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Addressing diverse needs in travel health provision

Liz Rosies RGN MSc(TravelHealth) PGCE
Travel Health Nurse

For travellers seeking health advice, the practice nurse will often be the first port of call. It is important for information to be communicated clearly and tailored to the individual, whether young or old

The Royal College of Nursing (RCN) competency and knowledge skills framework, which provides a benchmark for travel health provision, expresses the need to acknowledge equality and diversity  - and the travel clinic is the one place where this rings true.1

Older travellers
Recent research has shown that older people are more likely to be concordant with the travel health advice they are given. It is suggested that they adhere to food and water advice and are far more likely to take malaria prophylaxis. As a result, older people are far less likely to experience travel-related illness than their younger counterparts. While we often assume this is because they travel to low-risk destinations, research has also shown that 15% of Thailand's backpackers are over the age of 55 with 1.5% over the age of 80.2 This encouraging data indicates that older people are looking for advice when they travel and taking note of the health education they are given.

[[Box 1. Liz Rosies]]

As the body ages, physiological changes occur that increase the older traveller's vulnerability to health problems when they travel. After the age of 60 there is a noticeable slowing down of major organ systems.3 Many older people are also travelling with pre-existing medical conditions and various medication needs.

Due to the more complicated medical history and medication list, a thorough risk assessment is essential. While age is not a contraindication for travel, the effects that ageing can have on the body must be recognised. In a travel consultation this might require some 'precautionary counselling' to ensure the traveller remains in good health while away from home.4 The leading causes of death in the older abroad are documented as being cardiovascular disease and accidental trauma, but it is important to consider whether those deaths might have actually occurred had the traveller remained at home.5,6 This also highlights the need to stress the importance of good insurance for the older traveller.

If older travellers with pre-existing conditions require regular blood tests, such as those on long-term warfarin, needing regular INR blood tests, it might be worth considering the recommendation of a self-testing device. Patients can then learn how to use the monitor to test their own blood. By liaising with a specialist practitioner, patients will be able to perform self-testing while they are away from home and seek help accordingly should results differ from their required norm.

It is believed that the antibodies produced following vaccination may take longer to produce in the older. Therefore, it has been suggested that older travellers should seek travel health advice at least eight weeks before travel. Although research suggests lower responses for some vaccines in older people, there is little dispute that even a lower response is better than none at all in reducing disease related complications.7 Currently, yellow fever is the only vaccination where caution is advised in the over-60s age group. While adults over 50 who contract yellow fever are at a higher risk of severe disease and death, an adult over 60 is nearly six times more likely to suffer adverse effects from the vaccine. An adult over 70 is more than 10 times more likely to suffer severe side-effects. It is suggested that caution should be taken when the traveller is going to a low-risk yellow fever area, even when certification is required, when an exemption certificate could be issued following a thorough risk assessment.8

Young travellers
When we consider the needs of the child, research indicates that the most common health problems facing younger travellers are diarrhoeal illness, malaria and accidents, especially those involving water. Children visiting friends and relatives (VFR) face individual health issues and are also known to be at high risk of TB and intestinal parasites, with this group being the most unlikely to visit the travel clinic for advice.9 When giving advice to parents of young VFR children it is important that they are aware of the risks to the child when travelling, which will be vastly different to their own. Recent data show that 48% of VFR travellers to Asia do not take out insurance when they travel and many of those travelling do so as family groups.10

[[Box 2. Liz Rosies]]

Every child should be up to date with all of the childhood routine vaccinations.11 Due to the under-developed immune system of a child, some vaccinations are considered unsuitable for those under 12 months. Anti-malarials should be used from birth with child doses calculated on the body weight of the child.12 Recent outbreaks of measles around the world and in the UK have alerted health professionals to the need to ensure these routine vaccinations are up to date.13

For parents who had previously refused measles vaccination, the travel clinic might be a good time to revisit the subject and offer up-to-date advice on the growing problem of reduced herd immunity and the high risk children face of contracting the disease. While the routine immunisation programme in the UK suggests vaccination at 13 months, infants should be given the MMR if travelling to a risk area from six months of age, with a further two doses; at 13 months and before entering school.14

We often assume that infectious disease is most likely to affect our travellers, but research has shown that trauma is responsible for up to 20% of deaths in overseas travellers, with children being at particular risk, especially when travelling by car.5 Second to death from road traffic accidents comes drowning. If children are unable to swim, parents should ensure they take suitable buoyancy aids if they are travelling to destinations close to water. With drowning mortality rates highest in the under-fives, it is essential that children are
supervised at all times near water.15 

It is advisable for parents to consider checking government websites for the latest travel information regarding newsworthy health risks before travel. For example, recent travellers to Germany were alerted to the outbreak of the haemolytic uraemic syndrome (HUS) and bloody diarrhoea. Many young children were affected in Germany during the outbreak, which also led to travellers being cautioned to observe good food and water hygiene as well as care in handling fresh fruit and vegetables.16 

Conclusion
A final thought is never to assume anything. I often remember as a young travel health nurse seeing a couple in their late 80s planning a month-long trip to Africa. I was full of enthusiasm and offered advice on every eventuality - explaining how hepatitis B could be caught sexually and from blood, quoting statistics that would blow your mind, all gained from a recent study day. Exuberance and enthusiasm for my specialism fuelled my repertoire. Imagine my dismay when they left with mixed emotions - the older gentleman downcast and his dear wife elated. It was only later when I questioned them that I realised that my own poor communication skills resulted in the gentleman thinking he would not be able to have sex with his wife in Africa for fear of hepatitis B and the lady grateful she would have a month without the romantic gestures of an amorous older gentleman!
 
It is important that our messages about travel health are adapted to the individual, be it the older or younger traveller, and also that we ensure information has been communicated, and understood, with action taken accordingly.
 
References

  1. Royal College of Nursing (RCN). Competencies: an integrated career and competency framework for nurses in travel health medicine. London: RCN; 2000.
  2. Alon D, Shitrit P, Chowers M. Risk behaviors and spectrum of diseases among older travelers: a comparison of younger and older adults. J Travel Med 2010;17:250-5.
  3. Abrass IB. The biology and physiology of aging. West J Med 1990;153(6):641-5.
  4. Dawood R. Travellers Health: How to Stay Healthy Abroad. Oxford: Oxford University Press; 2002.
  5. Redman CA, MacLennan A, Walker E. Causes of death abroad: analysis of data on bodies returned for cremation to Scotland. J Travel Med 2011;18:96-101.
  6. Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travelers: an analysis of deaths related to international travel. Ann Emergency Med 1991;20:622-6.
  7. Keystone J, Kozarsky P, Freedman D, Nothdurft H. Travel Medicine. New York: Mosby Elsevier; 2008.
  8. Khromava AY, Eidex RB, Weld LH. Yellow fever vaccine: an updated assessment of advanced age as a risk factor for serious adverse events. Vaccine 2005;23:3256-63.
  9. Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004;291:2856-64.
  10. National Travel Health Network and Centre. Travel insurance: Foreign and Commonwealth Office Advice. Available from: www.nathnac.org/travel/news/travelinsurancefco_030611.htm
  11. Department of Health (DH). Immunisation Against Infectious Disease ('The Green Book'). London: DH; 2006.
  12. National Travel Health Network and Centre. Malaria Chemoprophylaxis. Available from: www.nathnac.org/pro/factsheets/malariaproph.htm
  13. National Travel Health Network and Centre. Measles risk during travel - update May 2011. Available from: www.nathnac.org/pro/clinical_updates/measles_180511.htm
  14. Department of Health (DH). Health Information for Overseas Travel (the 'Yellow Book'). London: DH; 2010.
  15. Cortés LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travellers. J Travel Med 2006;13(1):21-34.
  16. National Travel Health Network and Centre. Outbreak of Vero cytotoxin-producing E. coli in Germany - update. Available from: www.nathnac.org/pro/clinical_updates/ecoligermany_100611.htm

Resources
European Health Insurance Card www.ehic.org.uk
Fit For Travel www.fitfortravel.nhs.uk
Foreign and Commonwealth Office www.fco.gov.uk
Age UK (Leisure and Travel Information Advice)
www.ageuk.org.uk/travel-lifestyle
Centers for Disease Control and Prevention (Teach Children
About Rabies)
www.cdc.gov/rabiesandkids

Further reading
Wilson-Howarth J, Ellis M, Levene B. Your Child Abroad: A Travel Health Guide. New York: Bradt Travel Guides; 2004.