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TRAVEL HEALTH

In the UK most travel health advice is provided by nurses. An RCN competency document gives clear guidance on standards expected. Advice to travellers mainly concerns disease prevention; no vaccine is 100% effective. Vaccines are POMs. Nurses without a prescribing qualification can administer them under a Patient Group Direction (PGD) or a Patient Specific Direction (PSD) - see Nurse prescribing. In England, Wales and Northern Ireland, the National Travel Health Network and Centre (NaTHNaC), funded by UK Health Security Agency, and in Scotland, TRAVAX, supported by NHS Scotland, promote standards in travel medicine and provide travel health information for health professionals and the public. 

RCN. Competencies: Travel health nursing: career and competence development;  2018 https://www.rcn.org.uk/professional-development/publications/pdf-006506

National Travel Health Network and Centre (NaTHNaC) https://travelhealthpro.org.uk

TRAVAX https://www.travax.nhs.uk

Fit for Travel (information for the travelling public provided by NHS Scotland) https://www.fitfortravel.nhs.uk/home

Pre-travel risk assessment

Anyone planning overseas travel should seek advice 6-8 weeks before departure. To allow identification of hazards and discussion of risk reduction, you should ask travellers to provide as much detail about their trip as possible, including: Destination Length and purpose of trip Type of accommodation Season Activities planned. Online advice for individual countries, including detailed map is available from NaTHNaC www.nathnac.org/ds/map_world.aspx

MASTA is a commercially funded nationwide network of private travel health clinics. The MASTA website offers a free ‘Do I need vaccinations’ checker. A tailored individual Travel Health Brief provides up to date information on the health risks in the countries travellers intend to visit, with advice on managing risks and the vaccines and antimalarials they need to have. https://www.masta-travel-health.com

General advice to offer travellers

  • Food/water hygiene
  • Insect bite avoidance
  • Safe sun
  • Effects of altitude
  • Safe sex - pregnancy, STI risk
  • Personal safety: accident prevention (e.g. traffic accidents, drowning), vaccinations, pregnancy, alcohol, non-prescribed drugs
  • Malaria prophylaxis
  • Access to/supply of prescription drugs
  • Travellers’ thrombosis/"economy class syndrome"
  • Reminders about travel insurance, visas, proof of vaccination (yellow fever).

Advice on travel and living abroad; travel advice, country by country, including the latest advice on coronavirus (COVID-19) travel.  https://www.gov.uk/foreign-travel-advice

Vulnerable travellers

People for whom a pre-travel consultation is particularly important include:

  • Elderly people
  • People with pre-existing conditions (medication supplies, time zones)
  • Babies and young children
  • Pregnant/breastfeeding women
  • Backpackers
  • People visiting friends and relatives (VFR) in country of origin (who often wrongly assume that they have resistance to malaria).

Vaccinations and prophylaxis, according to destination

ALWAYS CHECK LATEST ADVICE. THERE IS A COST TO PATIENTS FOR CERTAIN VACCINES AND MEDICINES

  • Cholera
  • Diphtheria, tetanus and polio booster
  • Hepatitis A
  • Hepatitis B: cost
  • Japanese encephalitis: cost
  • Malaria: cost
  • Meningitis ACWY: cost
  • Rabies: cost
  • Tick-borne encephalitis: cost
  • Typhoid
  • Yellow fever: cost.

Immunisation Against Infectious Disease: The Green Book https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

CDC. Health Information for International Travel (Yellow Book) 2012 Centers for Disease Control and Prevention (CDC), 2020 https://wwwnc.cdc.gov/travel/page/yellowbook-home-2014 

WHO. International Travel and Health, including the latest advice on travel during the COVID-19 pandemic.   https://www.who.int/travel-advice

Practice Nurse featured articles
Travel health updates – monthly feature by travel expert Jane Chiodini

Tropical infectious diseases Dr Hector Maxwell-Scott

Travel health update, including update on GP contract requirements for vaccination provision; June 2021. Jane Chiodini  

PGDs for private travel vaccines in England Jane Chiodini 

Fitness to fly Jane Chiodini 

MALARIA

A serious and sometimes fatal disease prevalent throughout the tropics. It is caused by infection with a protozoan parasite spread by the bite of an anopheles mosquito. Preventive drugs (prophylaxis) should be taken by anyone travelling where malaria is endemic. The choice of regimen depends on the resistance of malaria parasites in area to be visited.

 ALWAYS CHECK LATEST ADVICE ON PROPHYLAXIS FOR DESTINATION

Advice to patients Take antimalarials as instructed: read the instructions. Seek medical advice if flu-type symptoms occur within 12 months of exposure. No regimen is 100% effective. Try to avoid mosquito bites: cover up if out at night (long sleeves, long trousers), use insect repellent and if sleeping in an unscreened room or outdoors use an insecticide-impregnated bed net.

Public Health England Malaria Prevention Guidelines for Travellers from the UK, 2014 (updated June 2021) https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellers-from-the-uk

Travel Health Pro  Malaria Travel health information (Health professionals) https://travelhealthpro.org.uk/factsheet/52/malaria

RABIES

Almost always fatal encephalitis caused by the rabies virus, acquired from the saliva of an infected animal. Infection is usually via a bite, but scratches or licks to broken skin or mucous membranes are equally risky. May enter the UK via unvaccinated pets. There is no treatment. Consider pre-exposure immunisation for people visiting areas where rabies is endemic.

 Advice if bitten in a country where rabies is present

    • Wash site with soap and water
    • Seek immediate medical advice/begin post-exposure treatment
    • Consider tetanus booster and antibiotics

Rabies post-exposure treatment: management guidelines; updated September 2020. https://www.gov.uk/government/publications/rabies-post-exposure-prophylaxis-management-guidelines  

TICK-BORNE ENCEPHALITIS (TBE)

Caused by flaviviridae viruses; transmitted by the bite of an infected tick (a pin-head sized, blood-sucking arthropod) or ingestion of unpasteurised milk from infected animals. TBE attacks the nervous system; it can cause mild febrile illnesses or potentially fatal meningitis and encephalitis. There is no specific treatment. The TBE virus is almost exclusively restricted to areas within Europe (forested areas of central, eastern and northern Europe; Western subtype) and Asia (eastern Russia, parts of China and Japan; Far Eastern subtype). A licensed inactivated vaccine is available. Awareness of the risk of tick bites is essential. Prevention is by covering limbs (long sleeves, long trousers), use of insect repellents (DEET-containing) on socks, outer clothes and exposed skin; also, by not drinking unpasteurised milk. A tick attached to the skin should be removed completely as soon as possible. Remove by gently gripping the tick as close to the skin as possible, preferably using fine-toothed tweezers or similar instruments, pulling steadily away from the skin and ensuring complete removal of mouthparts. Do not try to remove with lighted cigarette ends or squeeze the body of the tick. Unvaccinated individuals bitten by ticks in high-risk areas should seek local medical advice immediately. Vaccination is indicated for spring/summer travel in endemic areas. High-risk groups are those who hike, camp, cycle, hunt or undertake fieldwork and individuals who intend to reside in these areas or work in forestry, farming and the military (see Green Book).

Tick Alert Facts and news about TBE https://www.tickalert.org

YELLOW FEVER (YF)

One of the most deadly viral infections and a notifiable disease; endemic in tropical Africa and South America. Caused by the yellow fever virus, a flavivirus, and transmitted by several mosquito species. An International Certificate of Vaccination or Prophylaxis is required to enter countries where there is risk of YF. YF vaccine is safe and effective, although certain contraindications apply (history of thymus disease, see Green Book). Since 1969 YF vaccination has been regulated under International Health Regulations (IHR), to help protect YF-free countries from introduction of the disease. Only registered Yellow Fever Vaccination Centres (YFVC), regulated in England, Wales and Northern Ireland by NaTHNaC and by Health Protection Scotland in Scotland, can administer the vaccine; there are strict requirements for training, standards and audit.

NaTHNac Yellow Fever Zone - easy access to information for YFVCs, vaccination recommendation maps and updated country certificate requirements. https://nathnacyfzone.org.uk

The Green Book. Yellow fever Chapter 35  

Practice Nurse featured article

Travel Health Update September 2020 Jane Chiodini

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