pot plant bases and any collections of water in and around houses and tend to also be a day biter and rather aggressive.
So dengue is pretty hard to avoid, because they're very sneaky, aggressive, day biting mosquitoes that hang around where people do, but mosquito bite prevention is really important and one of the most effective things that travellers can do to reduce the risk of malaria, dengue and of, in fact, all of the other many vector-borne diseases, like Japanese Encephalitis in Asia. There's hundreds of different viruses mainly that are transmitted by biting insects.

DYANI LEWIS:
With things that are transmitted from person to person such as the flu, which you said is very common, there are large events like the Olympic Games, or things like that, that bring a lot of people together all at once. This must be an absolute hot bed of infection.

TILMAN RUFF:
Yes. Sometimes this has been quite well controlled like, for example, the Olympics have generally been pretty well managed. Apart from injuries, diarrhoeal infections and respiratory infections, there's not been major epidemics associated with those. The largest frequent gathering of people is the Hajj Pilgrimage in Saudi Arabia to Mecca every year. That attracts up to three, three-and-a-half million people from all over the world, living in very close proximity for several weeks at a time. Certainly there have been major problems with infectious disease outbreaks during the Hajj, simply from that number of people coming together, both of blood-borne viruses, of hepatitis C related to some of the procedures and rituals of the Hajj. Respiratory infections like influenza and whooping cough, probably most famously meningococcal infections, so meningococcal meningitis the commonest globally bacterial cause of severe infections of the coverings of the brain. 
A number of strains of meningococci have a spread through pilgrims to the Hajj to other parts of the world, from South Asia to Africa for example, through the Hajj. So yes, those large gatherings of people can really be an important source of transmission of infectious diseases around the world.

DYANI LEWIS:
Yeah, so you've brought up an important point, which is that people don't just get sick on their trip, but they can bring back some infectious diseases to their home countries as well. Is that a large problem for travellers to be aware of?

TILMAN RUFF:
It is a very important problem. Some diseases, even if they're not very common may be important from a long term perspective from several different points of view. Some may cause long lasting infections and long term complications, HIV, Hepatitis C, Hepatitis B, for example, some sexually transmitted infections like syphilis, other STIs that are associated with long term infertility or inflammatory disease, particularly in women. So there can be important long term sequelae for the individual. Many of those infections might also be infectious for others in the long term and a number of these people can carry or have without necessarily knowing about them, or without knowing about them for a very long time. Then sometimes people can carry infections that they can transmit to others, completely unaware of them, even if they're not at risk of any major sequelae themselves and polio is an example of this.
Travellers have been well documented to have brought polio virus home and infected others around them, often without knowing it or without getting sick themselves. Then there are infections of public health importance, so it's not so much the risk to the individual, but the potential to introduce an infection, for example, into a receptive area. The most common one that's of concern here is yellow fever and it's the reason why the International Health Regulations mandate yellow fever immunisation as something that countries can regulate. So that countries have different policies, but many require immunisation of all the travellers coming from yellow fever infected areas against yellow fever. Some countries in Africa require all travellers to be immunised against yellow fever, because they're receptive and they don't want more yellow fever being introduced.
Countries like Australia that don't have yellow fever, but the tropical part of northern Australia has potentially yellow fever transmitting mosquitoes and if a traveller was incubating yellow fever when they returned from an endemic region in Africa or Latin America, then they could potentially set up a local outbreak. We see this with other insect-borne diseases. For example, we have periodic outbreaks of dengue in north Queensland, in northern Australia, and they basically come from tourists and travellers that arrive usually in Cairns with incubating dengue. But we also know that mosquitoes can travel too and that we occasionally see, for example, outbreaks of malaria around airports, even in cold places like in northern Europe, from mosquitoes that have hitched a ride from Africa or somewhere else.

DYANI LEWIS:
I'm Dyani Lewis and my guest today is infectious diseases specialist, Associate Professor Tilman Ruff. We're talking about how to stay healthy when you travel here on Up Close. Tilman, travel itself can also present a risk, apart from what infectious bugs we might gather along our way. If we focus on air travel, what are some of the risks of travelling in an aeroplane?

TILMAN RUFF:
There are a number of issues related to travelling in a plane. Firstly, you're sitting down for a very long period time often not doing very much, so that's a problem in terms of blood clots in the legs and potentially flicking off to the lung, which can be fatal. Even healthy people can get deep venous thrombosis as a result of prolonged trips and that particularly is a risk for flights longer than about six to eight hours. It's hardly a risk for flights shorter than that. So a very common thing that's sensible for people to do is to keep moving, to be well hydrated, to drink plenty of fluid, not too much alcohol and caffeine. To wear elastic stockings often makes them more comfortable as well as helps reduce the risk of clots in the legs, so that's an important issue. People at serious risk who've had clots before or may have other medical conditions may need something to thin their blood down before travel.For people with heart or lung disease of any severity, the aircraft cabin is pressurised to the equivalent about 2500 metres altitude. So for people who have significant activity limitations on the ground, their capacity to cope with a reduced level of oxygen in the aircraft cabin may be an issue. So that's particularly for more severe heart or lung disease. For people with diabetes, sorting out meals and time zones and insulin with changing time is really important. That's occasionally an issue for other people who are on very strict regiments for medication. Because you've got a lot of people sitting very close together for a long period of time, there are also issues of infection transmission on planes. There have been examples of SARS, TB and flu and other respiratory infections that have been transmitted on aircraft. That's relatively uncommon but an important issue.

DYANI LEWIS:
What about things like the radiation with being up in the air, you're closer to cosmic radiation. Is a lot of travel over your life time a detrimental thing?

TILMAN RUFF:
Well, certainly radiation is another particular interest of mine. Yes, the effects of radiation are independent of the source and our current understanding is that there's no dose of radiation below which there is no adverse health effect. So the more you have, the more cumulatively is the added risk of - particularly of cancer and other long term chronic disease. Every little bit extra adds to that risk. There's no question that that flying at high altitude - most aircraft fly around eight to 10,500 to 11,000 metres high. It's higher than Mt Everest, it's a fair way up, and there is a higher radiation from cosmic sources that are not being filtered out by the atmosphere to the same extent.
It's mainly an issue for aircraft workers and particularly pregnant aircraft personnel. The foetus is the most radiation sensitive person. Young children and foetuses are at least three to four times more sensitive to the adverse effects of ionising radiation exposure than adults. So it is an occupational issue for flight attendants who maybe particularly in the early stages of pregnancy, but I don't think has actually been really adequately addressed. For most people travelling the doses are pretty small, compared with other exposures in our lives, medical X-rays and the background radiation that we all suffer. Unless you're travelling very, very, very frequently over very long distances, it's probably not so much an issue for the traveller, because the doses are really quite small. But for those who are working in the air, I think it's an important occupational health issue.

DYANI LEWIS:
So what about some of the other forms of transport, buses, trains or motorcycles, that sort of thing?

TILMAN RUFF:
Yeah, thanks for raising that, because while infections are common and often make travellers ill, it's injuries that, to put it bluntly, kill them more often than anything else. So if you look at travellers across the board, the commonest causes of travel-related death are injuries, not infections. Most of that is motor vehicle related, all sorts, motorbikes having a particularly high risk of injury and of severe injuries and fatal injuries. So being careful about the road and road rules is a really important part of travel health advice. It distresses me to see travellers taking risks while they're away that they would never contemplate taking at home; drinking and driving, riding motorcycles without adequate training, without protective clothing and good standard helmets. You see Australians all over Bali riding motorbikes in shorts and T shirts carrying surfboards without decent helmets, that's a real issue.
In developing country settings, some of the poorer developing countries have very few vehicles and actually not much of a road trauma problem, but in most developing countries now the density of vehicles is increasing, the road infrastructure is often quite poor. There is often all sorts of pedestrian and animal traffic, as well as vehicles that are often overloaded and may be poorly maintained. Road rules are often not very well observed, street lighting and infrastructure tends to be poorer, so the accident rate per kilometre in most developing countries is much higher than in settings like Australia or Europe. If an accident happens then access to emergency care may be more difficult. The potential for an infected blood transfusion or an infection acquired during hospital treatment, the access to good care may be limited. So what's maybe a relatively simple injury, if it happens in a setting where good care is available, like a broken leg, it might become a life threatening in a place where you're a day away from a decent hospital.
So injury - minimising those risks, not being silly, not taking on things that you're not properly trained to do, making sure that if you get in vehicles, tend to avoid driving at night, try and drive in the day and make sure that there are functioning brakes, good tyres, seatbelts - really important, seatbelts for everybody in a vehicle - and preferably avoid motorcycles.

DYANI LEWIS:
You mentioned that people take risks that they wouldn't otherwise take in their home country and in recent years there have been a number of cases in the media where Australians have died in water accidents. I imagine this is also a common source of injury or death potentially in travel?

TILMAN RUFF:
Yes, it is and water-related injuries are after road trauma, the next most common source of injuries, more than climbing or adventurous type activities. But it's water activities, particularly in unfamiliar settings. Again, people tend to do things, take risks in the sort of release and holiday mode that travellers are often in, encouraged by their peers perhaps, encouraged by the availability and, perhaps, low cost of things that they mightn't normally do at home and take risks with watercraft, with boats, with surfing, with swimming, with kayaking, with both fresh and marine activities. Even Australians who generally are pretty water savvy can get into trouble. In cultures where water experience and swimming are less common, particularly for example North-East Asians, Chinese and Japanese in Australia frequently get into trouble in the water. 
I've personally seen inexperienced people get into trouble in Indonesia, pretty commonly. Drownings in a popular tourist destination like Bali, which has some very treacherous beaches, are surprisingly common. There's usually several to a dozen a year.

DYANI LEWIS:
When we think of travellers we do often think of the short term holiday type of traveller, but there are also obviously international students and expatriates who travel for work or to stay with family for extended periods of time. Are there particular risks for these types of travellers?

TILMAN RUFF:
The group that's been identified in more recent years as a particular group for attention that are at increased risk of a range of things, are people who are - it's called VFR, visiting friends and relatives. So these are a variety of people, but often people who come from a particular country or culture who are returning home to spend time with friends and relatives, often showing off children or grandchildren. Who, because they're going home at least in a cultural sense, feel a sense of familiarity, often don't appreciate the need for protective measures, often assume that because they might have grown up in that setting, that they still have some useful immunity to malaria or things that, in fact, wane quite quickly, often don't seek travel health advice, are typically staying for longer periods, often in village settings, engaging much more in the local environment, more closely interacting with lots of people. Kids get shown off to a whole village, so that the risks of a number of infections are really substantially increased.
Food and water borne infections like typhoid, malaria are significantly higher in people visiting friends and relatives than in travellers across the board. Often they're not very well prepared, so that's a particular group for attention. But otherwise it's particularly people who are doing long term travel in high risk settings, or settings that are remote from good medical care, missionaries, pilgrims, aid and development workers, humanitarian workers, those sorts of people who particularly should get good advice before they travel.

DYANI LEWIS:
It seems that this is really the crux of the issue, isn't it, appropriate forward planning and preparation for wherever you're going?

TILMAN RUFF:
I think that's really the crux of it, Dyani, yes that if you're travelling just the same as getting the ticket, packing and getting insurance should be a routine part of preparation, getting health advice and making sure that you're in good shape, that you're well informed. That if you have any chronic medical conditions that might need treatment that could get unstuck while you're away that they're as optimally controlled as possible, that you've seen your regular doctor, that you've got all the things you need in terms of medication, equipment, test results, documentation, know what to do if you get into trouble if you get an asthma attack or your diabetes goes out of control or if you have an epileptic seizure. Management of chronic illness, pre-existing illness is also an important part of travel health advice and then specific preparations for the travel in terms of first aid equipment. 
A simple first aid kit is appropriate pretty much for everybody to take Depending on the complexity and nature of the trip, other measures to manage diarrhoea, for example, insect repellents, condoms, sunscreen, all of common things that people are likely to need. If you're doing adventurous or remote expeditions these first aid kits can get pretty big. Then also vaccines, medications and education about being safe, because while there are very important travel-related risks that can be reduced through immunisation and preventive medication for malaria, for example, the majority of travel-related illness is not specifically preventable by those measures. It's really being safe and sensible about food and water, about environmental exposures, about avoiding any mammal that can bite where there's rabies risk, about reducing risks of injury and so forth that are the mainstay of protecting travellers.
Then also it's important for people to know that if they return and they've been in a malarious area, for example, and they develop a fever, even a month or two, or three later, they need to get timely care. So the continuum of sort of before travel, during travel and after travel, that there are important aspects of being safe and knowing what to do at each of those stages.

DYANI LEWIS:
Tilman, thank you for being my guest today on Up Close and talking with us about travel medicine.

TILMAN RUFF:
My pleasure, thank you.

DYANI LEWIS:
Associate Professor Tilman Ruff is an infectious disease and public health physician with the Disease Prevention and Health Promotion Unit of the Nossal Institute for Global Health at the University of Melbourne. You can also hear Tilman on Episode 144, where he speaks about the health effects of radiation, available on the Up Close website. Relevant links, a full transcript and more info on this episode can be found on our website at upclose.unimelb.edu.au. 
Up Close is a production of the University of Melbourne, Australia. This episode was recorded on 18 July 2013. Producers were Kelvin Param, Eric van Bemmel and myself, Doctor Dyani Lewis, audio engineering by Gavin Nebauer. Up Close is created by Eric van Bemmel and Kelvin Param. Until next time, goodbye.

VOICEOVER:
You've been listening to Up Close, we're also on Twitter and Facebook. For more info visit upclose.unimelb.edu.au. Copyright 2013, the University of Melbourne.


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