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Making the most of the travel health consultation

Carolyn Driver
RGN RM RHV FPCert
MSc(Travel Med)
Independent Travel Health Specialist Nurse
Cheshire
Chairperson
British Travel Health Association
E:thecompany@driverc.freeserve.co.uk

Practice nurses are providing health advice more and more frequently to travellers going to exotic or unusual destinations. In the year 2000, UK residents made more than 53 million visits abroad, and over eight million of these were to countries outside North America and Western Europe.(1) Studies on the effects of travel on the individual's health demonstrate that the greater the climatic and cultural change experienced by the traveller, the greater the chance of health-related problems.(2)
These studies also show that vaccination can  prevent only approximately 5% of travel-related ill health; in fact the individual's lifestyle and activities pose a greater threat to their health than the diseases that may be endemic in the country they are visiting. For example, trauma is one of the most significant causes of both mortality and morbidity in travellers, especially those below 40 years of age.(3)
 
The travel health consultation: structure and resources
The most important commodity needed for a travel consultation is time. In an ideal world travel advice should be organised into specific clinics, just like diabetes, asthma, cervical cytology and many other clinical specialties. This allows for adequate allocation of appointment time and efficient use of resources. If a clinic is not possible then the nurse needs to arrange  the allocation of a suitable length of time with reception staff for any requests for "travel vaccinations". Good travel advice, appropriate vaccinations (following "informed" consent) and malaria prevention advice cannot be given in a 10-minute appointment. An initial appointment should be for a minimum of 20 minutes (preferably half an hour) in order to perform a proper risk assessment and follow-up with the necessary vaccinations and advice (see Table 1).

[[NIP08_table1_77]]

Tools required for risk assessment

A patient history sheet/questionnaire

This can be designed to suit the individual surgery's record system. It may be partly filled in by the patient in the waiting room but should always be carefully gone through during the consultation to ensure that all questions were properly understood. Ideally this sheet will also have space available to record the advice given, vaccinations administered and, where appropriate, malaria chemoprophylaxis recommended.

A good atlas
This is helpful so that you can establish exactly where the patient is travelling to.

Vaccination and malaria recommendation information
Charts such as Travax (which comes with the Practice Nurse journal) or the insert in Pulse are a useful starting point, but they must be regularly replaced as the new versions are published. They can give only broad recommendations, and the coding system used for some recommendations can be confusing. Nurses using these charts should read them thoroughly, including all the explanatory notes and "Keys".

Books
The Department of Health's "Yellow Book" (Health information for overseas travel)(4) and the WHO's International travel and health(5) contain a lot of useful details, and both contain maps highlighting specific risk areas for some of the major diseases. Both publications contain information on malaria prevention and the various regimens for chemoprophylaxis. The WHO book is published annually, so if using the most recent copy the information will be reasonably up to date. The "Yellow Book" is not published as frequently and although the current edition is recent, the nurse must realise that within a short time some of its information may become less valid. The content of both books can be viewed on their respective websites.

Online resources
An online database such as Travax (see below), which is updated daily, is the ideal tool for the nurse wanting travel advice. There is a vast amount of information on the database, including country-specific recommendations covering not just the vaccine-preventable diseases and malaria chemoprophylaxis, but also nonvaccine-preventable diseases, recent disease outbreaks, notes on special requirements such as visas, and whether there are any reciprocal healthcare arrangements. Background information can be found on many of the travel-associated diseases as well as information for specific types of traveller. Malaria advice is very comprehensive, and there are links to maps showing areas of individual countries where malaria transmission occurs. This is invaluable when assessing the specific risk for a traveller. The information can be printed off and given to the patient, or they can be referred to the public access sister site called "Fit for Travel", which contains similar information but is aimed at the traveller.
There are many other websites that the nurse can use to gain information, although these are not as easy to use during a consultation - see Resources.

Advising the traveller
Once all the information has been gathered and information sources checked then lifestyle advice can be given and vaccination plus malaria prevention recommendations made.
One of the issues to consider when recommending vaccinations is how the infection is spread:

  • Is it person to person - diseases of close association such as tuberculosis, diphtheria and meningitis are more of a risk for those going to work abroad or who will be staying in low-budget accommodation where they will be mixing closely with the local population. They are less of a concern for the "package" or short-term tourist.
  • Is it insect-borne - mosquito-borne infection is more prevalent in rural situations, especially in the rainy season. Generally there is no transmission of malaria above 2000m, so those going on high-altitude treks such as in the Andes or Himalayas may not need chemoprophylaxis.
  • Is it spread by contaminated water or food? - those staying in low-budget accommodation or in remote areas where sanitation is poor will be at greater risk than those in the "luxury" hotels (although even the luxury hotel is only as safe as its kitchen porter's standard of hygiene!).

Some of the points to consider when advising about malaria prevention are:

  • Is there transmission in the area being visited?
  • Is there any drug resistance in the area?
  • Are there any contraindications to the recommended drugs?

Involve the traveller in this decision - discuss the options available and help them to choose the best malaria prophylaxis for them. It is important to reinforce the need for bite avoidance measures.

Lifestyle advice
As mentioned earlier, it is important that the traveller understands that their lifestyle while abroad can put them at risk. It is just as important to discuss issues such as food and water precautions, suncare, accident prevention, altitude and safe sex, as it is to administer vaccinations or prescribe antimalarial drugs. 
It would be impossible to give all the advice in depth, so the broad topics should be mentioned and then written material given for the traveller to read later. Practices may choose to compile their own information sheets, but many leaflets are available free from the Department of Health (see Resources), or material can be printed from Travax.

Documentation
Record all advice, vaccinations and chemoprophylaxis recommendations that have been given in the patient's records. Be specific about the exact brand of vaccine given. This can be helpful in future years, as boosting schedules may vary from one company to another or (rarely) products get recalled, such as recently occurred with VAQTA (one type of hepatitis A vaccine).
Private prescription proformas are necessary - remember malaria chemoprophylaxis is not available on the NHS, and mefloquine, doxycycline and malarone are all prescription- only medications.
Give the patient a record of their vaccinations and encourage them to keep it safe and bring it whenever they attend for vaccination, whether this is at a travel clinic or their general practice. Keeping it with their passport may prevent it from being lost.
Remind them when boosters are due - consider a recall system for hepatitis A boosters.
Ensure that any item of service and reimbursement claims are made and that the vaccine stockbook is up to date.

References

  1. Government Statistical Service. The UK in figures. London: Office for National Statistics; 2000.
  2. Cossar J, Reid D, Fallon R, et al. A cumulative review of studies on travellers, their experience of illness and the implications of these findings. J Infect 1990;21:27-42.
  3. Fairhurst RJ. Accidents and the traveller. In: Cook G, editor. Travel associated disease. London: Royal College of Physicians; 1995.
  4. Department of Health. Health information for overseas travel. London: The Stationery Office; 2001.
  5. WHO. International travel and health. Geneva: WHO; 2002.

Resources
Department of Health. Health information for overseas travel. London: HMSO; 2001.
W:www.the-stationery-office.co.uk/doh/hinfo/index.htm
A copy was sent out to each GP and practice nurse when the book was published but extra copies can be purchased through HMSO stores
WHO. International travel and health. Geneva: WHO; 2001.
W:www.who.int/ith
Can be purchased from HMSO stores
Malaria Advisory Committee. Guidelines for malaria prevention in travellers from the United Kingdom for 2001. Commun Dis Rep 2001;4(2).
W:www.phls.co.uk

Further resources
Leaflets
Health advice for travellers - T6
Think Malaria
Travel Safe
(re HIV) 
All available free from:
Department of Health
PO Box 777
Nottingham
NG15 0DU
T:08701 555455
Telephone
Advice Lines
(for healthcare professionals)
Malaria Reference Laboratory
T:0891 600350
Hospital for Tropical Diseases London
T:09061 337733
Liverpool School of Tropical Medicine
T:0151 708 9393
Websites
WHO  W:www.who.int/index.html
Foreign and Commonwealth Office
W:www.fco.gov.uk
Centers for Disease Control and Prevention (USA)
W:www.cdc.gov