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Advising travellers with specific medical conditions

In this age of excellent transport links and equal opportunities the adventure of travel is available for all persons, regardless of disability or medical condition. Advising patients with an existing medical condition can be a daunting prospect for the travel clinic nurse

Liz Rosies
RGN MSc(TravelMed) PGCE
Travel Health Adviser
Lecturer
Author of www.travelhealth.co.uk

Since July 2007 new European legislation states that people with special requirements and disabilities are to receive new protection. This means that airlines are no longer able to refuse passage to a person on any European flight based on their "disability or reduced mobility" unless they are a definite threat to the safety of the aircraft and/or other passengers.(1)
This emphasis on equality for all people to have the right to travel means that the travel clinic nurse must sometimes assess and advise patients with very complex medical conditions. However, everyone deserves to be fully informed. Specialist advice is essential, be it in a dedicated travel clinic or an opportunistic moment in a specialist clinic. 

Pretravel risk assessment
Before any plans are made to travel or tickets purchased, the traveller should be advised to have a routine health check-up. It is advisable that those with a pre-existing medical condition be given a thorough check-up well in advance of any planned travel in order to both assess their personal health and discuss the feasibility of a journey. This early assessment will also determine a patient's fitness to fly.(2) Because many patients arrive at the travel clinic at the last minute, it is advisable for travel clinic staff to work in partnership with those running specialist clinics to educate patients on the need for good planning before travel. 
The traveller should be encouraged to think through the trip before booking - consideration of the destination, climate, dietary requirements and access to special foods, as well as consideration of the health risks that could exacerbate their condition is essential, eg, travellers with asthma would do well to avoid highly polluted areas.(3) Consideration should also be given to the availability of medical treatment should an emergency require hospitalisation. Some travellers might require routine medical care while away or extra medication supplies. Good preparation and advice at the earliest stage will allow for a plan to be put in place to determine future actions. 
It is also important to remember that in some circumstances travel might actually be considered as an unrealistic option for the patient concerned. A health professional should not be afraid to discuss this with the patient or seek a second opinion should this be the case.
Once the decision to travel has been made and an assessment conducted, the consultation will need to focus on preparing the patient for travel and provide tailored advice for the individual with detailed attention to their travel plans and specific health issues:(4)

  • Travellers with an existing condition should consider travelling with a companion who is aware of their condition and able to assist in an emergency. This is particularly important for the epileptic traveller.(5)
  • Travellers with diabetes should receive specific advice on local food and drinking water so they can consider dietary needs and blood sugar control.(6)
  • With travellers' diarrhoea being the most common problem for travellers, advice should be clear to those with existing digestive disorders where such a problem could exacerbate existing disease.(7) Consideration of diarrhoea prophylaxis might be indicated in this instance.(8) Immunocompromised patients will also need specialist advice on preventing opportunistic infections.(9)
  • Purchasing an identity bracelet with a patient's medical condition is advisable and will give added peace of mind when travelling.(10)

Insurance
All travellers should have travel insurance and in some cases an extra premium might be required. Patients are advised to first contact a specialist charity or association related to their specific condition, rather than opting for high-street policies. This will allow for a policy from a company that has an understanding of their situation and will avoid unnecessary premiums. 
It is important that a patient declares their existing condition on any policy purchased, as failure to do so will cause the policy to be invalid when it might be needed most. An insurance policy should include adequate repatriation cover to the UK in the event of an emergency. It should also provide an emergency telephone number to which they have 24-hour access for medical advice. It is also important to remind patients that the insurance policy will only be as good as the availability of local medical services, and a copy of the documentation should be carried with them at all times.(11)
For those travelling to countries within the European Economic Area (EEA) a European Health Card (EHC) should be obtained. This card replaces the old E111 and will enable a traveller to obtain emergency healthcare within the EEA and Switzerland. This card also entitles those travelling with a chronic disease or pre-existing illness to receive the care and treatment they would expect at home through a reimbursement scheme while travelling. This does not, however, negate the need for insurance, as the EHC will not cover repatriation costs.(12)

Medication and specialist equipment
Those with pre-existing conditions who require regular medication should also be issued with a letter from their GP or consultant outlining medication requirements, as well as a copy of their prescription.(13) Names of any medication should be listed in the letter with generic names and doses required. This is essential as many countries have specific regulations about bringing certain types of medication into the country.
Supplies of medication will need to be issued for the duration of the trip and "a little bit more". Travellers should be advised against keeping all of their medication supplies in one location, should baggage get lost or stolen en route. If travelling with a companion, it is advisable to divide it among different bags. Some medication, such as insulin, will require special care when transporting.  
For some conditions, putting together an emergency plan for the worst-case scenario will provide the patient with reassurance. The provision of emergency medication is advisable especially for an asthmatic traveller.
With heightened security measures at airports travellers can only keep the medication that they will need for the journey with them in their hand luggage. The rest will need to be placed in the hold. If a traveller wants to carry more medication with them on the flight, special permission will be required from the airline to make the necessary arrangements. It is important to remember that this will take time so planning ahead is essential. Relevant paperwork should be completed well in advance with essential documentation from a doctor or consultant. For medications that could potentially ruin if frozen, a request can be made at check-in to ensure the luggage is placed in a "warm" part of the aircraft, but if this is required it is worth contacting the airline in advance.(14)

Vaccinations and malaria
Vaccinations and malaria prophylaxis should be discussed with the individual traveller according to their condition and types of medication they are already taking. Vaccination efficacy can be limited in immunocompromised patients. Care should be taken when advising travellers with epilepsy, as certain types of medication can limit their choice of prophylaxis. Likewise, some antimalarial medication can interact with cardiac drugs causing bradycardia.(15) In some instances, such as for people with asthma, further vaccinations outside of the general recommendations, such as influenza and pneumococcal, might be advised.(16)

Preparing to fly
Once a trip is confirmed it is important that the patient is prepared for the journey. Any specially required meals should be ordered in advance with the travel agent or at least 24 hours prior to flying from the airline. However, in the case of a traveller with diabetes they might only need to check their carbohydrate intake regularly and, if required, top-up with snacks on the journey. They might need to take extra snacks and should be advised not to take their insulin until they see their food coming as flights are unpredictable and all kinds of things could delay the food arriving.
Airlines should be prewarned about special seating requests as well as transfer needs from check-in to the aircraft. BAA airports provide a full service for those travelling with special needs, from transport to adapted telephones for those with hearing aids in the terminals.(17) Extra medical equipment onboard the flight, such as oxygen, will also need to be ordered via the airline in advance. The risk of deep vein thrombosis should be assessed and advice given.(18) Travellers with a pacemaker might wish to inform the airline before travel to prevent unnecessary embarrassments when passing through security equipment at airports.

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References

  1. Department of Transport. New guidelines to protect disabled travellers. London: DT; 2007. Available from: http://www.dft.gov.uk/consultations/closed/consulcivilaviationreg07/newr...
  2. World Health Organization. International travel and health. Chapter 2: Travel by air - health considerations. Geneva: WHO; 2005. Available from: http://whqlibdoc.who.int/publications/2005/9241580364_chap2.pdf
  3. Burley P. Air pollution and asthma: the dog that doesn't always bark. Lancet 1999;353:859-60.
  4. Raeside F. Risk assessment travel medicine and migrant health. London: Churchill Livingstone: 2000.
  5. NATHNAC. The yellow book. Chapter 14: Travellers with pre-existing conditions. Available from: http://www.nathnac.org/yellow_book/14.htm
  6. Diabetes UK. Diabetes and travel. Available from: http://www.diabetes.co.uk/travel.html
  7. HPA. Foreign travel-associated illness. London: HPA; 2005. Available from: http://www.hpa.org.uk/publications/2005/travel/travel.pdf
  8. Diemart D. Prevention and self-treatment of travellers diarrhoea. Clin Microbiol Rev 2006;19:583-94. Available from:http://cmr.asm.org/cgi/content/full/19/3/583
  9. Lankester T. The traveller's good health guide. London: Sheldon Press; 2006.
  10. MedicAlert. Identity bracelets. Available from: http://www.medicalert.org.uk
  11. Foreign and Commonwealth Office. Travel insurance. Available from: http://www.fco.gov.uk/servlet/Front?pagename=OpenMarket/Xcelerate/ShowPa...
  12. Department of Health. The EHIC: free or reduced cost treatment. London: DH; 2008.
  13. Walker E, Calvert L. Travel medicine and migrant health. London: Churchill Livingstone; 2000.
  14. Department for Transport. Liquids and air travel - what are the requirements? Available from: http://www.dft.gov.uk/transportforyou/airtravel/airportsecurity/requirem...
  15. HPA. Guidelines for prevention of malaria in travellers from the United Kingdom. London: HPA; 2007. Available from http://www.hpa.org.uk/publications/2006/Malaria/Malaria_guidelines.pdf
  16. Fit For Travel. Asthma and travel. Available from: http://www.fitfortravel.nhs.uk/advice/travellers/asthma.htm
  17. British Airport Authority. Available from: http://www.baa.com. Individual airports can be accessed via this link and followed through to "special needs" pages.
  18. BMA. The impact of flying on passenger health: a guide for healthcare professionals. London: BMA; 2004. Available from: http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFFlying/$FILE/Impactofflying.pdf


Further reading

Chiodini J, Boyne L, Grieve A, Jordan A. Royal College of Nursing Competencies: an integrated career and competency framework for nurses in travel health medicine. London: RCN; 2007. Available from: http://www.rcn.org.uk/development/publications/?a=7874