COMMON QUESTIONS

Travel Health Advice for Backpackers Peter A. Leggat and Marc T. M. Shaw

There has been an increasing trend for people to travel internationally, further afield, but fewer people are now going on programmed package tours.1 One of these groups of travelers comprises backpackers, who are distinct from endurance hikers or trekkers and longer-term and more remote expeditioners. Backpackers comprise individuals who travel alone or in a small group on a limited budget, and usually stay in hostels (hostelers), campsites, or similar low-cost accommodation, and carry their belongings in personal load-carrying equipment, most notably backpacks. Individual travel through backpacking, especially hosteling, appears to have become more popular for three probable reasons: travelers are seeking more costeffective means of traveling and accommodation; they are looking to travel to regions where there is less likelihood of meeting fellow travelers; and they are looking for travel with more risk attached. International hosteling and backpacking organizations have evolved to provide a major networked accommodation resource for hostelers and backpackers. Personal responsibility has become a paramount issue in any pretravel assessment. This common questions paper examines the likelihood of backpackers becoming ill or injured on their travels, what problems they may face, what health

precautions they should they take, and what advice should be provided by travel health advisers to prospective backpackers, but does not cover in detail some of the specific issues of related traveler groups, such as hikers, trekkers and expeditionary groups. Are Backpackers More At Risk? Backpackers may be more likely to have accidents than people traveling as part of an organized tour group, or traveling for business purposes. As they are more likely to be younger,2 they are more likely to take risks, take part in adventure sports and other activities, travel to “off the beaten track”destinations,or hire cheap,unroadworthy vehicles, as mortality due to accidents tends to be higher in younger age groups.3 Backpackers may stay in cheaper hosteling accommodation, and this may lead to increased fire risks and insecurity.4 With cost of travel being an issue, backpackers are more likely to be less discriminating about where and what they eat, and they are more likely to contract endemic infectious diseases, especially travelers’ diarrhea, which, with respiratory tract infection, is among the most common ailments reported by travelers on return.5,6 Also, they may not be in a position logistically or financially to access adequate medical care or pay for medication if they become ill. A Danish study of guests at a large youth hostel in Copenhagen suggested also that only about one-fifth carried condoms with them and only half of men and no women used condoms in sexual encounters, although the sample was small.7 This exposes backpackers to the risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV).

Peter A. Leggat, FAFPHM, FACTM, FFTM: Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia; Marc M. T. Shaw, FRNZCGP, FACTM, FFTM: Medical Director, Worldwise Travellers Health Centres of New Zealand, Auckland, New Zealand. The first author lectures free on travel health to Youth Hostel Association Travelers’ Information Evenings in north Queensland. The second author has assisted in expeditions, including the Blake Expedition in South America. The authors had no financial or other conflicts of interest to disclose.

What Are the Common Health Problems Reported by Backpackers? Previous studies have suggested that between 62% and 82% of backbackers experience some form of illness and/or injury abroad.6,8,9 Common problems reported by backpackers included musculoskeletal conditions, traumatic injuries and gastrointestinal upsets.9 Backpackers who camp out may also be at increased risk

Correspondence: Associate Professor Peter A. Leggat, School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland 4811, Australia. J Travel Med 2003; 10:340–345

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of some parasitic diseases, such as giardiasis and intestinal amoebiasis from drinking untreated water from creeks and streams.10,11 Other common problems of travelers, such as insect bites, sunburn, headaches, lacerations, coral cuts, ear infections, and diarrhea, have also been reported from backbackers surveyed in north Queensland, Australia.8 There are also particular hazards related to the activities that the backpackers undertake, e.g. diving, snorkeling, or white water rafting.7 Some activities of backpackers have been associated with a risk of infectious disease, such as white water rafting and leptospirosis in Australia,12 and camping and Rocky Mountain spotted fever in the US.13 The risks associated with wilderness trekking by backpackers in the US have been discussed elsewhere; however, in addition to gastrointestinal diseases, common problems included blisters, skin irritation, and acute joint pain, as well as occasional vector-borne diseases, such as Lyme disease.14 Similar problems are experienced by expeditionary groups.15 A few studies examining the psychological problems of travelers, usually young travelers but not specifically backpackers, have indicated that illicit drug use may be a precipitating cause of one-fifth or more of psychological problems in some returning travelers.16,17 Concerns have also been raised in one study about backpackers’ compliance with health advice for malaria, as well as the adequacy of this advice, particularly in terms of malaria chemoprophylaxis, where backpackers reported lower usage.18 It is important to reinforce knowledge of the risks associated with the major infectious diseases, which may be associated with travel to particular destinations. For example, hepatitis A virus (HAV) infection is much more common among backpackers, with a rate of up to 2% per month, compared with other nonimmune travelers to developing countries.19 In contrast, hepatitis E virus infection was not found to be a problem among backpackers to tropical countries.20 How Do We Encourage Backpackers to Seek Pretravel Advice? Most travel health industry advertising tries to encourage travelers to seek travel health advice at least approximately 6 to 8 weeks prior to departure abroad; this ensures that prospective travelers develop an appropriate immunization schedule, if necessary, to confirm the maturity of disease immunity. This protocol is especially applicable to backpackers, who may be traveling to more adventurous destinations and need to undertake full and prolonged courses of vaccinations, e.g. for rabies. Backpackers generally want to be more informed about their health and safety abroad, and have responded positively

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to hosteling organizations including travel health advice in their information evenings.2,21 Interestingly, a recent study indicated that most Australian hostelers do now report seeking timely health advice before traveling overseas.2 What Sources of Advice are Available for Backpackers? There are several possible sources of travel health advice available to backpackers. As a significant proportion of backpackers are students, those who have access to subsidized student health services should be encouraged to seek travel health advice and vice versa. There is also an increasing number of travel health clinics worldwide.22 These clinics are also likely to have the status of yellow fever vaccination centers, and provide a comprehensive service for backpackers.22 General practitioners may also advise students on travel health issues. In addition, particular travelers’ health information sources are available.23 Written sources of travel health advice may be provided by global organizations (e.g. World Health Organization), travel health clinics, travel guides, hosteling organizations, and travel insurance companies. What General Travel Health Advice Should be Given to Backpackers? The areas of travel health advice to be covered in a pretravel consultation by a travel health professional are given in the table.24,25 Vaccination against diseases such as HAV infection has been shown to be cost-effective for high-risk groups, such as backpackers.26 As well as ensuring that prospective backpackers have appropriate vaccinations for the areas they intend to visit, and antimalarial tablets where necessary, travel health advisers will also need to provide travelers with preventive health and safety advice; simple things like “Take an extra pair of protective eyeware, take an emergency dental kit, and take as few medications as possible but with as many applications as possible.” In addition, backbackers will need to be given advice on common travel-related health problems, such as: travelers’ diarrhea, food and water protection, hand cleanliness, and standby therapies for gastrointestinal disease and common first aid problems, such as eye problems and injuries, discussed elsewhere.27 Backpackers need reinforcement on issues such as: sun protection, awareness of marine hazards, attentiveness to local venomous creatures and animals, protection against insect vectors in areas where, for example, malaria, dengue fever, leishmaniasis and other arthropod-borne diseases are prevalent, and last, but not least, the need to always practice safe sex and the handling of body fluids.

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Table Areas that Might be Covered in Pretravel Preparation of Backpackers Going Abroad 24,25 Advise/discuss Insects Ingestions Infections Indiscretions Injuries Immersion Insurance Inquires

Nets, repellents and insecticides Maintaining good food and water purification Protection of health in body and mind, and of the environment STIs, HIV Accident avoidance, safety, sun protection Schistosomiasis, swimming risks Health and travel insurance Finding medical assistance abroad, and knowing what to do if ill

Vaccinate

Always

National immunization schedule vaccines, e.g. measles, mumps and rubella Often Hepatitis A and B Sometimes Japanese encephalitis Meningococcal disease Polio Rabies Tetanus-diphtheria Typhoid Yellow fever Senior travelers Influenza Pneumococcus

Prescribe

Always Sometimes

Regular medication in two lots (in case one is lost) Antimalarial medication Condoms Diarrheal self-treatment Broad-spectrum antibiotics

All travelers abroad need to take a medical and first aid kit, which they can use properly, and backpackers are no different. Standard first aid kits marketed for backpackers are available from many commercial first aid kit providers. It is important that these kits are equipped to manage minor but incapacitating injuries, such as chaffing and blisters, as well as lacerations, fractures and other severe injuries. Unlike in more sophisticated expeditions, doctors, nurses and other health professionals usually do not accompany backpackers. It may well be that backpackers also take a book on “travelers’ health care” when they travel abroad. In addition, they should take with them a doctor’s letter to cover any medications that they are carrying. The letter should have generic drug listings, as proprietary names for common medications differ worldwide, in case there is loss of any prescription medications. As there is no point in having a first aid kit

without knowing some first aid, backpackers, especially those traveling to remote locations, would be best advised to undertake a basic first aid course.A number of the larger first aid providers, such as the Red Cross, heart foundations and St John Ambulance (major provider in many Commonwealth countries), often provide practical community first aid courses. A recent study of hostelers indicated that about one-third reported having a current first aid certificate,21 so the message “having a medical kit and knowing how to use it” appears to be getting through. What Advice Do I Give Backpackers Concerning Safety? All travelers run the risk of accidents and injury while traveling and while abroad. Many feel that the metaphor “the safety of travelers is like a barometer of the safety of that country” is true, and so the tradition of a high standard of safety and health generally enjoyed in many developed countries may not be applicable to the country to which backpackers may be traveling. There are some recurrent issues that should be addressed by travel health professionals. Backpackers should be advised not to travel alone, but to backpack with friends. They should also be advised to stay in accommodation which meets some kind of familiar standard, and which is usually offered by a number of the larger, more reputable hosteling organizations. Where such hostels are absent, local lodges may be present, and local advice should be sought, if possible. If the accommodation looks seedy, it probably is, and backpackers should be advised to avoid staying in such places. If the accommodation does not have mosquito nets on the windows, then this probably reflects the fact that the hotelier is not interested in looking after the prospective client. It is important that backpackers obtain local advice before venturing off into the unknown and be prepared for their journey, and there are many books (e.g. Lonely Planet, Rough Guide) that will help to this end. Where available,and where travelers are spending extended periods in a foreign country, backpackers should register with their embassy or diplomatic mission, which in some cases can be done online. Backpackers should also be advised concerning the psychological problems that may be triggered by the use of illicit drugs,16,17 and possibly other factors, such as extreme poverty-stricken environments. They should be made aware that possession of illicit drugs may be a serious offence in many of the countries that they are traveling to, attracting the death penalty in some countries. Backpackers should be advised not to carry for anyone else illicit drugs or packages where the contents are unknown. Personal safety advice for travelers abroad has been covered in some detail elsewhere.28

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What Advice Do I Give Backpackers Regarding Travel Insurance?

What Advice Can I Give About Backpacking Equipment?

Because of the costs of medical and dental treatment abroad, which may not be covered by private health insurance or national health services from the home country, and the high costs associated with aeromedical evacuation, all backpackers should be “guided” into taking out comprehensive travel insurance that includes health and health benefits such as aeromedical evacuation in an emergency. Reciprocal health agreements between some countries, such as agreements that Australia and New Zealand have entered into with other countries such as the UK and Eire, however, are often restricted to some types of emergency care and usually do not cover, for example, routine trips to the doctor or dentist, replacement prescriptions and ambulance travel. A disappointing finding in a recent study of Australian hostelers was that only two-thirds of hostelers would always take out travel insurance.21 Some activities have a relatively high injury rate, e.g. skiing, mountaineering and other adventure sports, and it is worthwhile advising backpackers to check exclusion clauses in their prospective policy and to make sure that intended activities will be covered by the level of travel insurance taken out. Health and travel insurance is discussed elsewhere.29

Experienced backpackers will generally seek professional advice and obtain information from various sources on the selection of their backpacking equipment. There is specific backpacking terminology, and travel health advisers may be interested in consulting a backpacking glossary.30 It is important to advise backpackers to choose and trial a comfortable backpack, which is ergonomically designed so that it distributes the load and does not put excessive strain on any part of their back. Injuries of the sternoclavicular joint, as well as “pack palsy”, have been observed in some backpackers.31,32 The backpack should be durable, made of lightweight materials and have appropriate padding on the shoulder straps to avoid pressure injuries. Only essential items should be carried, and the contents, where possible, should also be made of lightweight and durable materials. Backpackers should store or forward excess baggage, especially those who will be doing any significant hiking. Backpackers need to be particularly reminded of the dimensions of their backpack, so that they do not injure fellow travelers who are in close proximity to them. Equally important is a pair (and a back-up) of comfortable hiking boots, which fit correctly and have been “broken in” beforehand, to prevent blisters and other lower limb injuries.

What if the Backpacker is Unwell Upon Return?

What Additional Precautions do I Suggest for Backpackers Undertaking Adventure Travel?

If a backpacker presents to their local health service or general practitioner some months after returning home, with symptoms such as unexplained fever or prolonged or bloody diarrhea or blood in the urine, the diagnosis should be considered in relation to the patient’s travel history. It is important for travel health advisers who see a number of travelers to have access to a database which gives information about the distribution, prevalence and recommended prevention of diseases in countries around the world. Fever or related acute symptoms in a traveler returning from a malarious area should be considered as malaria until proven otherwise. Malaria due to Plasmodium falciparum can be fatal, and so any febrile illness in returning travelers needs to be urgently assessed with a view to ruling out malaria, dengue fever and typhoid fever. Such diseases would be considered possible within the certain parameters of their incubation time. Malaria (particularly P. vivax), amoebiasis, schistosomiasis and some helminthic infestations may also cause symptoms some months after the patient has returned, and may be difficult to diagnose, so assessment by appropriate travel health professionals is necessary.

Every backpacker undertaking adventure travel needs to assume an element of responsibility for their own welfare. Adventure and wilderness travel has been discussed elsewhere.33,34 Several key points are, however, worth reinforcing to all backpackers: • Travel with good equipment that can cope with the climatic conditions expected. • Obtain professional advice from more experienced expeditioners on the wide range of outdoor equipment available. • Take an adequate supply of high-calorie food for the expected duration of the expedition, plus an extra day (at least) if one is heading for remote areas. • Boil water taken from creeks and streams or use microfilters or water purification tablets. • Be aware of the risks of accidents in their immediate surroundings, especially, for example, when taking photographs in mountainous or wilderness areas. • Take a mobile phone if possible, in case of accidents. Many areas of the world now have mobile phone coverage.

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• Plan a realistic itinerary, bearing in mind the terrain and fitness levels of any exploring party. • Inform others (friends, relatives, park authorities, local police, etc.) of one’s plans and expected date of return. • Before departure, check the weather forecast for the intended area of travel. Backpackers planning to hike in remote mountainous and cooler areas will need to pack adequate cold and wet weather gear, as conditions can change rapidly, particularly in mountain areas. Hypothermia can be a concern in many adventure tourism activities. Backpackers trekking in mountainous areas should also be advised about acute mountain sickness and its management. At the other extreme, those planning to compete in endurance events in summer may encounter higher temperatures and humidity. Therefore, adequate hydration prior to and during the event is important to prevent heat illness. Backpackers should use sunscreen of factor 15 or above, particularly if they are outdoors between the hours of 11 am and 4 pm, and in certain climates (especially those in which there is a risk of excessive sun exposure or disease), covering up with light cotton clothing or wetsuits is also recommended when swimming. Skiers, snowboarders and climbers are at high risk of reflected glare from the snow, as are sailors from water-reflected glare. In addition to causing sunburn, this glare can damage the cornea and conjunctiva of the eye. In this condition, called snow blindness, the eye can become painful and gritty, with edema of the eyelids, conjunctiva and cornea. Wraparound goggles provide the best protection for snow activities. A full account of the eye problems of travelers, including snow blindness, has been published elsewhere.27 Is there Anything Else that Backpackers should Know? A variety of resources are available that may assist in reinforcing travel health and safety advice for backpackers. Travel guides, books and other publications represent a major source of travel health advice for hostelers.18 Brochures for backpackers from official sources, such as foreign affairs departments, may also provide useful tips on backpacking overseas.35 There are also several commercially available travel health guides, which would be suitable for backpackers.36–38 Hosteling organizations may also provide health and safety information for backpackers in their publications or at their Internet sites.39 Often, such advice may be at variance with that given by a travel health professional, and so it is important that backpackers are encouraged to discuss any discrepancies, to prevent any confusion about either disease or its management.

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Conclusion Travel is an exciting adventure to the prospective backpacker, and the experiences gained provide greater understanding of differing cultures and societies. Many countries rely on the income from tourism and are very welcoming to tourists, and host country inhabitants often wish to learn about the country of the backpacker in return. With a little preparation and common sense, the backpacking experience can be a shared one of giving and receiving with mutual respect. Travel health professionals can play a useful role in maintaining backpacker health and safety while they are abroad. References 1. Behrens RH. Protecting the health of the international traveller. Trans R Soc Trop Med Hyg 1990; 84:611–612, 629. 2. Leggat PA. Health advice provided to hostelers from Australia: influence of a travelers’ information evening. J Travel Med 2002; 9:24–28. 3. Prociv P. Deaths of Australian travellers overseas. Med J Aust 1995; 163:27–30. 4. Wilks J, Pendergast D, Wood M. Accidental deaths of overseas visitors in Australia 1997–2000. J Hospitality Tourism Manage 2003; 10:79–89. 5. Leggat PA, Leggat FW. Travel insurance claims made by travellers from Australia. J Travel Med 2002; 9:59–65. 6. Shaw MTM, Leggat PA, Weld LH, et al. Illness in returned travellers presenting at GeoSentinal sites in New Zealand. Aust N Z J Public Health 2003; 27:82–86. 7. Worm AM, Lillelund H. Condoms and sexual behaviour of young tourists in Copenhagen. AIDS Care 1989; 1:93–96. 8. Peach HG, Bath NE. Health and safety problems and lack of information among international visitors backpacking through north Queensland. J Travel Med 2000; 7:234–238. 9. Crouse BJ, Josephs D. Health care needs of Appalachian trail hikers. J Fam Pract 1993; 36:521–525. 10. Smith LA. Still around and still dangerous: Giardia lamblia and Entamoeba histolytica. Clin Lab Sci 1997; 10:279–286. 11. Welch TR, Welch TP. Giardiasis as a threat to backpackers in the United States: a survey of state health departments. Wilderness Environ Med 1995; 6:162–166. 12. Smythe L, Dohnt M, Symonds M, et al. Review of leptospirosis notifications in Queensland and Australia: January 1998–June 1999.Commun Dis Intell 2000; 24:153–157. 13. Gove S, Slutkin G. Infections acquired in the fields and forests of the United States. Emerg Med Clin North Am 1984; 2:623–633. 14. Boulware DR, Forgey WW, Martin WJ. Medical risks of wilderness hiking. Am J Med 2003; 114:288–293. 15. Shaw MTM, Leggat PA. Life and death on the Amazon: illness and injury to travelers on a South American expedition. J Travel Med 2003; 10:268–271.

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16. Potasman I, Beny A, Seligmann H. Neuropsychiatric problems in 2,500 long-term young travelers to the tropics. J Travel Med 2000; 7:5–9. 17. Beny A, Paz A, Potasman I. Psychiatric problems in returning travelers: features and associations. J Travel Med 2001; 8:243–246. 18. Chatterjeee S. Compliance of malaria chemoprophylaxis among travelers to India. J Travel Med 1999; 6:7–11. 19. Steffen R, Banos A, deBernardis C. Vaccination priorities. Int J Antimicrob Agents 2003; 21:175–180. 20. Potasman I, Koren L, Peterman M, Srugo I. Lack of hepatitis E infection amongst backpackers to tropical countries. J Travel Med 2000; 7:208–210. 21. Leggat PA, Leggat FW. Knowledge and acceptance of first aid and travel insurance by hostelers from north and central Queensland, Australia. J Travel Med 2002; 9:269–272. 22. Hill DR, Behrens RH. A survey of travel clinics throughout the world. J Travel Med 1996; 3:46–51. 23. Leggat PA. Sources of health advice for travelers. J Travel Med 2000; 7:85–88. 24. Leggat PA, Ross MH, Goldsmid JM. Introduction to travel medicine. In: Leggat PA, Goldsmid JM, eds. Primer of travel medicine, 3rd edn. Brisbane: ACTM Publications, 2002:3–21. 25. Ingram RJH, Ellis-Pegler RB. What’s new in travel medicine? N Z Public Health Rep 1996; 3(8):57–59. 26. Arnal JM, Frisas O, Garuz R, Antonanzas F. Cost effectiveness of hepatitis A virus immunisation in Spain. Pharmacoeconomics 1997; 12:361–373. 27. Leggat PA, Speare R, Moon ME. Sore eyes and travelers. J Travel Med 1999; 6:45–47.

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28. Leggat PA, Klein M. Personal safety advice for travelers abroad. J Travel Med 2001; 8:46–51. 29. Leggat PA, Carne J, Kedjarune U. Travel insurance and health. J Travel Med 1999; 6:243–248. 30. Backpacker Jargon. Available at: http://www.backpacker. com/jargon. Last accessed 17 June 2003. 31. Shoaib A, Mehraj Q, Jepson F. Injuries of the sterno-clavicular joint in backpackers. J R Army Med Corps 2002; 148: 267–269. 32. Corkill G,Lieberman JS,Taylor RG.Pack palsy in backpackers. West J Med 1980; 132:569–572. 33. Weiss EA.Medical considerations for wilderness and adventure travelers. Med Clin North Am 1999; 83:885–902, v–vi. 34. Zell SC. Environmental and recreational hazards associated with adventure travel. J Travel Med 1997; 4:94–99. 35. Department of Foreign Affairs and Trade. Backpacking overseas? Some tips. Brochure. Canberra: DFAT, 2001. Available at: http://www.dfat.gov.au/consular/backpacking.html. Last accessed 18 June 2003. 36. Mills D. Travelling well: the essential handbook for healthy travel. Brisbane: The Travel Doctor, 2001. See http://www. tmvc.com.au. Last accessed 18 June 2003. 37. Cohen J. The traveller’s pocket medical guide and international certificate of vaccination, 4th edn. Melbourne: The Travel Clinic, 2002. See http://www.travelclinic.com.au. Last accessed 18 June 2003. 38. Fry G, Kenny V. Travel in health: a guide to healthy travelling overseas. Dublin: Newleaf, 2001. 39. Hosteling International Homepage. Available at: http://www. iyhf.org/home_gb.html. Last accessed 18 June 2003.

Siach boy, Zambia. Submitted by Dr. Marc Shaw.