Travellers' Health and Tropical Medicine

Last updated 1 Jun 2026 · Travel Medicine / Infectious Disease

📋 Key Information Summary

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Pre-travel consultation ideally 6–8 weeks before departure to allow adequate time for vaccination schedules, malaria prophylaxis initiation, and risk assessment.
Traveller's diarrhoea (TD) affects 20–60 % of travellers to high-risk regions (South/Southeast Asia, sub-Saharan Africa, Central/South America); empirical azithromycin is first-line self-treatment for moderate-to-severe cases.
Malaria prophylaxis must be tailored to destination-specific resistance patterns — atovaquone–proguanil (Malarone®), doxycycline, or mefloquine are the principal Australian-available options.
Standby emergency treatment (SBET) for malaria should be offered to travellers visiting remote Plasmodium falciparum–endemic areas with delayed access to medical care.
Yellow fever vaccination is required for entry to certain countries and must be administered at a designated Australian yellow fever vaccination centre ≥10 days before travel.
Hepatitis A + typhoid vaccines are the most commonly indicated travel vaccines for Australians travelling to developing regions.
Japanese encephalitis vaccine (Ixiaro®) is recommended for travellers spending ≥1 month in endemic rural areas of Southeast Asia and the Western Pacific.
Rabies pre-exposure prophylaxis is recommended for travellers to rabies-endemic countries, particularly those at risk of animal contact or visiting remote areas.
Dengue, Zika, and chikungunya are mosquito-borne viral infections without specific antiviral therapy; strict daytime mosquito bite avoidance is the primary prevention strategy.
Travellers with chronic disease, pregnancy, immunosuppression, or age >65 years require individualised pre-travel risk assessment and may need modified vaccination and prophylaxis strategies.
Aboriginal and Torres Strait Islander travellers may face unique barriers including remote clinic access, health literacy, and cultural considerations — engage culturally appropriate health services early.
Post-travel screening is essential for any traveller returning with fever, diarrhoea >14 days, rash, or eosinophilia — consider malaria, typhoid, schistosomiasis, and strongyloides.

Introduction & Australian Epidemiology

Approximately 10 million Australians travel overseas each year, with popular destinations including Indonesia (Bali), Thailand, India, Vietnam, and countries across sub-Saharan Africa. Travel to these regions carries significant risks of infectious diseases that are uncommon or absent domestically. Pre-travel health care in general practice is a critical preventive intervention that reduces morbidity, mortality, and healthcare costs associated with travel-related illness.

Travel medicine encompasses a broad scope: risk assessment based on itinerary, duration, and traveller factors; vaccination; chemoprophylaxis; behavioural counselling (food and water hygiene, insect bite avoidance, safe sexual practices, altitude illness prevention); and post-travel screening and management.

In Australia, the most commonly diagnosed travel-related infections include traveller's diarrhoea, malaria (approximately 500–700 imported cases annually, mostly Plasmodium falciparum and P. vivax), dengue fever, hepatitis A, typhoid, and campylobacteriosis. Imported malaria remains a significant cause of preventable death, with delayed diagnosis and inadequate chemoprophylaxis identified as recurring contributing factors. The Australian Government Department of Health and Aged Care, the Australasian Society of Clinical Immunology and Allergy (ASCIA), and the Royal Australian College of General Practitioners (RACGP) all provide frameworks for evidence-based pre-travel care.

General practitioners are uniquely positioned to deliver comprehensive pre-travel advice, administer vaccines, prescribe chemoprophylaxis, and manage returning unwell travellers. This guideline provides an Australian-focused, evidence-based framework for the prevention, assessment, and management of the most important travel-related health conditions.

Pre-Travel Health Care & Key Checkpoints

Timing of the Pre-Travel Consultation

The ideal pre-travel consultation occurs 6–8 weeks before departure. This allows sufficient time for multi-dose vaccine schedules (e.g., hepatitis B, rabies, Japanese encephalitis), immune response development, and initiation of malaria chemoprophylaxis where required. However, even last-minute travellers (≤2 weeks) benefit from risk assessment, single-dose vaccines (typhoid, hepatitis A, yellow fever), malaria prophylaxis, and counselling.

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Minimum timeframes: Yellow fever vaccine requires ≥10 days before entry to countries with entry requirements. Some vaccines (rabies, Japanese encephalitis, hepatitis B) require multiple doses over 3–4 weeks for full protection. Do not defer consultation for last-minute travellers — partial protection and counselling remain valuable.

Structured Risk Assessment

A systematic approach to the pre-travel consultation includes the following components:

Itinerary Analysis

Countries and regions visited (urban vs rural), altitude, season, duration of stay, and transit countries. Check Smartraveller.gov.au and CDC Yellow Book for up-to-date country-specific recommendations.

Traveller Profile

Age, pregnancy status, chronic medical conditions, medications, immunisation history, prior travel, allergy history, and purpose of travel (backpacking, business, VFR — visiting friends and relatives).

Activity-Based Risk

Adventure travel, trekking at altitude, water sports, animal contact, sexual health risks, occupational exposure, and access to medical care at destination.

Vaccination Review

Update routine Australian NIP vaccines (measles-mumps-rubella, pertussis, influenza, COVID-19) and assess travel-specific vaccines (hepatitis A, hepatitis B, typhoid, yellow fever, Japanese encephalitis, rabies, meningococcal, cholera).

Chemoprophylaxis & Standby Treatment

Malaria chemoprophylaxis, standby emergency treatment (SBET), altitude illness prophylaxis (acetazolamide), and pre-packed antibiotics for traveller's diarrhoea.

Behavioural Counselling

Food and water precautions, insect bite avoidance (DEET-based repellent, permethrin-treated clothing), safe sex, sun protection, personal safety, travel insurance, and jet lag management.

Routine Vaccination Updates

Many Australian adults have incomplete or waning immunity to vaccine-preventable diseases. Before travel, confirm and update:

Measles-mumps-rubella (MMR): Ensure 2 documented doses, particularly for travellers born after 1966. Measles outbreaks remain common globally.
Influenza: Annual vaccination recommended, as influenza circulates year-round in tropical regions.
Pertussis (dTpa): Booster if >10 years since last dose or if travelling with infants.
COVID-19: Stay up to date with current booster recommendations per ATAGI guidance.
Varicella: Confirm immunity (history of disease or 2 documented vaccine doses) — chickenpox can be severe in adults.

Documentation

Provide the traveller with:

An International Certificate of Vaccination or Prophylaxis (ICVP) for yellow fever (mandatory for entry to certain countries).
A written itinerary-specific health summary including prescribed medications, doses, and indications.
Advice to carry medications in original packaging with a doctor's letter (especially controlled substances, syringes, and large quantities of prescription medicines).
Travel insurance details and information on accessing medical care abroad (embassy contacts, international SOS services).

Traveller's Diarrhoea (TD)

Epidemiology & Aetiology

Traveller's diarrhoea is the most common travel-related illness, affecting 20–60 % of travellers to high-risk destinations within the first 2 weeks of travel. High-risk regions include South Asia (India, Nepal, Bangladesh), Southeast Asia, sub-Saharan Africa, Central America, and South America. Intermediate-risk regions include China, Russia, and the Middle East.

The most common aetiology is bacterial, responsible for approximately 80–90 % of cases:

Enterotoxigenic Escherichia coli (ETEC) — the single most common cause (30–50 %).
Enteroaggregative E. coli (EAEC) — increasingly recognised, especially in South Asia.
Campylobacter jejuni — particularly common in Southeast Asia; increasing fluoroquinolone resistance.
Salmonella spp., Shigella spp., and non-cholera Vibrio species.
Viral causes (norovirus, rotavirus) are more common in children and cruise ship outbreaks.
Parasitic causes (Giardia lamblia, Cryptosporidium, Entamoeba histolytica) account for <10 % of acute presentations but are important in persistent diarrhoea (>14 days).

Prevention

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"Boil it, cook it, peel it, or forget it" — this remains the cornerstone of TD prevention. Despite rigorous food hygiene, TD rates remain high; hence, empirical self-treatment plans should be discussed at the pre-travel consultation.

Drink only bottled or treated water; avoid ice in drinks of uncertain origin.
Eat freshly prepared, thoroughly cooked food served hot.
Avoid raw or undercooked seafood, salads washed in local water, and unpeeled fruit.
Hand hygiene: alcohol-based hand rub before eating (note: alcohol rubs are less effective against norovirus and Cryptosporidium — soap and water preferred when available).
Bismuth subsalicylate (Pepto-Bismol®): 2 tablets QDS with meals may reduce TD risk by ~40 %; not recommended for >3 weeks or in aspirin allergy — limited availability in Australia, considered OTC import.

Severity Classification

Mild

Mild TD

1–2 loose stools/day, no functional impairment, no blood, no fever. Tolerable and may not require treatment.

Setting: Self-care with oral rehydration

Moderate

Moderate TD

≥3 loose stools/day, or significant nausea/cramping, or moderate functional impairment. No blood.

Setting: Empirical antibiotic + ORS; observe 24–48 h

Severe

Severe TD / Dysentery

≥6 stools/day, bloody stool (dysentery), high fever >38.5°C, severe dehydration, or inability to maintain oral intake.

Setting: Seek medical care; IV fluids may be needed

Management

Oral Rehydration

Oral rehydration solution (ORS) is the foundation of management for all severities. Commercially available sachets (Gastrolyte®, Hydralyte®) should be included in the travel medical kit. In resource-limited settings, homemade ORS: 6 level teaspoons sugar + ½ level teaspoon salt per 1 litre of safe drinking water.

Empirical Antibiotic Self-Treatment

Empirical antibiotics are indicated for moderate-to-severe TD. Current Australian recommendations (eTG):

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Azithromycin

Zithromax® · AzaSite® · Macrolide antibiotic

Adult dose 1000 mg PO single dose (first-line for moderate-to-severe TD)

Alternative regimen 500 mg PO daily for 3 days (dysentery or high fever)

Paediatric dose 10 mg/kg PO single dose (max 500 mg); or 10 mg/kg/day for 3 days if dysentery

Key notes Preferred in pregnancy (category B1); effective against Campylobacter with high fluoroquinolone resistance regions (SE Asia)

PBS status ✔ PBS General Benefit

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Rifaximin

Xifaxan® · Non-absorbed rifamycin antibiotic

Adult dose 200 mg PO TDS for 3 days

Key notes Effective for non-invasive (non-bloody) TD; less effective if dysentery or fever. Minimal systemic absorption.

Paediatric dose Not established for children <12 years

PBS status ✘ Not PBS listed for TD (Authority Required for hepatic encephalopathy only)

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Ciprofloxacin

Ciproxin® · Fluoroquinolone antibiotic

Adult dose 500 mg PO BD for 3 days

Key notes Second-line. Avoid in SE Asia where Campylobacter resistance is high (≥50 %). Avoid in pregnancy and children <18 years. Tendon adverse effects.

Renal adjustment eGFR 30–50: 250–500 mg BD; eGFR <30: 250–500 mg daily

PBS status ✔ PBS General Benefit

Symptomatic Agents

Loperamide (Imodium®): 4 mg initial dose, then 2 mg after each loose stool (max 16 mg/day). Safe in adults; avoid if dysentery (bloody stool) or fever without concurrent antibiotics. Not recommended in children <12 years.
Ondansetron (Zofran® ODT): 4 mg sublingual ODT for nausea/vomiting preventing oral rehydration. Available ODT formulation is ideal for travel kit.
Paracetamol: For fever and myalgia (1 g QDS PRN in adults).

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Red flags requiring urgent medical assessment: Bloody diarrhoea with high fever >38.5°C, signs of severe dehydration (oliguria, confusion, hypotension), inability to tolerate oral fluids, symptoms lasting >7 days, or neurological symptoms. Consider amoebic dysentery, invasive salmonellosis, or cholera in severe presentations.

Persistent Diarrhoea (>14 days)

If diarrhoea persists beyond 2 weeks post-travel, consider parasitic causes (Giardia, Cryptosporidium, Cyclospora, Entamoeba) and post-infectious irritable bowel syndrome. Order stool microscopy (×3 samples), Giardia/Cryptosporidium antigen, stool culture, and consider empiric metronidazole (400 mg TDS for 5–7 days — Giardia) while awaiting results. Refer for colonoscopy if symptoms persist beyond 4–6 weeks.

Malaria

Risk Assessment

Malaria risk is determined by the specific destination (country and region), altitude, season, duration of exposure, and type of accommodation. The Australian Government's Travel Health Pro (NaTHNaC equivalent resources via Smartraveller) and CDC malaria maps are essential tools. Key principles:

No prophylaxis is 100 % effective — mosquito bite avoidance measures must be combined with chemoprophylaxis.
Plasmodium falciparum predominates in sub-Saharan Africa, parts of Southeast Asia, and Papua New Guinea — carries the highest mortality risk.
Plasmodium vivax is common in South/Southeast Asia, Central/South America, and Oceania — relapsing form due to hepatic hypnozoites.
Chloroquine-resistant P. falciparum is widespread; chloroquine resistance in P. vivax occurs in parts of Indonesia (Papua) and Papua New Guinea.
VFR travellers (visiting friends and relatives) are at highest risk due to longer stays, rural settings, and lower perception of risk. Ensure targeted counselling.

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Malaria is a medical emergency in returning travellers. P. falciparum malaria can progress to cerebral malaria, severe anaemia, ARDS, acute kidney injury, and death within 24–48 hours. Any febrile traveller returning from a malaria-endemic area within 12 months must have urgent malaria blood films (thick and thin) and rapid diagnostic test (RDT) — treat as a medical emergency until proven otherwise.

Chemoprophylaxis Options

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Atovaquone–Proguanil

Malarone® · Antimalarial combination

Adult dose 1 tablet (250/100 mg) PO daily, starting 1–2 days before entering malaria area, daily while in area, and for 7 days after leaving

Paediatric dose 11–20 kg: 1 paediatric tab (62.5/25 mg); 21–30 kg: 2 tabs; 31–40 kg: 3 tabs; >40 kg: 1 adult tab. Same timing.

Renal adjustment Avoid if eGFR <30 mL/min

Key notes Well tolerated; take with food or milk. Short post-exposure course (7 days) is an advantage. Best option for short trips.

PBS status ✘ Not PBS listed (private prescription; travellers purchase at pharmacy)

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Doxycycline

Doryx® · Doxy® · Tetracycline antibiotic

Adult dose 100 mg PO daily, starting 1–2 days before entering malaria area, daily while in area, and for 28 days after leaving

Paediatric dose ≥8 years: 2 mg/kg daily (max 100 mg). Same timing. Avoid <8 years (dental staining).

Key notes Cheapest option. Take with food and full glass of water; remain upright 30 min. Photosensitivity — rigorous sun protection. Contraindicated in pregnancy.

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

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Mefloquine

Lariam® · Quinoline antimalarial

Adult dose 250 mg PO weekly, starting 2–3 weeks before entering malaria area, weekly while in area, and for 4 weeks after leaving

Paediatric dose 5–8 kg: ¼ tab/week; 9–19 kg: ½ tab/week; 20–30 kg: ¾ tab/week; 31–45 kg: 1 tab/week; >45 kg: adult dose

Key notes Weekly dosing is convenient for long trips. Contraindicated in psychiatric illness (depression, psychosis, seizure disorder). Start 2–3 weeks early to detect neuropsychiatric side effects. Not first-line due to tolerability profile.

Renal adjustment No adjustment required

PBS status ⚠ Authority Required

Prophylaxis Decision by Region

Region	Species	Resistance	Recommended Prophylaxis
Sub-Saharan Africa	P. falciparum predominant	Chloroquine-resistant	Atovaquone–proguanil, doxycycline, or mefloquine
Southeast Asia	P. falciparum + P. vivax	Multi-drug resistant (Greater Mekong Subregion)	Atovaquone–proguanil or doxycycline preferred
South Asia (India, Nepal)	P. vivax + P. falciparum	Chloroquine-resistant P. falciparum	Atovaquone–proguanil, doxycycline, or mefloquine
Central America (north of Panama)	P. vivax predominant	Chloroquine-sensitive	Chloroquine (if available) or atovaquone–proguanil; add primaquine for P. vivax radical cure if extended stay
Papua New Guinea / PNG Islands	P. falciparum + P. vivax	Multi-drug resistant including chloroquine-resistant P. vivax	Atovaquone–proguanil or doxycycline

Standby Emergency Treatment (SBET)

SBET should be prescribed for travellers visiting remote P. falciparum–endemic areas where access to medical care may be delayed >24 hours. SBET is not a substitute for prophylaxis and should be used only if fever develops and medical attention is unavailable within 24 hours.

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Atovaquone–Proguanil (SBET dose)

Malarone® · Standby emergency treatment

Adult dose 4 tablets (1000/400 mg) PO daily for 3 consecutive days. Take with food.

Paediatric dose 11–20 kg: 2 paediatric tabs; 21–30 kg: 3 tabs; 31–40 kg: 4 tabs; >40 kg: 1 adult dose (4 adult tabs). Daily for 3 days.

Key notes Best tolerated SBET option. Must still seek medical attention as soon as possible after taking SBET.

Treatment of Malaria (Australian Setting)

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All confirmed malaria cases in Australia should be managed in consultation with an infectious disease specialist. P. falciparum malaria with any severity features (parasitaemia >2 %, jaundice, renal impairment, altered consciousness, acidosis, hypoglycaemia) requires IV artesunate — contact your state/territory public health laboratory for emergency supply (available through Special Access Scheme or hospital emergency stock).

Uncomplicated P. falciparum: Artemether–lumefantrine (Riamet®) 4 tablets PO at 0, 8, 24, 36, 48, 60 hours (6-dose regimen). Weight-based paediatric dosing available. PBS Authority Required.
Severe/complicated P. falciparum: IV artesunate 2.4 mg/kg at 0, 12, 24 hours then daily until oral intake tolerated → complete with artemether–lumefantrine. Consult infectious disease team.
P. vivax / P. ovale: Chloroquine (where sensitive) + primaquine 30 mg daily for 14 days (radical cure — check G6PD status first). If chloroquine-resistant P. vivax (Papua, Indonesia): atovaquone–proguanil or quinine + primaquine.
G6PD testing is mandatory before prescribing primaquine or tafenoquine — risk of severe haemolysis in G6PD-deficient individuals.

Specific Infectious Diseases & Vaccinations for Travellers

Vaccine-Preventable Diseases

Hepatitis A

Hepatitis A is the most common vaccine-preventable travel infection. Recommended for all travellers to developing countries. Two doses (0 and 6–12 months) provide long-term (≥20 years) immunity.

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Hepatitis A Vaccine

Havrix 1440® / Avaxim® · Inactivated vaccine

Adult dose 1 mL IM at 0 and 6–12 months (Havrix 1440)

Paediatric dose 0.5 mL IM at 0 and 6–12 months (Havrix 720 junior, 1–15 years)

Protection onset ~2 weeks after first dose; can give up to day of departure for partial protection

PBS status ✔ NIP funded for Aboriginal and Torres Strait Islander children in NT, QLD, SA, WA. Otherwise private script.

Typhoid Fever

Recommended for travellers to the Indian subcontinent, Southeast Asia, Africa, and Central/South America, especially those visiting rural areas or eating adventurously. Two vaccine types are available in Australia:

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Typhoid Vi Polysaccharide Vaccine

Typhim Vi® · Injectable, single dose

Dose 0.5 mL IM, single dose. Booster every 2–3 years if ongoing risk.

Age ≥2 years

PBS status ✘ Not PBS listed (private prescription)

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Typhoid Oral Vaccine

Vivotif® · Live attenuated oral capsule

Dose 1 capsule PO on alternate days × 4 doses (days 1, 3, 5, 7). Complete ≥1 week before departure.

Age ≥6 years

Key notes Refrigerate capsules. Take on empty stomach with cool water. Avoid antibiotics 72 h before and during course. Booster every 5 years (limited supply in Australia — check availability).

PBS status ✘ Not PBS listed

Yellow Fever

Yellow fever vaccination is required for entry into certain countries in Africa and South America, and recommended for travel to endemic areas. The vaccine (Stamaril®) must be administered at a designated Australian yellow fever vaccination centre. A single dose provides lifelong immunity (WHO, 2013 amendment). The international certificate is valid from 10 days after vaccination.

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Yellow fever vaccine is a live vaccine — contraindicated in: immunosuppressed individuals, infants <9 months, pregnant women (except if high unavoidable risk), and those with thymus disorders or history of severe allergic reaction to egg. A medical waiver letter may be issued by the yellow fever centre for contraindicated travellers.

Japanese Encephalitis (JE)

Recommended for travellers spending ≥1 month in rural endemic areas of Southeast Asia, the Indian subcontinent, and the Western Pacific during the transmission season. Also recommended for shorter stays with significant outdoor exposure.

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Japanese Encephalitis Vaccine (Inactivated)

Ixiaro® · Inactivated Vero cell–derived

Adult dose 0.5 mL IM at day 0 and day 28 (can be accelerated to day 0 and day 7 if time-limited)

Paediatric dose ≥2 months: 0.25 mL IM (2 months to <3 years) or 0.5 mL IM (≥3 years), same schedule

Booster 12–24 months after primary course if ongoing risk; then every 5 years

PBS status ✘ Not PBS listed (private prescription; significant cost barrier)

Rabies

Pre-exposure prophylaxis (PrEP) is recommended for travellers to rabies-endemic countries (most of Asia, Africa, Central/South America), particularly those at risk of animal contact (trekkers, cyclists, veterinarians, children) or visiting remote areas where post-exposure prophylaxis (PEP) may not be readily available.

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Rabies Vaccine (Purified Chick Embryo Cell)

Rabipur® · Inactivated vaccine

PrEP dose (2-dose schedule) 1 mL IM on day 0 and day 7 (updated WHO 2-dose intramuscular schedule)

Higher risk schedule 1 mL IM on day 0, 7, and 21–28 (for immunosuppressed or those with limited follow-up)

Key notes PrEP does NOT eliminate the need for PEP after a bite — it simplifies PEP (no rabies immunoglobulin required, only 2 vaccine booster doses). Pre-exposure vaccination is strongly recommended for children travelling to high-risk destinations.

PBS status ✘ Not PBS listed (significant cost — approx. 0–0 per dose)

Mosquito-Borne Viral Infections (Non-Vaccine Preventable)

Dengue Fever

Dengue is transmitted by Aedes aegypti mosquitoes (daytime biters) and is endemic throughout tropical Asia, the Pacific, the Americas, and Africa. Four serotypes exist; sequential infection with a different serotype increases the risk of severe dengue (dengue haemorrhagic fever / dengue shock syndrome).

No specific antiviral treatment — supportive care: paracetamol (avoid aspirin/NSAIDs due to bleeding risk), aggressive fluid management for severe dengue.
Prevention: daytime mosquito bite avoidance is essential — DEET-based repellent (30–50 % for adults), permethrin-treated clothing, window screens, and air conditioning.
Dengvaxia® (dengue vaccine) is not available in Australia and is only recommended for seropositive individuals aged 9–45 in endemic settings.
Warning signs of severe dengue: abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, hepatomegaly, rising haemoconcentration with thrombocytopenia. Requires hospital admission.

Zika Virus

Zika virus is transmitted by Aedes mosquitoes and sexually. Most infections are asymptomatic or mild (low-grade fever, rash, conjunctivitis, arthralgia). The principal concern is congenital Zika syndrome (microcephaly and other birth defects) following infection in pregnancy.

Pregnant women should defer non-essential travel to Zika-endemic areas. If travel is essential, meticulous mosquito avoidance is mandatory.
Couples returning from Zika-endemic areas should use condoms or abstain from sex for: 3 months (male partner) or 2 months (female partner) before attempting conception.
Diagnosis: RT-PCR on serum (first 7 days) and urine (first 14 days); serology has significant cross-reactivity with dengue and other flaviviruses.

Chikungunya

Transmitted by Aedes mosquitoes; causes acute febrile illness with severe polyarthralgia that may persist for months. Prevention relies on mosquito bite avoidance. Ixchiq® (chikungunya vaccine) is approved in some countries (US FDA, 2023) but is not currently available in Australia.

Other Important Travel-Related Infections

Hepatitis B

Travellers at risk of blood/body fluid exposure (medical/dental procedures, tattoos, piercings, sexual contact) should be vaccinated if not already immune. The hepatitis B vaccine (Engerix-B®, H-B-Vax II®) is on the NIP for all Australian infants and catch-up for adolescents. Unvaccinated adults: 0, 1, 6 months (accelerated 0, 7, 21 days + 12-month booster available for travel). PBS General Benefit for at-risk groups.

Meningococcal Disease

Quadrivalent meningococcal conjugate vaccine (Menactra® or Nimenrix®) is recommended for travellers to the African meningitis belt (sub-Saharan Africa, especially during dry season Dec–Jun), pilgrims to the Hajj/Umrah (Saudi Arabia requires proof of vaccination), and close-contact settings. Nimenrix® is funded on the NIP for 12-month-olds and Year 10 students. For travel: private prescription.

Cholera

Oral cholera vaccine (Dukoral®) is considered for travellers to cholera-endemic areas working in humanitarian settings, healthcare, or with limited access to safe water. Three oral doses (day 0, 7, and ≥14 days before departure for adults). Not generally recommended for routine tourist travel. Not PBS listed.

Schistosomiasis

Risk for travellers to sub-Saharan Africa, Southeast Asia, and parts of South America who have freshwater contact (swimming, wading in lakes/rivers). Screen returning travellers with eosinophilia and relevant exposure with serology (stool/urine microscopy has low sensitivity in light infections). Treatment: praziquantel 40 mg/kg PO single dose (available through Special Access Scheme in Australia). PBS Authority Required for schistosomiasis indication.

Strongyloidiasis

Endemic in tropical/subtropical regions; acquired through skin contact with contaminated soil. Can persist for decades as chronic infection and cause hyperinfection in immunosuppressed patients (especially those receiving corticosteroids). Screen with strongyloides serology in at-risk returning travellers. Treatment: ivermectin 200 mcg/kg PO on days 1 and 2 (or 2 doses 2 weeks apart). Available through Special Access Scheme.

Altitude Illness

Relevant for trekkers to high altitude (e.g., Nepal, Peru, Kilimanjaro). Acute mountain sickness (AMS) and high-altitude pulmonary/cerebral oedema (HAPE/HACE) are preventable.

Acetazolamide (Diamox®) 125–250 mg PO BD for prophylaxis, starting 1 day before ascent. PBS General Benefit. Contraindicated in sulphonamide allergy.
Gradual ascent (<500 m/day above 2500 m), rest days every 3rd day, avoid overexertion.
Dexamethasone 4 mg PO BD as adjunct for HAPE/HACE — carry as emergency medication.
Nifedipine 20 mg PO TDS (modified release) for HAPE prevention in susceptible individuals.

Special Populations

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Pregnancy

Malaria prophylaxis: Atovaquone–proguanil and doxycycline are contraindicated. Mefloquine is preferred (Category B2 in Australia). If mefloquine is contraindicated, consider deferring travel to high-risk malaria areas.

Vaccines: Live vaccines (yellow fever, MMR, varicella, oral typhoid) are contraindicated. Inactivated vaccines (hepatitis A, hepatitis B, typhoid Vi, influenza, rabies) are generally safe. Japanese encephalitis vaccine — limited data; use if risk is high.

Zika: Defer non-essential travel to Zika-endemic areas. Meticulous mosquito avoidance if travel is unavoidable.

Traveller's diarrhoea: Azithromycin is preferred (Category B1). Avoid bismuth subsalicylate. ORS is safe.

Note: Long-haul travel increases VTE risk. Encourage hydration, regular movement, and consider compression stockings. Discuss thromboprophylaxis with the obstetric team if additional risk factors are present.

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Paediatrics

Malaria prophylaxis: Atovaquone–proguanil from 5 kg; doxycycline from 8 years; mefloquine from 5 kg. Weight-based dosing is essential.

Vaccines: Yellow fever from 9 months (≥6 months with special justification). Japanese encephalitis from 2 months. Rabies PrEP from birth. Hepatitis A from 12 months.

TD management: ORS is the mainstay. Azithromycin 10 mg/kg single dose. Avoid loperamide in children <12 years. Avoid bismuth subsalicylate in children <12 years (Reye syndrome risk).

Note: Children are at higher risk of animal bites (rabies), accidental ingestion of contaminated water, and severe dengue. Enhanced counselling on supervision and prevention is essential.

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Elderly (>65 years)

Vaccines: Immune response may be reduced — ensure adequate time between doses. Pneumococcal and influenza vaccines should be up to date. Yellow fever vaccine generally safe if no contraindications; consider risk–benefit carefully.

Malaria prophylaxis: All options generally applicable; consider drug interactions with existing medications. Mefloquine — increased psychiatric side-effect risk.

TD management: Higher dehydration risk. Ensure adequate renal function for dosing adjustments. Fluoroquinolones — increased tendon risk (avoid concurrent corticosteroids).

Note: Assess fitness to fly for those with significant cardiovascular or respiratory disease. Ensure adequate travel insurance coverage for pre-existing conditions.

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Immunocompromised

Vaccines: Live vaccines (yellow fever, oral typhoid, MMR, varicella, BCG) are generally contraindicated. Inactivated vaccines may have reduced immunogenicity — consider serological testing post-vaccination. For patients on rituximab, defer vaccination ≥6 months after last dose.

Malaria: Atovaquone–proguanil or doxycycline preferred. Consider drug interactions with immunosuppressants (e.g., cyclosporine levels with malarone).

Infections: Increased risk of severe outcomes from foodborne infections, Strongyloides hyperinfection, and opportunistic infections. Pre-travel strongyloides serology and empirical treatment if positive. Carry a written medical summary and medication list.

Note: Specialist pre-travel assessment by an infectious disease physician or clinical immunologist is recommended for travellers on biologics, chemotherapy, or post-organ transplant.

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Renal Impairment

Atovaquone–proguanil: Avoid if eGFR <30 mL/min — use doxycycline or mefloquine instead.

Ciprofloxacin: Dose reduction required (see TD section). Azithromycin does not require renal adjustment.

Altitude: Acetazolamide is renally excreted — reduce dose or avoid in severe CKD.

Note: Travellers on dialysis require specialist planning. Ensure access to dialysis at destination and carry sufficient supplies of erythropoietin-stimulating agents if applicable.

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Hepatic Impairment

Malaria treatment: Artemether–lumefantrine — use with caution in severe hepatic impairment. Quinine — reduced clearance; monitor levels if available.

Hepatitis A/B: Vaccination is particularly important as pre-existing liver disease increases the mortality risk of viral hepatitis. Ensure serological confirmation of response.

Avoid: Mefloquine in severe hepatic impairment. Halofantrine (not available in Australia) — QT prolongation risk.

Note: Travellers with cirrhosis are at increased risk of spontaneous bacterial peritonitis if they develop travellers' diarrhoea — consider empirical antibiotics earlier.

Post-Travel Screening & the Returning Unwell Traveller

Any traveller returning from a tropical or developing region with new symptoms should be evaluated with a travel history. The differential diagnosis is broad, but the following presentations warrant specific consideration:

Presentation	Key Differential Diagnoses	First-Line Investigations
Fever within 12 months	Malaria, typhoid, dengue, chikungunya, rickettsia, leptospirosis, hepatitis A/E	Malaria thick/thin films + RDT, FBC (thrombocytopenia, eosinophilia), LFTs, blood cultures, dengue NS1/IgM, urine MCS
Chronic diarrhoea (>14 days)	Giardia, Cryptosporidium, Cyclospora, Entamoeba, Campylobacter, post-infectious IBS, tropical sprue, coeliac	Stool microscopy ×3, stool antigen (Giardia/Crypto), stool culture, FBC (eosinophilia), coeliac serology
Eosinophilia	Strongyloides, schistosomiasis, hookworm, filariasis, toxocariasis, fasciola	Strongyloides serology, schistosomiasis serology, stool microscopy ×3, FBC differential
Rash + fever	Dengue, chikungunya, Zika, rickettsia (scrub typhus), measles, enterovirus	Dengue NS1/IgM, Zika PCR/serology, rickettsia serology, FBC
Genital ulcer / STI symptoms	Herpes, syphilis, lymphogranuloma venereum, chancroid, donovanosis	STI screen (NAAT for chlamydia/gonorrhoea, syphilis serology, HIV, hepatitis B/C)

⚠️

Always ask: "Have you been overseas in the last 12 months?" Malaria and typhoid can present weeks to months after return. Delayed presentation and missed diagnosis of malaria is a preventable cause of death in Australia. Refer to an infectious disease specialist for complex returning travellers.

Asymptomatic Post-Travel Screening

Consider screening asymptomatic returned travellers who have had significant exposure:

Eosinophilia on incidental FBC: Strongyloides serology, schistosomiasis serology, stool microscopy ×3, liver function tests.
High-risk sexual exposure: Full STI screen including HIV (window period testing at 2 and 12 weeks), hepatitis B, hepatitis C.
Tuberculosis exposure: Interferon-gamma release assay (IGRA/QFT-Plus) if known contact or prolonged stay in high TB burden country, particularly healthcare workers.
Blood/body fluid exposure: Hepatitis B, hepatitis C, HIV serology at baseline and 3 months.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians who travel — both internationally and to remote communities within Australia — face specific health considerations that require culturally sensitive and context-appropriate care.

Access to Pre-Travel Services

Many Aboriginal and Torres Strait Islander people live in regional and remote areas with limited access to dedicated travel medicine clinics. General practitioners and Aboriginal Community Controlled Health Organisations (ACCHOs) should be equipped to provide pre-travel assessments. Outreach models and telehealth may help bridge geographical gaps.

Vaccination Coverage

Routine vaccination coverage may be lower in some communities. The NIP funds hepatitis A vaccine for Aboriginal and Torres Strait Islander children in high-incidence jurisdictions (NT, QLD, SA, WA). Use pre-travel consultations as an opportunity to catch up on any overdue NIP vaccines, including pneumococcal and influenza.

Chronic Disease Burden

Higher prevalence of type 2 diabetes, chronic kidney disease, cardiovascular disease, and rheumatic heart disease impacts pre-travel risk assessment. Medication interactions with antimalarials and antibiotics must be carefully reviewed. Travel fitness assessments should address glycaemic control, medication supply, and access to medical care at the destination.

Cultural Considerations

Engage with the patient's cultural context and communication preferences. Use culturally appropriate health education resources (e.g., resources developed by ACCHOs, Aboriginal health workers, and Indigenous health promotion organisations). Respect obligations to Country, ceremony, and family that may influence travel plans. Discuss sexual health and blood-borne virus risks in a non-judgemental, culturally safe manner.

Remote Community Travel Within Australia

Travellers to remote Aboriginal and Torres Strait Islander communities within Australia should be aware of risks including melioidosis (Top End, wet season), strongyloides (endemic in some communities), and Q fever. Pre-travel advice should be provided to visitors and health professionals relocating to remote areas.

Malaria and Tropical Infections

Northern Australian residents, including many Aboriginal and Torres Strait Islander communities, live in regions where malaria vectors (Anopheles) are present but malaria is not currently endemic. Continued vigilance is required due to the risk of imported malaria and potential local transmission. Ross River virus, Barmah Forest virus, and Murray Valley encephalitis are locally relevant mosquito-borne infections.

Quick Reference: Travel Medicine Regimens

Syndrome / Indication

Drug

Duration / Schedule

Note

TD — empirical first-line

Azithromycin 1 g PO

Single dose (or 500 mg × 3 days if dysentery)

Safe in pregnancy; effective in SE Asia

Malaria prophylaxis — short trip

Atovaquone–proguanil

1–2 days pre → daily → 7 days post

Best for trips <1 week; private script

Malaria prophylaxis — long trip

Doxycycline 100 mg

1–2 days pre → daily → 28 days post

Cheapest; photosensitivity; avoid pregnancy

Rabies PrEP

Rabipur 1 mL IM

Day 0 and day 7

WHO 2-dose schedule; still need PEP if bitten

Altitude illness prophylaxis

Acetazolamide 125–250 mg

BD, start 1 day before ascent

Sulphonamide allergy — use dexamethasone

📚 References

1. Australian Government Department of Health and Aged Care. Smartraveller: Travel advice and advisories. Canberra: Commonwealth of Australia; 2024. Available from: https://www.smartraveller.gov.au
2. Freedman DO, Chen LH, Kozarsky PE. Medical considerations before international travel. N Engl J Med. 2016;375(3):247–260. doi:10.1056/NEJMra1508815
3. Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance of illness in returned travellers, 2007–2011. Ann Intern Med. 2013;158(6):456–468. doi:10.7326/0003-4819-158-6-201303190-00005
4. Steffen R, Hill DR, DuPont HL, Bär S. Traveler's diarrhea: a clinical review. JAMA. 2015;313(1):71–80. doi:10.1001/jama.2014.17006
5. World Health Organization. International travel and health: Malaria. Geneva: WHO; 2023. Available from: https://www.who.int/publications
6. Lalloo DG, Shingadia D, Bell DJ, et al. UK malaria treatment guidelines 2016. J Infect. 2016;72(6):635–649. doi:10.1016/j.jinf.2016.02.001
7. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health and Aged Care. Canberra: Commonwealth of Australia; 2024. Available from: https://immunisationhandbook.health.gov.au
8. Boggild AK, Geduld J, Libman M, et al. Travel-acquired infections and illnesses in Canadians: surveillance report from CanTravNet, 2009–2012. CMAJ Open. 2015;3(2):E171–E177. doi:10.9778/cmajo.20140070
9. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018.
10. Australasian Society of Clinical Immunology and Allergy (ASCIA). Travel allergy and immunisation resources. Sydney: ASCIA; 2024. Available from: https://www.allergy.org.au
11. Centers for Disease Control and Prevention (CDC). Yellow Book 2024: Health information for international travel. Atlanta: CDC; 2024. Available from: https://wwwnc.cdc.gov/travel/yellowbook
12. World Health Organization. WHO position on Japanese encephalitis vaccines. Wkly Epidemiol Rec. 2015;90(20):237–248.
13. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander health performance framework. Canberra: AIHW; 2023.
14. Lowe D, Engel K, Bhatt P, et al. Rabies post-exposure prophylaxis in Australian travellers. Med J Aust. 2020;212(4):172–176. doi:10.5694/mja2.50480
15. AHFS Drug Information. Atovaquone and proguanil hydrochloride. Bethesda: American Society of Health-System Pharmacists; 2024.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).