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The University Traveller

… Prepared by  TMA  Clayton, Vic:  Dr Craig Blandy,

Travel Risk has a Social Denominator

The university traveller travels to a university in another country for their studies or work. Over 2 million people travel for this purpose each year. The Australian Government Outbound Mobility Study (2008) states that there are 400,000 inbound people living in Australia on student or educational work visas and around 30,000 outbound. Most of these people link their academic and travel ambitions into a cultural experience. Australian universities are vibrant and culturally diverse communities that have evolved over the past decade as major contributors to world education.

Monash University operates a University Health Service for all students and staff. The Clayton campus has a population of nearly 20,000 with student enrolments and staff from nearly every country. These world people allow us, at the health service, the privilege to be the virtual traveller, enriching our travel experiences with their stories of home. It also allows us an insight into the influence of normal social customs and cultural exchange as risk factors in travel.

The desires and the risks of travel appear to have common denominators that are based in the learned social existence of the country of residence. Overall infectious disease is not the major risk to the health and wellbeing of travellers. The risks are embedded in the normal social behaviours of the landed destination abutted with those of the visitor. Those things that are known to the resident and are unknown to the visitor; or even those things experienced by the resident and not by the visitor.

There is a consistent message of understanding the nuances of the society; its rhythm. Most of the health risks of each group can be categorised in the same way; whether the person be here or there.

Preparation for Travel

Most inbound university travellers spend months studying the local nuances of life in Australia prior to arrival and are not easily misled by the early teasing of fellow students with stories of “drop bears” and “street kangaroos”. There is an American-Australian slang dictionary that is usually well studied to minimise social embarrassment such as the oft quoted example of the young man introducing himself to a young woman with “Hi … I’m Randy (Randolph)”.

Monash students travelling to overseas campuses of Monash University and overseas universities receive orientations to achieve a destination and cultural familiarisation.

First Principle: Understand the rhythm of the destination

Local Laws

Medications and Drugs
Australian customs law allows a person to bring with them up to 3 months of medication with evidence of its proper prescription in the country of residence. Many North American students are prescribed various medications for a range of mental health issues. Some of these medications are illegal in Australia. Australian customs law permits these students to carry with them a 3 month supply and then an Australian doctor needs to be consulted to gain special access to the medication. Each year there are students visited by efficient Australian customs officers following attempts to import medications, legally prescribed in another country, that range from marijuana to amphetamine derivatives. All travellers need to be aware of local laws; in this case ours.

For the outbound Australian it is illegal to take pharmaceutical benefit medications from Australia other than for personal use. Read more here.

A common request made to doctors is a letter listing the persons prescribed medications. This letter needs to describe the medication, form, strength and quantity needed. At the University Health Service we seek consent to declare the reason for use of the medication on the letter. Despite this letter, and the legitimate prescription of your medication in Australia you may still find yourself in close confrontation with foreign customs or police, just like some of our inbound students. In Greece it is illegal to transport codeine in any form, regardless of its clinical indication, and Singapore’s prohibition on chewing gum extends to Nicorette. So contact the embassy of the country you are visiting to ensure the medicine is legal in their jurisdiction. It is a good idea to carry medication in the original packaging to minimise confusion.

Second Principle: Understand the customs and laws

The Road

The major health risk to all travellers is road related injuries. The dangers of road and pedestrian travel have been addressed in the TMA Newsletter of August 2010; road travel in Vietnam. In Vietnam the traffic does not stop, like a school of fish it parts and goes around objects and those who have socially adapted responses to these patterns see it as organised, functional and in continuous flow. If you live there it has a predictable mass movement. In Bangkok it is more likely that mass movement is a complete stop, but it is consistent.

The student from Asia is not used to the pulse regulated movement of Australian city roads. It has a different rhythm; known to the resident and not to the visitor. It appears chaotic here with vehicles travelling at different speeds, in different lanes, changing lanes, and with incoherence in movement. How can a pedestrian find a path through a flow of traffic that has no tune? Why is a car required to stop just after just getting to speed? Given the predictability of the stop it makes little sense to get there quicker.

Many of the return travel consultations seen at the university health service involve accidents that occurred overseas; half of these relate to transport; roads, scooters, bikes and even walking. The risk that leads to the accident is often the lack of understanding of the rhythm of the road. In the main cities of Eastern Europe a pedestrian crossing offers the right to cross the road when it is clear; not a right to cross the road.

In the Baltic States it is a legal requirement for pedestrians to display reflectors, although this relies on vehicles having lights. Transgressors of either law face the same penalty and that penalty is increased by a factor of ten if either is under the influence of alcohol. The Nordic countries also advise reflectors.

Third Principle: Understand the Road

The Beach

Many visiting students cannot swim or do not know of the real dangers of the Australian seaside. They have a fear of Australian sharks and for this reason spend most of their time in the shallows, the rock pools or at the water’s edge. Some students have been injured peering into “blow holes” or experienced intensive medical care after collecting the blue-ringed octopus fascinated by its capacity for glowing blue rings. These are risks known to the resident and unknown to the visitor.

Outbound students have been known to organise travel plans around holiday destinations and walking on the beach can provide different risks; known to the resident and unknown to the visitor.

Chigoe “Jigger” Flea

The jigger flea is found in tropical and sub-tropical climates, particularly in many parts of Latin America, the Caribbean, and sub-Saharan Africa. In Brazil, it can be found both in northern and southern regions. At 1mm it is not seen by human eyes. It burrows into the skin for blood meal whilst incubating the offspring and swells to become a blister or even a callous. These nearly always become infected.

Hook Worm

At the edge of the beach, where the city merges with the sand are found the products of city life. Immersed in the sand the hookworm  may be waiting to complete its life cycle in the human. They are more common and more frequent in warm destinations where feral animals roam and barefoot walking is hazardous from more than the hookworm. There was a recent outbreak on a Miami beach traced to feral cats.

Fourth Principle: Understand places of recreation

Going Home

Our health service has the curious role of giving travel advice to world travellers on completion of their studies. Some have been away from home for five years and started a family. Natural immunity to exotic diseases such as malaria, typhoid and hepatitis A is diminished and their children have started life in a community relatively free of infectious diseases. Everyone needs their vaccinations updated including the vaccines they did not receive as children in their home country. There is also the risk that the rhythm of home may be forgotten.

Our university outbound travellers eventually become inbound. Most of their presentations relate to the following principle:

The Rhythm of Travel

Communities follow a socially constructed way of life; a rhythm. To reduce your travel risk at your destination learn the rhythm of the community and apply this to the road, the beach, the food and the law.


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Antarctica 2012

Dr Jason Rajakulendran, TMA member Sandringham, Victoria:

As I marvelled over another penguin documentary in 2010, I wondered.. for what length of time would Antarctica remain as it does today? A place of unparalleled isolation, natural beauty and biological diversity yet relatively untouched by human activity. In a win for common sense, an Antarctic treaty exists between the various countries vying for territorial claims. It specifies that the continent be used primarily as a place of research and not for resource mining until at least 2041. This question pushed me to book a trip about twelve months prior (increasingly the need due to booming Eco-tourism) and find out for myself. My easiest option was to depart on a ship from the Argentine port of Ushuaia after acclimatising in the Patagonian wilderness.

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Travelling with Cancer

…Written by Alice Springs TMA member : Dr D Mitchell

Special issues regarding flying
  • Cerebral oedema (swelling on the brain) may develop at altitude in people with brain tumours and within 6 weeks of craniotomy. Although there is no specific data to support the practice, anecdotally those patients with a brain tumour who are stable on a steroids, are usually advised to double the dose the day before air travel, and then to drop the dose back once they arrive at their destination.
  • Confusion and psychosis can occur during flights due to hypoxia and many other causes even without brain disease.
  • Intra-abdominal gas expansion can occur during flights within 10 days of bowel surgery or colonoscopy causing pain and threatening wounds. I have experience first hand after laparoscopic surgery… the experience was 8 days post-operatively, and the sensation was that I honestly thought I might explode! It was truly very unpleasant and I had wished at the time that we could have driven home instead of flying.
  • Exacerbation of lymphoedema (swelling of limbs) can occur during and after long air flights. Prophylactic use of compression garments can be useful at times.
  • Expansion of pleural effusion and ascites (fluid in the chest or abdomen) can occur during a flight but rarely develop quickly enough to cause acute symptoms.
  • Low cabin humidity may disturb or distress patients with dry mouths after radiotherapy or from narcotic medication. Hamilton’s Aqua spray may be helpful, FESS saline spray may assist with nasal passages and sucking on something acidic like pineapple juice can assist with dry mouths.
Other issues
  • Insurance: some health insurance providers may not cover people with cancer who travel outside Australia. Discussion regarding travel insurance should occur well before any trips are planned and booked.
  • Extra costs: The patient may need an escort and travel with their own oxygen or other medical equipment.
  • Medications: All prescription medications should be in carry-on luggage and ensure you have an appropriate letter for customs officials simvastatin online. Extra supplies of medications should be carried in case the return trip is delayed.
  • Medical documentation: Patients should carry a detailed letter from their treating doctor (oncologist, GP or other) covering the medical diagnosis, the treatment plan, any allergies, current medications and potential plans for the future in case of a change in condition. What has been discussed about specific interventions and resuscitation orders need to be clear . The timing of prescribed medication may need to account for time zone changes, eg pain medication still needs to be taken regularly.


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RUM Project … Spot Quiz

What you are supposed to do with old or expired drugs that may be laying around your house?

A) flush them down the toilet
B) put them in the household rubbish
C) thrown them in a fire
D) give them to the RUM Project
E) use them anyway – waste is bad

The correct answer is D 
It is not safe or environmentally friendly to put expired medication in the household rubbish, and especially do not flush them down the toilet. Medicines can contaminate the environment when discarded via landfill sites and sewerage facilities. Many medications are supplied packaged in blister plastic made of PVC, which, when incinerated, produce dioxin (usually found in Agent Orange).

RUM in this circumstance is not what we mix with coca cola, RUM stands for Return Unused Medicines. It is a free service, funded by our taxes. Your local Pharmacy has special yellow bins to receive the medicines, which are then sent for high tech disposal in Victoria. RUM guidelines advise it is best to remove cardboard outer packaging (and place in the household recycling paper bin). Then, take the meds to shops next time you go, and deliver the used tablets, bottles and blister packs… to your local pharmacy. Many TMA member clinics will collect expired drugs when restocking kits, and drop them at the pharmacy for you. More info.

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Travelling Children

Travelling Children
Some recent studies have documented the likelihood of illness in children travellers. They reported roughly one in 3 children who travel abroad, will acquire a travel-related illness. Diarrhoea, feverish illness, skin conditions, and respiratory problems were the most common. Infected insect bites and sunburn also rated a special mention. Risk varied by age groups and destinations (greatest for African destinations). Young children visiting friends and relatives in Africa or Asia were at greatest risk; they visit places less frequently visited by tourists, and so are exposed to more of the local diseases.In the U.K., imported diseases account for 2% of pediatric hospitalizations. In one group of child travellers with fever; 59% had specific diagnoses, mainly malaria, glandular fever (highest in age group 15-19 years), and dengue fever. There were also cases of typhoid and paratyphoid ( from Asia); meningococcal meningitis, tuberculosis, visceral leishmaniasis, and hepatitis A simvastatin 10 mg.

One study also highlighted high rates of fatigue, itching, nausea, and sunburn while children were abroad; symptoms of which were not common in adults. Interestingly, one study found children received four times more insect bites than their in parents. Adolescents (aged 15-19 years) behaved more independently, undertook more adventure travel and backpacking, and were more likely to acquire glandular fever, sexually transmitted diseases, and suffer trauma.


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Waterways at the Centre of the Earth – From Panama to Darien

TMA Member Goondiwindi : Dr Rowena Sheppard

The 77 kilometre long engineering feat known as the Panama Canal, is truly awe inspiring – a testimony to foresight and imagination, and to man’s ability to literally move mountains and to overcome the diverse obstacles of politics, finance, weather, landslides and tropical disease. The story of the canal, is also the story of yellow fever to which over 22,000 canal workers succumbed. Through the astute observations and efforts by Dr William Gorgas our first understanding of mosquitoes as a vector of diseases came into being. Even today Yellow Fever has case fatality rates of up to 50% in some parts of the world, but the canal itself has been declared Yellow Fever free.

It is astounding to see a 50,000 tonne steel ship rise above you as water fills the lock ahead, to watch the sun rise over the Caribbean and set over the Pacific. A maze of quaint “mechanical mules” haul the ships along through the locks, keeping them within feet of the sides, co-ordinated by a thousand eyes and voices, mingling with the groan of metal and the sounds of the jungle just beyond. A bustling and booming Panama city abuts the western verge of the canal.


Less than 400 km South of the highly trafficked Panama canal, lies one of the worlds most inaccessible waterways, in the hot humid, and heavily forested Darien jungle, a travellers journey backwards in time, in dugout canoes, into the sparsely villaged homelands of the Embera Indians.

Panama’s legendary Darien jungle and the 50 km wide delta of the Atrato river has defeated the Pan-American Highway and numerous attempts to tame and “civilize” its pristine wilds. This has largely protected the natural and cultural heritage in the area.

The Darien jungle has never taken kindly to drop-ins. In 1699, 900 Scottish settlers rushed headlong into the jungle. Indians or malaria killed most within months. In 1854, an American expedition began hacking through the tangle of deadly snakes and Gordian roots in search of a canal route. They wound up lost and so hungry they ate their dead. The Darien province can still play host to malaria and yellow fever, though the incidences are now much lower than that faced by our forebears.

Given this history, it is perhaps unsurprising that fewer than 700 DEET soaked tourists visit Darien province’s rain forests each year, bringing meager income to the locals. One is statistically more likely to meet a mercenary, narcotic trafficker or a logger than a camera toting tourist, but I was fortunate to be in the latter group and to be introduced to its gentle and still naïve peoples. Let us hope the eco-tourists prevail to help preserve this “soul” of Panama.

… Prepared by Dr Rowena Sheppard, Goondiwindi TMA

Goondiwindi TMA Clinic

Cressy Clinic is a truly country practice, situated 5 km out of Goondiwindi, across a couple of grids, and often with a few roos outside in the paddock!

Dr Rowena Sheppard has been a general practitioner in Goondiwindi for 23 years, with one of her many hats being the ability to provide accessible travel related medical services to the local community.

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South African Holiday

TMA Member – Geelong Dr Paul Davey


Dr Paul Davey the medical director of The Travel Medicine Alliance Clinic Travel Health Geelong has recently travelled to South Africa riding a motor bike for three weeks around this amazing country. Here are his thoughts regarding the safety of this destination.

South Africa is a wonderful place for an adventure and a holiday. I decided to travel there after talking to some clients who had recently returned. They had loved their trip but then made the observation that they were glad they had travelled now as they weren’t sure of what was going to happen to the country, and to its political stability when Nelson Mandela dies. I have for a long time advised my traveler clients that if they want to travel and the opportunity to go is present then go. If a trip is delayed obstacles can arise and we may never end up going. I decided I should follow my own advice and booked the trip.

Safety in South Africa

Lots of people who haven’t been to South Africa expressed concern re the safety of travelling in South Africa. We checked this out with the tour operators who gave very sensible advice.

“Most of the crime that occurs in South Africa takes place in the poor township areas and mainly affects the local people. We recognize that personal safety is an issue. In the big cities precautions are needed and we suggest the following: Don’t flaunt wealth; Don’t walk around the cities at night; Travel by taxi to destinations at night. With caution you can stop bad experiences happening.”

We had a wonderful time in South Africa, and following the above advice and being cautious meant that on no occasion did we feel that our safety was threatened. In the smaller rural towns we perceived no risk at all. The people were amazingly friendly and every South African we met loved their country.

General Advice

Dr Paul Davey has offered two general travel advice suggestions following on from his African Travel.

Seek Expert Travel Medical Advice


Whilst at a private game park in the Kruger National Park region, we met an Australian couple arriving late in the afternoon. They looked exhausted and I asked if they had come far and they explained how they had been staying only about 40 km away but had had to travel 600kms that day. As they were leaving in the morning for the short drive they had mentioned how after visiting the game park they were travelling on to Victoria Falls. They were then asked if they had been vaccinated against Yellow Fever. They hadn’t and when told that they wouldn’t be permitted back into South Africa unless they were vaccinated they had to make a 300 km trip to a medical centre where they could receive this vaccination. Before leaving Australia they had been to their local doctor and had asked regarding the need for this vaccination. Their doctor had checked regarding this and advised them that it wasn’t required. Unfortunately for them the immigration requirement by the South African government changed last year and it is now a compulsory vaccination against Yellow Fever if returning from Victoria Falls.

Travel Insurance is a MUST

During a motor bike trip our lead rider crashed into a truck whilst travelling at 120km/hour. Following this accident and whilst attending to the rider I attended a small medical clinic in Swaziland and then a larger clinic in South Africa before he was evacuated back to Pretoria. Our friend required road ambulance and air ambulance transfer and then open heart surgery to treat his injuries. The local facilities were basic at the level of a school first aid clinic. Transport to first class facilities was essential. The cost of the evacuation and treatment would have been astronomical. Travel Insurance in general and also specific insurance designed to cover the costs associated with increased risk activities be they motor bike riding, or mountain climbing or snow skiing or boarding is essential for all overseas travel.

… Prepared by Dr Paul Davey, Geelong TMA

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Kayaking in Remote Solomons 
- Morovo Lagoon

Prepared by TMA Member Maitland

Public Health Physicians also need travel health advice. Another satisfied (and healthy) Chromis customer. And the beautiful fish is our symbol. Check our website for more information on us and our services.

As we set out that first day, my daughter was convinced we were in a travel commercial. Under blue skies we paddled through clear warm tropical waters with spectacular views of the coral and sea life below. There were mangroves and palms to the waters edge, an occasional idyllic sandy beach and hardly a soul around. And even when the heavens opened that afternoon, we were delighted. Paddling in warm rain!

We camped in tents on a tiny uninhabited island that first night then visited local lodges for the next two. We explored islands and villages, clambered to a waterfall, shared an impromptu evening of music and had a brief insight into local culture and history. This is a beautiful and undeveloped region and kayaks are such a gentle, peaceful way to explore it.

Back at Uepi we sadly returned our boats and settled in for days of exploring the local reefs. The dive from the resort jetty was amazing; school fish, giant clams, reef sharks and a scorpion fish. And then there were scores of other snorkelling sites a short boat ride away; big drop offs, coral gardens, sea snakes and crayfish and an extraordinary diverse range of fish. On one special pre-breakfast snorkel our family had exclusive water time with a school of Manta Rays.

By good fortune our visit coincided with the Festival of Pacific Arts and Honiara was host to a superb mix of neighbouring peoples. For a few fascinating nights we soaked up the singing and dancing, traditional arts, short film festival, photo exhibition, and fireworks. Good fun.

We loved the Solomons and would happily return. We took the usual enteric precautions, took antimalarials and stayed well.”

… Prepared by patient of Chromis Travel Medicine Service 

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Acute Mountain Sickness (AMS)

… Prepared by TMA Member Maitland: Dr Puru Sagar Chromis

A survey among travelers departing from Cuzco International airport in Peru showed that almost half of all travelers (48.5%) interviewed reported symptoms of altitude sickness, and 17% had severe AMS. One in five travelers with AMS was forced to alter their travel plans. Three people were admitted to hospital and one was urgently evacuated.

Only one-sixth (16.6%) of the group used Acetazolamide (Diamox) for prevention of AMS, but more than 60% used coca leaf products.

Unfortunately, the use of coca-leaf products (usually tea) was found to be associated with a greater risk of developing AMS in this study. Use of coca-leaf can have other negative side-effects (changes in circulation and cardiac arrhythmias) as well as a positive urine drug screen to cocaine.

Other recent reviews have found that Diamox 250 mg half tab twice daily reduced the risk of developing AMS by about 48%. There was no benefit in taking higher doses. Diamox is strongly recommended for travelers flying into Cuzco (elevation 3,225 m) and is often required at lower altitudes (around 2,000 m).

These scientific studies underline the need to obtain accurate and up-to-date advice from an experienced travel medicine practitioner before undertaking trips to altitude. Prevention is really worthwhile.

The Travelling Well iPad app or iBook from Dr Deb the Travel Doctor has very useful information on preventing and recognizing altitude illness.


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No vaccines will prevent this one though being knowledgeable of your accommodation and environment might help. This rare, but rather topical virus is carried by rodents and can be passed on via contact with their excrement. It occurs in both North and South America and East Asia and was first isolated in 1978 in Korea.

No known illness has occurred in Australia though antibodies have been found in rodents in this country. The virus causes both respiratory disease (hantavirus pulmonary syndrome [HPS] and haemorrhagic renal problems [HFRS] with about 30% of those inflicted dying of the disease. Interestingly, it was investigated as a biological warfare agent by the US government – though this doesn’t happen nowadays. Imagine being attacked by weponised mouse urine!

A major outbreak has occurred in the United States over the last few months and new cases are still being discovered. There have been nine confirmed cases with three deaths in travellers to the ever popular Yosemite National Park. Most of the cases relate to a cluster of illnesses around the Signature Tent Cabins in Curry Village. Park records have shown that at least nine Australians could have been exposed in the period between June 10 and August 24 and urged to seek medical review if they become unwell. More info.

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