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Travellers' health: minimising the hazards of overseas travel

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Joyce Skeet, MSc (Travel Medicine), RN.

Practice Nurse, Holbrook Surgery, Horsham and Chanctonbury Primary Care Trust, West Sussex

The number of travellers presenting at the surgery requesting travel immunisations continues to increase; however, vaccination protects against only a small number of the health risks to which a traveller could be exposed. A thorough risk assessment and health promotion advice are therefore an essential part of travel medicine.

British residents made 56.8 million overseas trips in 2000 (Office for National Statistics, 2002), and the number visiting Africa, Asia and Latin America is growing. Sixty-seven per cent of these trips were for holidays, 17% were for business reasons, with the remaining 16% of travellers going abroad to visit family and friends.

By 2010, the Office for National Statistics predicts that UK residents will make as many as 86.8 million trips abroad for a range of reasons (ONS, 2002). Overseas travellers include tourists, business people, diplomats, journalists, students, technical troubleshooters, aid workers, pilgrims, immigrants, refugees, military personnel, sporting participants and spectators, and many others.

Travel medicine has evolved from a need to keep the traveller safe and healthy without destroying the joy of travel. In the past, travellers would have seen their GP to receive the correct travel immunisations. Because of the large number of travellers going abroad today and the general public’s heightened awareness of travel-related illnesses and diseases, primary health-care teams - and especially practice nurses - are now providing comprehensive pre-travel advice, as well as immunisations (Kassianos, 2001).

Health promotion has been part of the daily work of the primary care team for many years and research has indicated that pre-travel clinics could significantly reduce morbidity and incidence of illness among travellers (Kassianos, 2001). Primary-care travel clinics can provide a comprehensive service, which not only benefits the patient and family, but also generates income for the practice. One of the principal objectives of the health professional is to ensure that travellers are well informed about the health risks and diseases they could encounter abroad (Chiodini, 1998).

The public can get pre-travel health advice and information from many different sources, but the reliability of the information varies considerably. Some get advice from their travel agent when they book their holiday, others visit their GP or practice nurse, while others go to dedicated travel clinics. Now, with widespread use of the internet, many get their advice from the web.

Most patients in the UK are registered with a GP, where the practice nurse will be the main provider of travel health advice. It is important that practices offering a pre-travel health service have a nurse who has completed an accredited training course in travel medicine and that regular updates are encouraged to ensure that the most up-to-date information is available to those attending (Carroll et al, 1998). Doctors and practice nurses trained in travel medicine can spend considerable time giving pre-travel advice and administering vaccines to travellers, including time spent advising travellers on the telephone, making appointments, stocktaking, ordering and claiming for the vaccines.


Risk assessment
In the primary care setting the practice nurse or GP will have access to the patient’s medical history, current medication, known allergies and immunisation record, but the importance of an individual risk assessment for each traveller cannot be overemphasised. These details will enable the travel health adviser to tailor the advice offered to the individual and assess which immunisations and malaria prophylaxis are recommended.


Many travellers think that attending a pre-travel clinic is simply to establish which ‘jabs’ they will need to protect them while they are abroad. However, this visit offers the nurse the chance to address the misconception that vaccinations prevent only 5% of travel-related illnesses (Driver, 1999). It is important to build up a picture of where the traveller is going and what they plan to do on the trip. The information the nurse requires to enable the travel advice to be individually tailored is listed in Box 1.


Quick-reference charts published by various medical and nursing journals list recommended and compulsory vaccinations, and malaria prophylaxis. However, they offer limited health advice for travellers.


In the past two years, all GP practices have had the option of being linked to internet services. These and telephone information services provide continually updated information to health professionals on all aspects of travel health (Box 2; Box 3). The websites can be used during the travel health consultation, for example to show maps of malaria areas, recommended prophylaxis, immunisations and specific information on the traveller’s destination. Health advice leaflets can be printed off and given to the traveller to read at home. Pharmaceutical companies also publish leaflets, such as the Travel Healthy series from GlaxoSmithKline.


Travel immunisation
Following the pre-travel risk assessment, an immunisation schedule can be planned with the traveller. Explaining the rationale behind this schedule is important, to enable the traveller to make an informed choice and ensure that consent is valid (Parker, 1998). Most travel vaccinations are not compulsory, but a certificate of yellow fever vaccination is required for travellers visiting, or in transit through, an infected area. Some countries, including Australia and South Africa, require a valid international certificate of vaccination for yellow fever from travellers over one year of age coming from an infected area, such as countries in sub-Saharan Africa and tropical South America (DoH, 2001).


Travel vaccine schedule
Immunisations for travellers can be divided into five groups.


- UK immunisation schedule. It is worth checking that the traveller (child or adult) is up to date with the routine UK-recommended immunisations such as those for diphtheria, tetanus and polio - and when the last dose was given. In addition, the UK recommends that influenza and pneumococcal immunisations should be up to date for people in high-risk groups, such as those who have diabetes, respiratory disease, coronary heart disease and older people.


Last year, the chief medical officer clarified Department of Health guidelines on the combined tetanus/low-dose diphtheria (Td) vaccination (DoH, 2002), recommending that the single antigen tetanus for adults and adolescents be replaced by Td. A Td booster should be given to those whose last dose of tetanus was more than 10 years ago if they are going to areas where medical services are difficult to access.


This is recommended even if the traveller has had five doses of vaccine in the past. Primary immunisation consists of three doses of diphtheria, tetanus and pertussis (DTP), given four weeks apart (usual childhood course <10 years), then another dose of DTP at school entry or three years after the last dose, and a final dose of Td at age 13-18 years before leaving school (DoH, 2001)


- Immunisation against diseases of poor sanitation and hygiene. The most commonly given travel immunisation are against diseases such as typhoid, hepatitis A and polio. They are recommended when travellers are exposed to poor conditions of hygiene in developing countries (WHO, 2002)


- Immunisation against diseases spread by close contact. These include diseases such as diphtheria, meningitis and tuberculosis


- Immunisation against diseases carried by insects, such as mosquitoes and ticks. These include yellow fever, Japanese encephalitis and tick-borne encephalitis


- Immunisations for long-term travellers. For travellers undertaking extended travel abroad, immunisations are required against diseases associated with long-term travel, such as rabies and hepatitis B. Gap-year students, expatriates and missionaries may need to consider these immunisations.


Contraindications to vaccination include acute febrile illness, severe general reaction to a previous dose of the vaccine, hypersensitivity to any components of the vaccine and pregnancy. Possible local reactions such as swelling, redness and pain at the injection site and general reactions such as headache, fever, rash and flu-like symptoms may occur.


The date of departure is important when compiling recommended immunisations and malaria prophylaxis, in terms of when to start malaria tablets and advising on an immunisation schedule. All immunisations should be recorded on the patient’s primary care records with the date, batch number, expiry date and injection site and on a travel record card for the traveller to keep.


Travel vaccines must be stored as recommended by the manufacturer at the correct temperature in a locked fridge with an external maximum/minimum thermometer. The temperature must be checked and recorded daily (Kassianos, 2001). Domestic refrigerators are unsuitable for vaccine storage. Travel vaccines can generate a considerable income for the practice, so a stock control book or database should be used so all vaccines used can be accounted for.


Malaria and prophylaxis
Most of the cases of malaria in the UK are acquired abroad and over half occur in travellers who have visited family or friends who live in endemic regions of the world. In 2001 there were 1081 cases of malaria notified to the Public Health Laboratory Service (2001) in England and Wales.


The Guidelines for Malaria Prevention in Travellers from the UK for 2001should be available to all travel health advisers in primary care (PHLS, 2001). Using these comprehensive UK guidelines helps decide which malaria prophylaxis to recommend or prescribe for the traveller going to a risk area.


Advising travellers in the primary care setting can minimise the hazards of overseas travel (Box 4). Travellers should be advised to attend the surgery or a travel clinic if they feel unwell, especially if they have a fever, up to a year after they return from a malarious area.
Carroll, B., Behrens, R.H., Crichton, D. (1998) Primary health-care needs for travel medicine training in Britain. Journal of Travel Health 5: 1, 3-6.


Chiodini, J. (1998) Top tips for setting up a travel clinic. Practice Nurse 18: 16, 5.


Department of Health. (2001) Health Information for Overseas Travel. London: The Stationery Office.


Department of Health. (2002) Replacement of Single Antigen Tetanus/Low-dose Diphtheria Vaccine for Adults and Adolescents. London: The Stationery Office. Available at: www.doh.gov.uk


Driver, C. (1999) Happy holiday? Primary Health Care 9: 5,14-19.


Garelick, H. (1999) Safe water. In: Dawood, R. (ed.). Travellers’ Health: How to stay healthy abroad. Oxford: Oxford University Press.


Howe, J. (1998) Passion killers. Nursing Standard 12: 35, 22-23.


Kassianos, G.C. (2001) Immunization: Childhood and travel health. Oxford: Blackwell Science. (Continued on page 452)


Office for National Statistics. (2002) UK residents visiting abroad: by month, 1991 and 2001. Social Trends 33. Available at www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=6533


Parker, S. (1998) Legal aspects of travel medicine. Practice Nursing 9: 10, 25-26.


Public Health Laboratory Service. (2001) Guidelines for Malaria Prevention in Travellers from the United Kingdom for 2001. London: PHLS. Available at: www.phls.co.uk


Townend, M., Howell. K. (1999) Travel Health for the Primary Care Team. Salisbury: Mark Allen Publishing.


World Health Organization. (2002) International Travel and Health. Geneva: WHO.
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