BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 1. - Tropical Health
RADIO 4
THURSDAY 03/02/07 2100-2130
PRESENTER:
MARK PORTER
reporter: claudia hammond
CONTRIBUTORS:
RON BEHRENS
JO YIRRELL
RICHARD DARWOOD
MARY WARRELL
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about travel medicine and how to protect you and your family abroad. From hazards that, at best, can disrupt a once in a lifetime holiday or scupper a business trip - but which, at worst, can be fatal.
I'll be talking to a mother whose 20 year old son died from malaria after a gap year in Ghana. Not the only British student to have lost their life recently.
Claudia Hammond is off to Delhi and keen to avoid an upset stomach - the scourge of many a traveller to far flung places. Could packing a course of antibiotics be her answer to Delhi belly?
And I'll be finding out why British travellers are putting themselves at unnecessary risk from rabies. Globally it's the tenth biggest infectious killer of humans but there is an effective vaccine. So why don't more travellers go for it?
My guest today is Dr Ron Behrens, he's the NHS's only consultant in travel medicine and director of the busy travel clinic at the Hospital for Tropical Diseases in London.
Ron. I wanted to start by asking you whether the NHS had kept up with the rapid change in the type of holidays that we're going on, people are going - far more people are going abroad, they're going to all sorts of different places but it seems like my introduction answers the question - you are the only travel medical consultant in the NHS?
BEHRENS
Yes I am and really the change in travel has been quite dramatic, we've seen a 13% increase year on year, which is doubling every 10 years. And so there's been a dramatic increase but really the resources available to advise and prevent disease in travellers have really either stayed the same or in fact shrunk because there are now fewer and fewer primary care and GPs providing good travel medicine advice for this large group of travellers.
PORTER
Travel to - I talk about far flung exotic destinations - but you know package holidays now you can spend two weeks in a country that people know very little about, they know very little about the local threats and hazards. Do you think enough of them are seeking advice before they go?
BEHRENS
Well again we've looked into this and they're not. There are a number of reasons. First of all that most people now buy over the internet and there's very little warning on the health risks that they face. And as you say many are inexperienced or first time travellers and really have no insight to the health threats and hazards. And actually getting access to travel advice now is becoming more and more difficult as, in my experience, less is being provided in the primary care setting.
PORTER
Well earlier this month there was an enquiry into the death of a 19 year student who contracted malaria on trip to spend Christmas with her father in Uganda. And I wanted to start with malaria. She didn't take any malaria pills, she'd been in Uganda in the past and thought that she didn't need to, unfortunately she was found dead in her bed three weeks later. How common is malaria in returning British travellers?
BEHRENS
Well it's been static over the past 10 years, around 1500 to 2000 cases, but interestingly enough the biggest group that get malaria are what we call - are visiting friends and relatives - people who were living or were born in a malaria country and go back to visit. And it sounds like this person fits the bill.
PORTER
It's a classic case, yeah.
BEHRENS
And they invariably seem to think that the risk is different to what it is or they have immunity or for various other reasons tend not to either take tablets or seek advice.
PORTER
So this is a really - in most cases it's a failure of what we would call compliance - they're not taking the medicines or not taking the medicines probably, rather than being on the medicines and still catching it.
BEHRENS
Absolutely, very few people taking any medicine get malaria. And it comes down really to being aware that there's a significant threat and doing something about it.
PORTER
You talk about a significant threat, I mean can you quantify that in terms of various countries, I mean how risky is it to go - I mean what are your chances of catching malaria if you go to parts of Africa?
BEHRENS
Well I mean we can do that because there's a lot of work done in malarious countries and they define it by how many times you get bitten by a mosquito carrying malaria. And in places like East Africa you can get bitten twice a night by a mosquito carrying malaria. Similarly in West Africa. So that means twice a day you'll be exposed to malaria. And if you're not on effective drugs the risk is great because most people who are bitten will develop some evidence of that infection.
PORTER
You talked about visiting friends and relatives there, one of the problems I get with some of my patients is when they go out they're often staying with ex-pats who are out there who don't take malaria medication themselves or don't feel they need it. Can you build up any form of natural immunity?
BEHRENS
Yes you can and this is the whole complexity of this disease is that what happens for people living in malarious countries is they either die or survive and if you survive you develop your natural immunity but if you die, as most - many children - two million a year - do obviously those are the people who suffer the brunt of the disease.
PORTER
Well another student, Harry Yirrell, didn't finish his course of anti-malarials while on a gap year in Ghana. Not that he didn't want to - he just felt someone else needed them more. A decision that cost him his life. As Harry's mother Jo explains.
JO YIRRELL
He started taking his anti-malarials as soon as started travelling basically, within a couple of days, and he carried on taking them all through the Sahara and when he got there but when he got to Ghana, I think he had a false sense of security, he settled in with a community and got used to the way they lived ...
PORTER
Of course most of whom don't take any anti-malarials.
JO YIRRELL
Who don't take anti-malarials but do suffer from malaria. So Harry, who got very close to these children, saw these children with their bouts of malaria and felt that they needed his tablets more than he did. He obviously had a misconception that he was strong enough, possibly because he had Western medicine to fall back on, if that happened when he was there, and he stopped taking his tablets, he gave them away.
PORTER
Now at what stage of his trip was this - was this right at the end?
JO YIRRELL
I would say it would be a month that he didn't take anti-malarials for. He came home and he'd admitted that he hadn't taken them and we got the impression, knowing Harry, it would be for quite a while. But he wasn't ill when he was there.
PORTER
But he arrived home and he was fine, he obviously told you he hadn't finished his course, did you think it was significant at the time?
JO YIRRELL
Well when he arrived home he looked great and he did tell us about giving these anti-malarials and we said well that's probably the most stupid thing you've ever done Harry but there we are you're home safe and sound. And you don't think anymore of it because they are there.
PORTER
When did you notice that something was awry?
JO YIRRELL
About a week later, I mean Harry had started his rugby training, seeing friends, etc. etc., and he started off with a headache, this headache continued but went away with headache tablets. But then on the Friday he started showing a lot of sweating, the shivering and this went up and down. At this point I rang the doctor and said that he needed to see someone. Sent him off to the doctor's, he didn't arrive at the doctor's because he got diarrhoea because this is also one of the - one of the symptoms of malaria.
PORTER
Had you mentioned to the doctor that he'd come back from Africa and hadn't been taking his anti-malarials?
JO YIRRELL
Yes I had.
PORTER
You had, so the link had been drawn?
JO YIRRELL
Yes he did say there was some colds and flu and that going round but he said now you have to keep an eye on him. But then on Sunday morning he woke us up early and he just said to me - Mum, I feel like I'm going to die. So I just said - Right, we're going to hospital. He walked into the hospital but within an hour he was just completely drenched in sweat. He suddenly went downhill and then eventually had a blood test and they diagnosed him with malaria in the afternoon and started oral treatment. And then put him on intravenous treatment in the evening.
PORTER
And then what happened?
JO YIRRELL
Once he'd got rid of the headache he felt a lot better, was able to talk to us and he was fine but then a couple of days later he had breathing difficulties. So they finally got the parasites under control with treatment and they had gone but his lungs had deteriorated to such an extent that that was their main concern. We went home, showered, spoke to the lads - the other - I've got three other sons - and we had a phone call from the nurse who was on duty and said - Look, Harry's poorly again, are you on your way back? - Yes we are. We went back to the hospital as quickly as we could and they'd said to us we don't think he'll survive the night and in fact he died within the hour of us getting back to him.
PORTER
Looking back on Harry's illness what do you think might have been done differently?
JO YIRRELL
I just think time is of the essence. After looking after yourself and taking your tablets and avoiding bites from the mosquitoes, if you are unlucky enough to then get the symptoms, recognise them and immediately - and be strong and say to the medical professional that you're having to speak to, I have been travelling, I have got symptoms of malaria, test me for it now, don't hesitate.
PORTER
You were obviously aware that malaria was a dangerous disease before Harry went but were you aware that it kills people in this country?
JO YIRRELL
Absolutely not no.
PORTER
Jo Yirrell, whose 20 year old son died from malaria.
Dr Ron Behrens, the point was made there that it's important that doctors think about exotic diseases when they're seeing people who've returned from countries like this, so if somebody presents with a fever that malaria is up on that list. And in fact that was one of the criticisms of the case of the female student who died last year as well.
BEHRENS
I think it's very difficult to persuade doctors to ask everybody who comes into their surgery feeling unwell - Have you travelled? But without that question you cannot diagnose malaria, it has to be asked. So I tend to suggest to my travellers - tell the doctor spontaneously that you've been away to help get to the diagnosis because that's where so many times things fail when the travel history doesn't come out.
PORTER
And briefly, if they're going to develop malaria how long after they got back would they normally develop symptoms?
BEHRENS
It usually comes within the first month, often within the first few weeks, but it can occur up to three months, so it can be forgotten.
PORTER
I want to move on to something less serious, now Ron, but far more common and that's travellers' diarrhoea, of which they are number of possible causes?
BEHRENS
There are huge numbers of causes. Up to 70% of people who travel get travellers' diarrhoea, so it's a very common problem. And it's as frequent in India, Kenya and the Caribbean.
PORTER
Because you often see these hot spots, don't you, cruising on the Nile and Mexico often gets them but it can happen to anyone anywhere.
BEHRENS
Anyone, anywhere.
PORTER
And what's going on?
BEHRENS
Basically I think it's foreign food, foreign bugs and new diet in combination.
PORTER
So it's not one clinical entity, it's a range of different ...
BEHRENS
It's a whole range of bacteria predominantly with viruses and other parasites that get into your body and gives you the diarrhoea.
PORTER
Is anyone at particular risk?
BEHRENS
I mean there are certain groups that are much more vulnerable - the elderly, for one sort of group of travellers, but also people who've got stomach problems or on drugs that suppress acid can be more vulnerable and certainly people who are on various medications - it can interfere with the body's ability to fight the bacteria.
PORTER
Pick up on this antacid thing because a lot of people are on these drugs - drugs taken for heartburn - and presumably that's because acid in your stomach is one of the first line defences against infection?
BEHRENS
Yep.
PORTER
Is the evidence clear cut on that?
BEHRENS
It's not clear cut but we know - the evidence is clear cut that if you've had surgery on your stomach you're much more vulnerable and it's the same - roughly the same mechanisms.
PORTER
And where do people classically go wrong?
BEHRENS
Well interestingly there's a lot of hygiene and messages that people are given to avoid the risk and I think people should try and follow them. But the science suggests that no matter what you do you still catch it. There are so many influences on you being exposed. For example, as I always point out, the fly that lands on the fork that you then eat with may well be the cause of your diarrhoea and you can't control where that fly comes from or where it stops and then what happens afterwards.
PORTER
So brushing your teeth in bottled water won't make any difference.
Well our reporter Claudia Hammond is all too familiar with travellers' diarrhoea but seems remarkably unconcerned by a forthcoming trip to Delhi. That's because she has a trick up her sleeve. But first proof that she's not the only one who's been caught short on holiday.
VOX POPS
I went on holiday to a Greek island called Paphos and we spent the whole day riding round on a little rented motorbike and we ate some street food, some chicken, which was really delicious. Increasingly during the day my stomach gurgled and I had some funny pains but nothing really happened until I got off the motorbike when I got back to the flat where we were staying and I literally only just made it to the loo and I was in there all evening.
I was in India, in Rajistan out in the desert, and I was on this camel trip. While I was on it I suddenly realised I had these unmistakable and hideous stomach cramps. And I tried just bracing myself and carrying on but it wasn't going to work. So in the end I had to dismount from this camel and I just simply had to go. Then I couldn't get back on the camel, I just had to sort of run through the desert behind this camel train, periodically pausing behind shrubs and doing what I had to do and it was absolutely ghastly in every sense.
We camped out in the middle of the night and I was woken in the night by stomach cramps. So I kind of had to jump out of my sleeping bag and run - run off to a corner out of everyone's hearing and obviously my stomach was very, very bad and there was an evacuation and of course it was pitch black, I hadn't gone with my torch or anything and I kind of toppled over and just put my hands in it and there was nowhere to wash, there was no water or anything like that and I just had to kind of clean it all off with sand and that was quite nasty.
HAMMOND
Oh horrible. Stories like these are a bit of a rite of passage when it comes to backpacking but it's not just backpackers, in fact two in five people who go abroad on holiday get ill with some sort of stomach problem.
Now I'm just packing for a trip to India for work and I've just about got everything I need and what I'm making sure I take with me is the special travellers' diarrhoea kit. Whenever I go abroad, anywhere remotely interesting, I'm always the first person to be struck down with stomach problems. And I last went to India - ooh what 13 years ago and I had bacillary dysentery and I was so ill and I was ill for ages and it kept coming and going, so I thought it was just separate stomach upsets and never got tested for it and so I never got treated. Got back home, carried on getting on thinner and thinner, lost two stone in the end, went to the doctor, finally got tested, had antibiotics and three days later I was better.
So the experience of that was horrible but then I read a paper in the journal The Lancet all about the use of an antibiotic called ciprofloxacin for use in travellers' diarrhoea. And I've got some here, it comes in a little bag in this kit. Now the idea is that you take this along with the tablets that stop diarrhoea. But what I don't really know is whether this is really a good idea and how exactly it works.
So to find out I've come to the old home of the British press London's Fleet Street, to visit Dr Richard Darwood at the Fleet Travel Clinic.
DARWOOD
I think every traveller has to recognise that prevention doesn't always work and I think that there are really three important things that people should consider at least being equipped with. Firstly, oral rehydration - I think it's very important to be able to correct fluid loss quickly and efficiently.
HAMMOND
So these would be those little sachets that you see, that are often blackcurrant flavoured or lemon flavoured and you add water to them?
DARWOOD
Exactly. I think the next thing that people need is something to control the symptoms and then finally antibiotics - and I think they do have a place and it's been shown very convincingly that early treatment is the best option for people who've got serious symptoms.
HAMMOND
And the one that's often used is cyprofloxacin, how effective is that?
DARWOOD
Well it is highly effective, it does cover most of the likely bugs. Something like 80% of people will have complete relief of their symptoms following the first dose of the antibiotics.
HAMMOND
And is there anyone who can't take it?
DARWOOD
Well it's not suitable for children, it's certainly not suitable in pregnancy for example.
HAMMOND
Now I got my antibiotics from a travel clinic but could you get them from your GP to take away?
DARWOOD
It depends very much on your GP and his or her interests and willingness to prescribe medicines for use in circumstances that they can't easily control. So some are a bit reluctant to do it, the NHS doesn't cover medicines for use outside of the UK, which is only reasonable.
HAMMOND
So you have to get it on a private prescription presumably. And one of the reasons that some GPs aren't keen on it is that they think you shouldn't be prescribing antibiotics to people who aren't ill yet and that they shouldn't be sort of carrying them around and having antibiotics floating about like this.
DARWOOD
This is the whole area of what you might call just in case prescribing and when it comes to looking after people who are going on exotic or adventurous or even fairly routine travel we know that there's a rate of illness that people experience when they're abroad, we know that there's a problem of access, even if they can get medical care in many countries they can't necessarily get access to high quality medicines. I think the time to prepare for this is really before you go.
HAMMOND
And even more controversial is the idea of taking antibiotics prophylactically if you're going to an area where you think you probably will get ill, would you ever recommend people do that?
DARWOOD
They're really exceptional situations where even the briefest illness couldn't be tolerated, perhaps either in somebody who's very, very vulnerable through ill health of their own or possibly because of the circumstances of a trip, perhaps they're on a military mission or they're a world leader zipping into a refugee camp to see something in circumstances where they absolutely have to be healthy. But for the vast majority of travellers it's much better to keep this as a treatment option up your sleeve for use in defined circumstances than to just take it willy nilly.
HAMMOND
Now I'm going to India next week for work and since I'm not a world leader I won't be taking it prophylactically but I'll take some antibiotics with me. Wish me luck.
PORTER
Claudia Hammond, who is in India now, so far so good.
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing the health hazards posed by travelling abroad with my guest Dr Ron Behrens.
Ron, do you travel with ciprofloxacin?
BEHRENS
I travel everywhere with my tablets in my luggage because it is such a frequent problem this treatment, in many cases, is so effective and it's cheap treatment - you can save two days of a holiday for £3.00.
PORTER
Because just one tablet will do it?
BEHRENS
One tablet will cure 80% or so of episodes.
PORTER
Now let's move on to rabies vaccination. The World Health Organisation have just launched a campaign to increase uptake of the vaccine amongst travellers. We think of it as a rare disease here in the UK but it's actually of course very common in some parts of the world and according to the WHO is now the tenth most common cause of death from infection. Ron, what is rabies?
BEHRENS
Well rabies is a virus which is transmitted by mammals, usually dogs, but in some cases even bats. And it's transferred through broken skin. Once it invades the body it travels up to the brain and that travel is a literal term because it does actually have to migrate right from the foot or the hand to the brain and that ...
PORTER
And that can be slow.
BEHRENS
And it can be very slow and in fact the longest incubation that we're aware of is 11 years. Normally it's much quicker than that and it can be days, months or years.
PORTER
And do you have to be bitten or can this be relatively minor trauma?
BEHRENS
It has to penetrate broken skin, so you can have a cut on your hand and touch saliva in some way or other and it could still occur.
PORTER
So it's the saliva that's virus laden?
BEHRENS
It's the saliva or body fluids in fact - blood or faeces or urine.
PORTER
And it's not treatable?
BEHRENS
Once you have the symptoms it is not treatable.
PORTER
So you could have a relatively minor nip and not think about rabies, be home, four, five weeks later, sometimes months later, and if you develop the symptoms that's it?
BEHRENS
That's it basically.
PORTER
And just remind us what those symptoms might be?
BEHRENS
Well basically you get inflammation of the brain but very typically you become drowsy, you become disoriented, you can become quite aggressive. And in the last stages of this disease you develop what's called hydrophobia, which means you become frightened of water and you start behaving in bizarre ways when you hear or smell the seawater. It's a rare feature but it's what it's most commonly recognised by.
PORTER
Well it may not be treatable once you develop the symptoms but there is an effective vaccine, as I said it's the subject of a current World Health Organisation campaign. Dr Mary Warrell is from the Oxford vaccine group.
WARRELL
Rabies vaccine is extremely effective, there are no deaths from rabies known in anyone who's had this preventive course before they go - that's three doses of vaccine spread over a month. And then have booster doses if they are bitten sometime.
PORTER
And how well tolerated is the vaccine, does it cause any problems?
WARRELL
It is a safe vaccine and the main problem about having the vaccine is the cost. In this country now for a three dose course in the region of £90 and there are some students who don't have the vaccine because of the cost.
PORTER
What happens if you're travelling to a rabies endemic area but you've not had the vaccine and you think you may have been exposed, what should you do?
WARRELL
Any animal bite should always be immediately washed very thoroughly with soap and water, rabies is not the only infection you have from animal bites. And then you should seek the best medical help and they will tell you whether or not you should have a course of vaccine.
PORTER
So the vaccine can be given in the event of exposure?
WARRELL
Yes most of the rabies vaccine used worldwide is used after contact with a rabid animal and then it is a five dose course and rabies immune globulin, which is a ready made antibody to act immediately against the virus and this is also needed.
PORTER
And how effective is that if it's given after the event and how quickly does it have to be given?
WARRELL
Well ideally it should be given on the day of the bite and if the ideal treatment is given immediately then it is also very effective. But delays occur, the vaccine is often not available or affordable and immune globulin is a major problem because there's a global shortage, it is very expensive and hard to find and people should travel as far as is necessary, even returning to Europe, to have the correct treatment. But I should also add that if you've had the preventative treatment, the vaccine, before you leave you do not need this whole course of vaccine, you have a short course - just two doses of vaccine - and rabies immune globulin is not necessary.
PORTER
So the key message is that more people should be having the vaccine to protect themselves, the worse that's going to happen is that they won't have to cut short their trip after a relatively minor exposure and the best that happens it could save their life.
WARRELL
Certainly. I think that travellers to Asia, Africa and parts of South America should be very keen to have this excellent treatment.
PORTER
A very pro-vaccine Dr Mary Warrell talking to me earlier from our Oxford studio.
Ron, so far we've talked about jabs and pills effectively but there's a lot more to travel medicine - rabies being a case in point.
BEHRENS
Absolutely, I mean rabies is a good insurance but actually you can stop yourself getting rabies by not petting, handling, touching dogs. And in fact in a study in Thailand over 13% of travellers came into contact with an animal. So really the most effective message is really avoid contact.
PORTER
Presumably many of whom were unaware that they were in one of the worst areas for rabies in the world.
BEHRENS
Absolutely.
PORTER
Let's look at other threats - what do you think is the biggest single threat facing travellers as they go abroad?
BEHRENS
Well actually there are two important threats - the first being any injury and trauma, injury and trauma kills nearly as many people as another threat, which I'll talk about. But that threat really is related to change in behaviour and people behave differently when they travel - they drink and drive, they wear - they drive motorbikes and don't wear helmets, they are more likely to have accidents around resorts and that's been shown. And so behaviour related morbidity, particularly trauma, is particularly important. And alcohol is an important contributing factor. And trying to get people not to do stupid things is actually one of the messages I try and put across, highlighting the fact that they don't intend to but they do change their behaviour.
PORTER
Yeah I mean the drink driving example of people who would never dream of drink driving here in the UK, sometimes don't give it a second thought when they're abroad as if the risks are somehow less.
BEHRENS
And driving without a seat belt. In fact the statistics from the travel authorities show that you are a hundred times more likely to die on the roads in India than you are in any part of Europe per vehicle. So that is the actual risk of being injured on the roads.
PORTER
And of course the other behavioural problem is I presume sexual health - exposure to sexually transmitted diseases?
BEHRENS
That's exactly right and it's the same reason - people change their behaviour. And I think alcohol is a very important contributing factor to that.
PORTER
What about people who've got existing medical problems? One of the things that I see in the practice is someone, they have a heart problem and then they say now I deserve a holiday and they go off to the far end of the world ...
BEHRENS
That is the commonest cause of deaths in travellers - people who've got underlying medical problems who travel and they then obviously have an exacerbation or a complication. And as you point out if you've just had a heart attack the worst thing you could probably do is go on a holiday to a tropical country because one, that trip may make things worse; secondly, access to medical care is much more limited and thirdly, you're out of an expert environment. So really underlying medical problems requires very careful attention and very careful discussion and particularly insurance and this is another big problem I come across is that people don't appreciate that even if you're taking blood pressure tablets or cholesterol tablets you need to be properly insured because if you have a heart attack you will not be properly covered for that without having it declared.
PORTER
Particularly in somewhere like America. So it's the pills and jabs that often drive people in for travel advice but they're not necessarily the most important part.
BEHRENS
No, what I do is I educate people, tell them to look after themselves and particularly how to manage problems as they arise and that really is what I feel I'm most usefully doing for them and I'm glad that they come to me for a jab but they come out much the wiser.
PORTER
Dr Ron Behrens, thank you very much, that's all we have time for.
Don't forget you can listen to any part of the programme again by using the Listen Again facility on our website bbc.co.uk/radio 4. Next week I'll be finding out how advances in medicine have transformed the odds of survival for people who have sustained serious head injuries. But, as I'll be discovering, surviving the initial trauma is often just the start of a much longer journey of recovery, from which few emerge completely unscathed.
Ends
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