Travel and health: make sure your dream overseas event doesn't turn into a nightmare!

Andrew Hamilton looks at how athletes training and competing abroad can stay well and ensure maximum performance

The Brazilian author Paulo Coelho once wrote “If you think adventure is lethal, try routine!” Going somewhere different is great for the mind. Going somewhere different to train and/or race is great for the mind and body – witness the rise in popularity of races, competitions and training camps in exotic locations. However, athletes intending to travel to faraway shores this summer for that dream event also need to think ahead; an infection or bout of illness can not only scupper race performance, it has the potential turn your dream adventure into a nightmare. In this article therefore, we’ll look at how you can best protect your health and fend off illness both before you leave and while you’re away.

Illness and the athlete

Modern life seems to be full of health and safety regulations and health advice warnings. Indeed, many people of a more ‘mature’ age (myself included) who grew up in a far less regulated world, might often wonder how on earth we managed to survive this long! However, before you write this off as just another ‘nanny-state gone mad’ article, you need to remember that as a competitive athlete, your needs when travelling abroad for training camps or competition are different from Mr or Mrs Couch Potato.

When your goal is to travel in order to compete, you need to bear in mind that any illness or infection can have a much greater significance. For example, even a mild tummy upset or upper respiratory tract infection (cough, cold, sore throat etc) that wouldn’t really bother the average holidaymaker can be very detrimental to an athlete’s individual performance. The same is true for longer-lasting infections and post-infectious periods, without full recovery of physical performance. When a sedentary office worker has already recovered enough to return to work, most athletes are still performance impaired, or even unable to train. Also, evidence suggests that during particularly strenuous training and competition, illness can make athletes potentially more prone to infections than their sedentary counterparts^{J Exp Med. 1970;131:1121–36 Am Heart J. 1989;117:1298–302 Eur J Epidemiol. 1989;5:348–50}.

If you’re heading off on a training camp or planning to participate in a prolonged period of competition therefore, you need be proactive about protecting your health. Panel 1 shows the key areas you need to be thinking about as soon as you select your destination(s). You also need to be aware that the time constraints around some vaccinations (see later) might mean that a short-notice trip becomes a risky proposition, in which case you may have to consider different destinations.

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Panel 1: Pre-trip planning

The best approach to ensuring maximal health while you travel abroad is to adopt a planned, stepwise approach:



Research your destination (not just the country, but also the region(s) of the country you will be visiting or residing in). The prevalence of disease and associated health risks can vary tremendously from area to area within a country. Consider your accommodation too; in the tropics for example, better food hygiene and creature comforts such as air conditioning can make staying in modern hotels in a large city less risky than ‘less salubrious’ rural accommodation.



Identify which vaccinations are needed for your destination (see table 1). Contact your doctor at the earliest opportunity to arrange a consultation. He/she should be able to arrange for the necessary vaccinations. Remember however that the issue of the ‘best’ vaccination plan isn’t cut and dried. That’s because general public health vaccination guidelines cannot be easily transferred to elite athletes for all the reasons given above. As a rule of thumb, the evidence suggests that for athletes, a more aggressive vaccination plan is better than a minimal one^{Sports Med 2014; 44:1361–1376}. For example travellers from the UK heading to Nigeria are minimally ‘advised’ to have vaccination courses or boosters for diphtheria; hepatitis A, poliomyelitis, tetanus, typhoid and yellow fever. It is also suggested they consider vaccination against cholera, hepatitis B and meningococcal meningitis. Discuss your individual requirements with your doctor (erring on the side of caution).



Draw up a vaccination plan with your doctor. The timing of the vaccinations will to a certain extent be dictated by the vaccine requirements. However, if you plan ahead, there’ll be quite a bit of flexibility. This can be useful as some vaccinations may have temporary side effects and you’ll want to avoid timing these before any other competitions prior to your trip abroad.



Arrange your travel insurance well in advance, making sure it includes ample medical cover. Most experts recommend £2m of medical cover if you are travelling abroad, which should include repatriation in case you need to be flown back to the UK. Many insurance companies also offer a 24-hour emergency helpline, which can be extremely useful, particularly if you are in a different time zone. Make sure any insurance you buy covers you for participating in sports activity, including race/competition. It might cost a bit more but is worthwhile for peace of mind. Also check to see whether there are any Foreign & Commonwealth Office (F&CO) advisories against travel to your destination country or region (for example due to the threat or terrorism or civil unrest). If there are, bear in mind that most insurers will not pay out should the worst come to the worst.



Before travelling, put together a medical bag with essentials for minor illnesses. Some things to keep in your med kit include medicines for the common cold and sore throats (remember it will be winter if you travel to the southern hemisphere); anti nausea and diarrhoea medicine; medicine for aches and pains; antiseptic ointment, plasters and bandages; and original containers for all prescription medications. Put any emergency numbers in your med kit, including that of your doctor/medical practice, next of kin and of course your health insurance details while travelling. Make any extra copy or two of this in case you misplace it while away.

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Which vaccinations?

Deciding which vaccinations you will need is something best discussed with your GP. As already mentioned, some vaccinations are strongly recommended, while others are ones that you might wish to consider. The recommended vaccinations are not only dictated by your destination and accommodation, but by your anticipated sporting activities.

Mountain bikers for example are at higher risk of crashes and spills; it’s especially important therefore that tetanus immunisations are kept up to date (tetanus infections can be easily picked up from the soil through an open wound). Tetanus infection is potentially very serious. During the years 2001 to 2008, there were 233 tetanus cases in the United States, with a 13% fatality rate (30 deaths). Worldwide, tetanus is a significant cause of death worldwide, especially in Asia, Africa, and South America. In 2006 alone there were 290,000 fatalities worldwide from tetanus^{Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association; 2008}. Bear in mind also that not every infectious hazard can be vaccinated against. Some may require you to modify your activity or take special precautions. An example of this is a disease called melioidosis, which is a seasonal hazard across parts of Northern Australia and Southeast Asia (see figure 1). Melidosis is caused by bacteria called burkholderia pseudomallei, which normally live deep in the soil. However, after heavy rains, they can be found on the surface, in muddy puddles and can even be airborne.

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Figure 1: Worldwide prevalence of melidosis^{Trans R Soc Trop Med Hyg,102 Suppl 1(SUPPL. 1),pp. S1-S4}

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Once inside the body (usually through a cut or graze, or through the lungs if inhaled) symptoms can appear up to 21 days later, and can include a chest infection, difficulty breathing, fever, confusion and a headache. Treatment involves antibiotics, but between 10 and 15 per cent of infected people die from the disease even with the best medical care. The recommendation therefore is that waterproof footwear should be worn when walking or running through muddy or wet terrain, while gloves should be worn to prevent soil or mud-soaked items coming into contact with the skin.

As a rule of thumb, the vaccination requirements are greater in tropical and sub-tropical countries, and also in poorer and developing countries whose health infrastructure is likely to be less well developed than in modern Western nations. Table 1 below shows the recommended vaccination requirements for athletes travelling to developing countries (where the requirements tend to be highest).

TABLE 1 RECOMMENDED VACCINATIONS FOR TRAVELLERS TO DEVELOPING COUNTRIES 2022 10 04

VACCINATION	LESS THAN 2 WEEKS	LENGTH OF STAY 2 WEEKS TO 3 MONTHS	MORE THAN 3 MONTHS	COMMENTS
Review and complete age-appropriate childhood schedule.DTaP (diphtheria, tetanus, whooping cough), poliovirus, pneumococcal, and Haemophilus influenza type b vaccines may be given at 4-week intervals if necessary to complete the recommended schedule before departure.Measles: 2 additional doses given if younger than 12 months of age at first doseVaricella (whooping cough)Hepatitis B*	Recommended	Recommended	Recommended	*If insufficient time to complete 6-month primary series, accelerated series can be given.
Yellow fever	Recommended	Recommended	Recommended	For regions with endemic infection.
Hepatitis A	Recommended	Recommended	Recommended	Indicated for travellers to areas with intermediate or high endemic rates of Hep A infection.
Typhoid fever	Consider	Recommended	Recommended	Indicated for travellers who could be consuming food and liquids in areas of poor sanitation.
Meningococcal disease	Consider	Consider	Consider	Recommended for regions of Africa with endemic infection and during local epidemics. Also required for travel to Saudi Arabia.
Rabies	Consider	Recommended	Recommended	Rabies vaccination is not routinely recommended since the vaccine has a high number of considerable side effects and the disease might be prevented by exposure prophylaxis. It should be possible to prevent animal bites in athletes by other measures and, when an incident occurs, postexposure prophylaxis can be administered even after the bite. The recommendations here therefore pertain to those travelling in remote areas where rabies in endemic, and where access to prophylactic treatment may be difficult.
Japanese encephalitis	Consider	Consider	Recommended	For regions with endemic infection. For high-risk activities in areas experiencing outbreaks, vaccine is recommended, even for brief travel.

Most races and/or training camps take place in more developed regions, with lower vaccination requirements. However, given that participating in certain sports can increase your risk of infection (and also remembering that athletes may need a more aggressive approach to vaccination), the need to sit down and discuss your requirements with your GP or physician cannot be stressed enough. He/she will also be aware of the latest travel health advisories, which can and do change at short notice.

A final word on vaccination; while much of the emphasis is on immunisation against tropical diseases, you should also think about flu vaccination, especially if travelling to the southern hemisphere, where the coming months are winter months – ie influenza season. This is the case even if you had a flu jab last autumn, because differing vaccines (containing different flu strains) are often recommended in the northern and southern hemispheres.

While away

Properly vaccinated, you’ll be protected against most serious illness and infections while away. However, no amount of vaccination will protect you against common forms of gastroenteritis, which is the most frequent complaint of travelling athletes^{Clin J Sport Med. 2011 Jan;21(1):62-66}. Known more commonly as travellers’ diarrhoea (TD), gastroenteritis is usually caused by eating foods contaminated with viruses, bacteria, or parasites.

Gastroenteritis occurs very frequently when travelling abroad, especially to the tropics. During a reconnaissance trip to India prior to the Youth Commonwealth Games in 2008, the support team experienced a 50% incidence of TD! With that in mind, scientists at the Olympic Medical Institute in London sought to develop a protocol to prevent and manage TD in athletes^{Br J Sports Med. 2009 Dec;43(13):1045-8}. The researchers implemented the following strategies with the athletes during their later travel to the games themselves:

• All team members received written and verbal guidelines for the prevention of TD (see box 2).
• Researchers gave all team members hand sanitising gel along with guidelines for its use.
• Management offered team officials optional antibiotic prophylaxis (ciprofloxacin)8.

During the subsequent trip, the prevention protocol was implemented and only 20% of the team members reported new onset of TD. The team managed these illnesses with fluids, solid flood as tolerated, and the drug Loperamide (Imodium) if symptoms interfered with training.

Following the recommendations in panel 2 will of course restrict your food options while away. With that in mind, you may want to take some food items with you, such as cereal and protein bars, carbohydrate drink powders (to be mixed with bottled water only!), breakfast cereals and liquid meal replacements. However, you need to check carefully what can and cannot be brought into the country of destination in order to avoid breaching import laws.

It’s also highly recommended that you don’t remove any nutrition products from the manufacturer’s packaging in order to save weight or space in your suitcase. Strange powders or potions in unmarked containers may arouse the wrong kind of interest from customs officials – something I personally discovered when I visited Cuba a few years ago, and nearly spent my adventure break staring at the four walls of a Havana jail!

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Panel 2: Suggestions for the prevention of traveller’s diarrhoea in athletes

*Eat only from reputable establishments with good food hygiene, not from street vendors. Avoid raw or undercooked foods. If you must sample the flavours of the area, wait until the competition is over.



*Wash hands frequently with soap and water and follow with antibacterial sanitiser (alcohol gel). This is especially important before eating.



*Wash vegetables and fruits in sanitary water and carefully peel them.



*Avoid drinks with ice in them.



*Brush teeth with bottled, boiled or filtered water.



*Avoid opening mouth in the shower.



*Drink only fluids which are filtered, boiled, or from sealed containers.



*Discuss with your doctor the possible use of prophylactic probiotics and antibiotics prior to departure.

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Insect-borne disease prevention in athletes

No discussion on disease prevention would be complete without a mention of insect-borne disease risk, the main risk being from mosquitoes and ticks.

Mosquitoes – You might assume that the only significant risk from mosquitoes is that of malaria when visiting certain tropical areas (see figure 2). However, mosquito-borne diseases also include West Nile virus, yellow fever virus, and dengue virus, which may occur outside of the tropics. In the US for example, West Nile virus occurs seasonally (typically between July and October), especially in California, Arizona, and Colorado^{Vector Borne Zoonotic Dis 2004;4(1):61–70}.

Regardless, the prevention of mosquito bites is the cornerstone strategy. If you visit or travel through an endemic area, you should wear an insect repellent such as deet (N,N-diethyl-mtoluamide), picaridin (KBR-3023), or oil of lemon eucalyptus (p-menthane-3,8 diol). You can also apply Deet and permethin to your clothing. If you use a sunscreen simultaneously, the insect repellent should be applied on top of your sunscreen and removed at the end of the day. Long-sleeved shirts and tops that are tucked into long trousers are also useful.

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Figure 2: Worldwide malaria risk^{US Centre for Disease Control (CDC); www.cdc.gov}

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Ticks – Ticks are small, bloodsucking insects related to spiders, mites and scorpions. There are many different species of tick, each preferring to feed on the blood of different animal hosts. If given the opportunity, some of them will feed on human blood too. The one most likely to bite humans in Britain is the sheep tick. There
are other ticks in Europe and N America and they carry different diseases. In the USA the highest risk comes from the Deer tick.

Tick-borne diseases include rickettsial diseases, Lyme disease, babesiosis, tick-borne relapsing fever, and occasionally, tularemia and Q fever. Athletes who participate in outdoor activities in a rural setting are more susceptible to tick bites. These sports include cross-country running, mountain biking, adventure racing and recreational outdoor sports such as hiking. Due to the life cycle of the tick, the most likely time to acquire a tick bite is in the late spring and summer (see figure 3).

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Figure 3: Life cycle of the tick

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The risk of each type of tick-borne disease will depend on the infectious organisms responsible for these illnesses and their particular lifecycles in ticks. For example, in the UK, Lyme disease is a real risk with an estimated 2,000-3,000 new cases reported in England and Wales each year^{www.nhs.uk/Conditions/Lyme-disease/Pages/Introduction. aspx#symptoms – accessed Feb 2017}. In the US, common tick-borne diseases include Rocky Mountain spotted fever, human monocytotropic ehrlichiosis, and human granulocytotropic anaplasmosis^{J Infect Dis 1999;180(3):900–3}. These potentially lethal diseases are difficult to diagnose because they often mimic viral syndromes with flu-like symptoms in the early stages. Indeed, studies suggest that as many as 60% to 75% of patients presenting with a tick-borne disease may be initially misdiagnosed^{Ann N Y Acad Sci 2003;990: 295–30 J Infect Dis 1984;150(4):480–8}.

There are no proven vaccines for some tick-borne illnesses, but all are preventable by careful vigilance and protection. If your activities place you at risk of a tick bite, you should remain vigilant about your training and competition environment. Ticks thrive in a wooded environment and at the edge of woods, with surrounding high vegetation but they are uncommon in well-mown grass. When training in wooded areas, wearing light-coloured clothing can help you to identify a tick. Long training bottoms tucked into tightly woven socks and closed training shoes will also help minimise exposure. Deet at 10% to 25% should be applied to the skin while Permethrin can be applied to your clothing (not skin).

After training in a tick-infested environment, your clothes should immediately be removed - and if possible, cleaned and dried (tumble dryers are very effective at killing ticks!). You should also carefully check for ticks in the nymphal phase (the stage between larvae and adulthood), which may be as small as the size of a pin head. Areas to pay particular attention to include your hair, ears, armpits, belly button, and legs. If a tick is attached, the technique of tick removal is critical. Tweezers with fine tips should be used as close to your skin as possible and the tick pulled directly away. Squeezing the body of the tick may allow contamination from the tick to enter the bite wound. In the case of Lyme disease, you’ll almost certainly remain infection-free so long as the tick is removed with a few hours or so. However, ehrlichiosis (another tick-borne disease in temperate climates) can be transmitted more rapidly. The routine use of preventive antibiotics is generally not recommended because less than 5% of bites are Lyme infected, especially with a flat tick. However, following a high-risk exposure (when the tick has been engaged for more than 24 hours and is engorged with blood), a single dose of 200 mg of doxycycline is believed to be effective^{N Engl J Med 2001;345(2):79–84}.