Women Traveller Scenarios

Candace Corroll

When women are travelling they may experience unique gender specific problems due to their physical differences from men and due to social forces.

The purpose of this session is to highlight common problems women may face and offer various solutions.

Abby is a 22 year woman going to Korea to teach English as a Second Language. She is going alone, although she has some contact phone numbers of people from her organization. She has never travelled before. She is physically healthy and has received all her immunizations but wants to know if there is anything else she should do before she leaves.

Abby has had a recent physical. She is sexually active but has not had a PAP test done recently. It is strongly recommended that she do so before she leaves. She is also taking the birth control pill and wishes to stay on it even though she will not have a current sexual partner. She was concerned about getting traveller's diarrhea or taking other medication (such as antibiotics) that would affect the effectiveness of the pill. Her doctor discussed the new Birth control Patch (Evra) which is put on the skin for 3 weeks of the month and is not affected by nausea or stomach upset which can happen with travellers diarrhea.

Because she was going to be away for so long she was given information on how to find a doctor in Korea: www.istm.org (The International Society of Travel Medicine lists available clinics in many countries), www.iamat.com (International Association Medical Assistance to Travellers has a free list of Clinics that also agree to standardize their prices, www.voyage.gc.ca (gives a list of Canadian Embassies and Consuls that will not provide medical services but will give information).

Barbara is an 18-year-old mother of two twins age 8months. She is going to return to Ghana to visit her parents and show her children. Barbara wants to leave her 2 twins in Ghana for at least a year so she can finish her school. She wants them to receive all the immunizations they need including Yellow fever.

Barbara was informed of the various vaccinations related to travel to Ghana for her 3-week trip. Based on what she will be doing it was recommended that she receive Tetanus-diptheria, Polio, Typhoid, Hepatitis A and B; and Yellow fever along with mefloquine for malaria.

Her twins were healthy with 38-week gestation births now at 8 months of age with normal developmental milestones and no problems. They are under the care of a regular paediatrician. They are up to date on their regular childhood immunizations. It was recommended that they receive an early MMR vaccine (which does not actually count toward the recommended 12 month vaccination since circulating maternal antibodies may partially neutralize the MMR, yet this vaccine will cover them for their immediate trip.

Twinrix Junior was recommended and started. The hepatitis B component is specifically emphasized for children visiting Developing countries or long periods, as a great burden of Hepatitis B is acquired from innocent activities- such as roughhousing with other Hep B positive children in routine play, or living in a household with Hep B. The Hep A component is normally recommended for children over 12 months but in this instant these children would be living long term in Ghana and not be breast fed so the doctor recommended this to them off label. They were too young for the typhoid vaccine or the multivalent (menomune) meningitis vaccine.

Yellow fever is prohibited in children less than 9 months because of the risk of encephalitis yet these children would be at high risk of yellow fever in Ghana. Barbara was offered the choice of waiting for them to be a few months older and receiving it in Ghana versus receiving it just after their turning 9 months in Canada. She chose the latter.

Lastly a 3-month supply of mefloquine was prescribed for each twin with instructions to continue antimalarial treatment after the children are reassessed in Ghana. Barbara was repeatedly cautioned of the importance of continuing an effective malaria treatment and to ensure that her Mother also continues this medication. Because of the children's likely weight gain over the next few months the doctor felt it would be harmful to recommend a static prescription without periodic reassessment. Barbara's twins were an extremely complicated case and all decisions were well discussed in detail.

Cara is a 25-year old nurse who just returned from Hawaii. She went to a bar with her girlfriend and later woke up the next day alone in an empty house with her clothing missing. She realized that a man must have put something in her drink and has no memory of what had happened. This happened 2 weeks ago and she wants to be checked out. Despite what has happened to her she does not seem anxious or upset.

At this point the chain of evidence is so weak that forensic evidence is difficult or impossible to establish. The main focus should be on Cara's health.

Counselling by a nurse or doctor skilled in Rape management should be initiated.

Blood tests for Syphilis, Hepatitis B, C and HIV were ordered. This case happened before routine use of post exposure antivirals was widespread. In this case it is probably too late to be of benefit (these medications have significant side effects as well)

A proper gynacological exam was done with swabs for gonorrhea and chlamydia sent. After these were taken antibiotics were given to empirically treat for these conditions.

Lastly Cara was examined for any other injuries. She was offered follow-up both for results as well as for further counselling.

The police in Hawaii were notified and a bartender admits to having seen a man put a pill into her drink but did nothing. No charges were laid.

Dian is a backcountry camper and is going with some girlfriends to camp in Northern Thailand for two weeks. She would like to put together a first aid kit, which will include items for feminine problems.

Dian is specifically asking for tests and medications to diagnose and treat bladder infections. A dipstick urinalysis was recommended with a prescription for Ciprofloxacin to treat any positive results. Two of Dian's friends are nurses and can do this easily.

Dian's group are also all taking doxycline for antimalaria prevention but they know that doxycycline is associated with increased incidence of yeast infections. Additional items for their "female" first aid kit include canestin inserts and Diflucan (Fluconazole) pills.

Ella age 26, is Dian's friend and wants to go as well but just found out she is pregnant. Can she still go, and are all the medications recommended for Dian all right for Ella to take?

Ella is healthy and is not having any problems with her pregnancy. It has been established that her pregnancy will be in the 2 nd trimester during her trip to Thailand. Unfortunately she will be travelling to a very drug resistant malaria area. This area of Thailand is resistant to both Chloroquine and Mefloquine. She may not take Doxycline because this will stain childrens' teeth. The medication Malarone will work in that area but its safety in pregnancy has not yet been established. Malaria is often more severe in pregnant women. At present there is no good effective antimalarial for pregnant women going to this part of Thailand. Ella's situation highlights that many drugs or immunizations are different for pregnant women .

The website www.motherrisk.com is very detailed in describing both theoretical and proven risks from medications and is a good resource.

Fiona, Dian's other friend just delivered her baby and wants to now take her 12-month old son with her. She wants advice for her and her baby.

She was advised of the same vaccines and antimalarials as the others. Doxycline is not recommended for breast-feeding mothers. Motherisk was again consulted for each medication or drug.

Fiona then decides that she will instead spend her vacation in Dominican Republic where she has heard there is a malaria drug that she may take.

Fiona is informed that the vaccines commonly recommended for the Dominican Republic- tetanus diptheria and Hepatitis A are safe for her but she still needs to take an anti-malarial such as chloroquine or mefloquine and these do cross over into breast milk. However, her son is not protected by her breast milk and must take his own medication adjusted for his weight. Anti malarial drugs are not pediatric sized so Fiona may want to take the prescription to a compounding pharmacist to adjust for the proper dose. Her son is up to date on all his childhood vaccines including the newer pneumonia, varicella, and meningitis shots so the only vaccine he needs is the pediatric Hepatitis A vaccine.

Lastly Fiona was counselled that even though her son is up to date on his basic childhood immunizations and has received both hepatitis A and appropriate malarial medication, travel is still difficult on the very young as their immune system are still immature. Fiona should be meticulous with hygiene and see a doctor promptly or any problems encountered by her son..

Geraldine is 83 and lives alone but enjoys going on trips by herself. She wants to go to Bhutan on a trek but her Daughter doesn't think she should. They come in together and want to speak about what the actual risks are. Geraldine is taking medication to anticoagulate her blood, which has to be checked every day. Is there any compromise that can be reached so that Geraldine may still travel?

Geraldine represents a small but growing type of adventure traveller- seniors who are now travelling to remote areas. Many of these trips are well organized but clinicians may be called upon to give a risk assessment. Traditionally this has been with regards to infectious diseases but now may include a fitness to travel assessment. It may be beyond the doctor or nurse to be able to assess all risks but we should be able to help establish some facts and allow the patient to make an informed decision.

Geraldine has several medical problems, so it is recommended that she have a full medical exam by her family physician, making sure he knows what she will be doing. If she is going to a remote area she should have enough medications. The remoteness of her travel and failure to be able to be speedily evacuated must be understood. Portable Coagulocheks are now available for people on anticoagulants to be able to monitor themselves. (www.coaguchek.com)

The proper risks are explained for Geraldine so that she can make an informed decision. On speaking with her and her daughter she appears competent and clear minded with no signs of Alzheimer's or other dementia, and the final decision will rest with her. Her daughter is still anxious but attending with her mother has helped her to articulate her concerns. At her insistence Geraldine has agreed to make sure her insurance will also cover Helicopter evacuation and Overseas Funeral arrangements. This has also led Geraldine to modify some of the more risky parts of her trip.

Helena came in with her husband 3months ago and received several immunizations. At the time she did not believe that she was pregnant, but has now found out that she is 4 months pregnant. She and her husband are very worried that her immunizations may have hurt their baby.

Helena's vaccine record was reviewed. On the form she had checked off that she was not pregnant and had written the date of her last normal period, which is important for clinics to ask and document.

She had received tetanus-diptheria, inactivated polio, Hepatitis A and Hepatitis B, all of which are fine in pregnancy; but she also received the live MMR vaccine.

The MMR vaccine would normally not be given, but this was recommended because she had never received it before and was going to an area of the world high in measles. It is well recognized that infection with measles, mumps, and rubella during pregnancy can cause birth defects. The MMR vaccine is attenuated but still not recommended for use in pregnant women. There are no documented fetal malformations caused by the MMR vaccine yet it is still not recommended for pregnant women. Women are advised not to conceive for 3 months after receiving the vaccine.

This patient had also seen a Genetics counsellor to reassure them. The Geneticist who advised them of the likelihood of a normal birth (compared with baseline). The inadvertent use of MMR is not a reason for a therapeutic abortion.

Iris is planning to go on a trip around the world with her partner Janice. They want to know what countries are friendly to Lesbian couples and if there is anything they need to know. At this point they do not know which countries they are going to yet.

Many countries have different laws and beliefs with regards to open displays of homosexuality, so that assumed rights may be very different abroad. Open displays of sexuality may lead to prejudice and violence in some countries. The International Lesbian and Gay Association www.ilga.com has a data base of specific countries and their attitudes and can help travelers abroad.

Kellie, a patient seen 6 months ago calls long distance from Suriname worried that she has caught an STD and might also be pregnant. She does not have any people she can talk to and doesn't trust the local doctor.

In this case we had Kellie check to see if she was pregnant as this is something that every doctor can easily diagnose all over the world. When it was established that she wasn't we gave her the contact number for the Canadian Embassy. They found her a gynecologist in the Capital. At first she did not want to pay extra to see him. We spoke with the Agency that sent her (while maintaining her anonymity) and we were ale to establish her insurance would cover this and rely this back to her. We stressed that several types of STDs may cause severe problems (infertility and Pelvic Inflammatory Disease) and must be treated. She agreed and was treated.

If she was pregnant and wanted an abortion there is a serious exists concerns of unsafe back door abortion clinics. They still exist in many parts of the world. The Marie Stopes Foundation provides information about emergency contraception and abortion listed by country. (www.mariestopes.org.uk/abortion1icpd.html )

A Brief Outline of information for Women Travelers:

Compiled by Candace Corroll and Dr Gary Podolsky

Emergency Contraception

Women travelling the world may become pregnant. Proper birth control methods, such as condoms or female condoms, should be arranged before you depart.

Many countries do offer emergency contraception i.e.) the morning after pill.

The consortium for emergency contraception website will give travelers up to date information about where they are going: http:/www.path.org/cec.htm

Emergency contraception website : http://not-2-late.com

Women travelers, as with men, may acquire tropical infectious diseases and their treatments can significantly affect women. Often the complications and severity of tropical infections are worse for pregnant women.

Contraception and Travel

Many other different methods of contraception exist. For more information, check Maria Stopes International website: http://www.mariestopes.org.uk/abortion.html

Pregnant Travelers

Travelling is discouraged if:

-congenital or acquired heart disease

-history of blood clots

-severe anemia

-chronic lung disease

-obstetric risk factors

If pregnant, all women should be assessed early in their pregnancy, prior to travelling.

PAP tests for all women are also recommended to screen for cervical cancer.

Immunizations During Pregnancy

Additional Website links for women:

Office of Population Research Emergency Contraception -website with information on emergency contraception searchable by country . http://ec.princeton.edu/worldwide/default.asp

Marie Stopes International- provides information about emergency contraception, abortion, and sexual health by country httpwww.mariestopes.org.uk/abortion.html

.The Centre for Reproductive Law and Policy provides list of countries where abortion is legal and what restrictions exist. http:www.crlp.org/abortion1icpd.html

WHO Gender and Health Technical Paper -article on gender and health. (use search engine as site frequently changes) h ttp:www.who. int

Organization of Tetrology Information Services For further information on drugs in pregnancy, see: http://orpheus.ucsd.edu/CTIS/index.html

Appendix: Vaccines for Children Traveling

Children travelling with their parents may need their vaccinations adjusted either because of the decreased availability of pediatric follow up where they are going, or because of the increased risk of diseases in areas they will be visiting.

Changes in Schedule for Routine Immunization due to Travel

Note :   When vaccines are given younger than routinely recommended or when vaccine intervals are shortened, vaccinations may need to be repeated at a later date.

Special Notes on Immunizations for Children

Cholera Vaccine - Is not recommended. The risk of Cholera to travelers is very low. Breast-feeding protects children. In older children close attention to food and water will help to protect them.

Hepatitis A - is given to children over 1 yr old. (This is 2 years in the US literature) Breast-feeding protects small infants by way of passive immunoglobins from mothers' milk. (Immunoglobulin is now de-emphasized for children as the vaccine or mothers milk gives better protection. The immunoglobulin now in use contains less antibodies against Hepatitis A since this is reflective of current blood donors not having anti-hep A antibodies compared with prior generations.)

Japanese Encephalitis Vaccine is given to children over 1yr old who are travelling to rural areas endemic with this infection during the peak transmission season. Japanese Encephalitis is recommended if persons are staying in areas near rice paddies or pig farms, where the risk of JEV mosquitoes is high.

Rabies - Children may be more susceptible to rabid animal attacks than adults. Parents may consider this vaccine if their child is staying in a high-risk area for rabies.

Typhoid - Breast fed infants are protected from this. For older children careful boiling or chlorinating water prevents this disease. The new injectable vaccine is given to children between ages 2-6. An oral typhoid vaccine is available for older children.

Yellow Fever - Vaccination against t his mosquito borne infection is required for travel to some countries. It is never recommended to children under 4 months, and only in exceptional circumstances for children 6-9 months. Infants greater than9 months may be vaccinated if they require it.

Other Travel Concerns for Children

Diarrhea - No good vaccine exists yet but Pepto-bismol can also be given for children to prevent traveller's diarrhea.

Pepto-Bismol Preventative-Treatment, to be started on the day of travel and up to 3 weeks. This will decrease traveler's diarrhea by 50%.

Each dose may be taken every 4 times per day

Children and Bugs - Preventing insect bites is very important in preventing many diseases. The following are recommended:

•  Placing nets over baby carriages and cribs

•  Eliminating standing water around living quarters

•  Stay inside between dusk and dawn.

•  Dress children carefully in long sleeved clothing over neck, wrists, and ankles

•  Not allowing children to go barefoot

•  Cover skin with DEET 20-30% - This is higher than what many others recommend. DEET is safe to use on children when used correctly. Apply on exposed skin, but not on irritated skin and wash it off after use.

•  Use a flying insect spray in living and sleeping quarters

•  Sleep in an air-conditioned area when possible

Malaria Medication and Children

Children are very susceptible to malaria and over 2 million die of it each year.

Chloroquine is safe and well tolerated but has a bitter taste. Eating adult strength doses can harm children. Chloroquine should be kept in a safe place away from children.

Mefloquine (Larium) Is very safe in children. Neurological agitation from mefloquine is not seen in children as with some adults.

Malarone i s a new medication and is more expensive. It is taken daily according to weight.

Doxycycline is safe for 9+yrs . And is safe in lactating mothers, but not in pregnant mothers.

Adolescent Health Visits

Infant and childhood vaccinations have greatly decreased the incidence of many childhood infections. Teens and young adults still remain susceptible to vaccine preventable diseases like Hepatitis A and B, Measles, Mumps, and Rubella. In order to protect young adults and teens an adolescent health visit is recommended at age 11 or 12.

This is a good opportunity for parents and their family doctor to discuss the recommended vaccines and decide what immunizations their child needs. This visit can also affirm the adolescent's comfort level with attending the doctor's office in the future.