This site is intended for health professionals only

Setting up a travel health clinic in general practice

Joyce Skeet
RGN MSc Travel Medicine (Glasgow) MFTM
Practice Nurse Holbrook Surgery Horsham
West Sussex

Most people enjoy travelling and the World Tourism Organization forecasts that by the year 2020, international worldwide arrivals may reach nearly 1.6 billion, with 378 million of these being long-haul travellers. The forecasted arrivals by region will be Europe (717 million tourists), East Asia and the Pacific (397 million) and the Americas (282 million), followed by Africa, the Middle East and South Asia. However, it is worth noting that the growth in the arrival of international tourists has slowed recently due to the credit crunch and oil price rises.1

Statistics show that British residents alone made 66 million visits abroad in the 12-month period from March 2009, with an increasing number going to Africa, Asia and Latin America. Travellers include tourists, businessmen and women, diplomats, journalists, students, technical trouble-shooters, aid workers, pilgrims, immigrants, refugees, military personnel, sporting participants, spectators and more recently, medical tourists.2 One of the world's fastest-growing industries is  tourism and in 2007, international tourism generated US $856bn (€625bn). This was due to the increase of cheap air travel, accommodation and package tours. With this rapid growth and the speed of travel, many people can be back in their homes before the signs of illness present.3

Travel medicine has evolved out of a need to keep the traveller safe and healthy, without destroying the joy of travel. In the past, the traveller would have seen their GP with the main focus being on immunisations. Due to the number of travellers going abroad today and increased awareness among the general public of travel-related illness and disease, primary healthcare teams can now provide comprehensive pre-travel advice as well as immunisations to their patients. 

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 illness in travellers.4 Such clinics can provide a comprehensive service that is not only beneficial to the patient and his family, but that also generates income for the practice.

In recent years there has been an increased interest in providing this service and many GPs and practice nurses have embarked on training programmes for travel medicine to give them the specific knowledge and qualifications to meet this demand (see Box 1 for a list of courses available).

[[Box 1 trav]]

The public can get their pretravel health advice and information from many different sources, although the reliability of this information may be questionable. When booking their holiday, many people are advised by their travel agent to visit their GP or practice nurse. Some go to a dedicated travel clinic and now with the internet, many check online.

Travellers who book their last-minute holiday online often have no idea what advice or immunisations are recommended for their destination. One of the principal objectives of the health professional is to ensure that the traveller is well informed about the health risks and diseases that could occur during their stay abroad; therefore, many surgeries are considering setting up a dedicated travel clinic to provide this service for the benefit of their practice population.

Practicalities of setting up a travel clinic

  • How many travellers are seen for advice and immunisations currently? An audit of travellers seen in the last three to six months could be a starting point.
  • Does the practice have a nurse who is trained or is interested in being trained to deliver a professional pre-travel and immunisation service to the practice population?
  • Could the treatment room be used for the travel consultation? Is there ample space for a couch in case of a traveller fainting or for use of emergency equipment in the rare case of anaphylaxis? Is there room for a dedicated vaccine fridge?
  • Has the practice access to a dedicated internet travel advice service, eg, TRAVAX (see Resources)? Many primary care trusts (PCTs) already subscribe to this service, so the travel nurse can log on for up-to-date information on destinations, malaria areas, prophylaxis, advice sheets and immunisations.

Vaccine ordering, storage and maintaining the "cold chain"

  • It is important that vaccines are stored at the correct temperature (2–8ºC) in a vaccine fridge; this should be locked when not in use and the minimum and maximum temperature recorded daily.
  • One nurse in the surgery should be nominated to be in charge of the vaccines. This will include checking expiry dates, maintaining the level of vaccines without stockpiling, ordering as necessary and checking and storing all deliveries so that the "cold chain" is not broken.
  • The vaccine fridge should have a dedicated electricity supply to ensure that the power is not accidentally switched off, as the replacement cost of the vaccines could be considerable.
  • Vaccines should not be stored too tightly as it is necessary for air to circulate.
  • Vaccines should not be stored in the door compartments of a fridge.
  • If vaccines are reconstituted they must be used inside the time recommended by the manufacturer.
  • All used ampoules and syringes must be discarded into a sharps bin.

Pretravel questionnaire
Many surgeries have developed a pretravel questionnaire, to be completed by the individual before an appointment. The form can be downloaded from the practice website or collected from reception, and when completed, scanned or recorded into the patient's computerised notes before they attend the consultation.

The questionnaire should include destination, departure date and length of stay, accommodation, planned activities, previous immunisations, medications and medical conditions. This ensures that the healthcare professional has much of the traveller's itinerary in advance and can plan the consultation appropriately.

Travel clinic protocol, patient group directions and patient specific directions
A protocol for the travel clinic should be in place, stating how it will operate, who is responsible for making appointments, ordering vaccines, stock taking and the general overseeing of the clinic.

PGDs (see Resources) are documents that make it legal for medicines to be given to groups of patients; one for each vaccine that will be used in the travel clinic should be signed by the nurse responsible for its administration.

A (PSD) is a written instruction from a qualified and registered prescriber for a medicine including the dose, route and frequency to be supplied or administered to a named patient.5 This is required for administration of some vaccines that are not available on the NHS and where a charge to the patient can be made, eg, rabies, Yellow Fever, meningitis ACWY or hepatitis B.

Documenting and record keeping
The travel consultation should be documented in the patient's computerised notes and include risk assessment and advice given, backed up with written material that the traveller can read at their leisure. Recording malaria advice and prophylaxis discussed, vaccines given, batch numbers, expiry dates and sites of injections is also important.

Consent
The traveller will need to be informed of the vaccines that are required or recommended for their planned destination, and their possible side-effects. Consent must be obtained before any vaccine is administered; this can be verbal or written, and it is not a legal requirement to obtain consent in writing.

Malaria prophylaxis
Travellers who will be visiting a malaria area will need to be advised of the appropriate prophylaxis for their destination. They need to understand the correct administration and that compliance is essential to prevent malaria. A copy of the Guideline for Malaria Prevention in Travellers from the United Kingdom issued in 2007 by the Health Protection Agency is essential for advising travellers.6

Becoming a Yellow Fever centre
The practice could become a Yellow Fever centre so that any traveller registered with the practice or other practices in the area can be offered a Yellow Fever vaccine if it is required for their destination. For details on how to become a Yellow Fever centre, visit the National Travel Health Network and Centre (NaTHNac) website (see Resources).

Guidelines and competencies
Delivering Travel Health Services: RCN Guidance for Nursing Staff, issued in 2005, is a useful booklet giving recommendations for best practice for nurses planning to deliver a travel health service.

The RCN Competencies: an integrated career and competency framework for nurses in travel health medicine was published in April 2007 and, for the first time, sets out a set of guidelines and standards for the care of travellers by healthcare professionals. Both of these publications are available online or from RCN Direct (see Resources).

Conclusion
There are many benefits of running a dedicated travel health clinic. First, the healthcare professional can concentrate on one topic and deliver an accurate and focused service for the traveller. There is also the opportunity to update records as many of these "well" patients do not attend the surgery regularly.

Running a travel clinic can generate substantial income for the practice by offering comprehensive pre-travel health consultations, with income from private vaccines and prescriptions and possible sale of travel goods, and many travellers registered at other practices may be attracted by the service offered. It is most rewarding to provide good pretravel health advice to travellers to help ensure that they stay healthy and safe while abroad.

Resources
Foreign and Commonwealth Office
W: www.fco.gov.uk
Health Protection Agency
W: www.hpa.org.uk
Malaria Reference Laboratory
W: www.malaria-reference.co.uk
National Travel Health Network and Centre
W: www.nathnac.org/travel/index.htm
NHS Patient Group Directions
W: www.pgd.nhs.uk
Royal College of Nursing Direct
W: www.rcn.org.uk/support/rcn_direct_online_advice
Travax – advice for healthcare professionals
W: www.travax.nhs.uk
World Health Organization
W: www.who.int/ith
 
There are a number of travel health publications available to the primary care team and useful additions to the practice library would be: 
Dawood R. Travellers Health: How to Stay Healthy Abroad. 4th ed. Oxford University Press; 2002.
Kassianos GC. Immunization: Childhood and Travel Health. 4th ed. Oxford: Blackwell Science; 2001.
Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F. Travel Medicine and Migrant Health. Oxford: Churchill Livingstone; 2000.
Royal College of Nursing. Delivering Travel Health Services: RCN Guidance for Nursing Staff. London: RCN; 2005.
Royal College of Nursing. RCN Competencies: an integrated career and competency framework for nurses in travel health medicine. London: RCN; 2007.
Townend M, Howell K. Travel Health for the Primary Care Team. London: Mark Allen Publishing Ltd; 1999.

References
1. World Tourism Organization. Tourism 2020
Vision. Available from: http://www.unwto.org/facts/eng/vision.htm
2. Office for National Statistics. MQ6 Transport Travel and Tourism: overseas travel and tourism. London: ONS; 2009.
3. Office of Travel and Tourism Industries (OTTI). World & US International Visitor Arrivals & Receipts. Available from: http://tinet.ita.doc.gov/outreachpages/inbound.world_us_intl_arrivals.html
4. Kassianos G. Immunization: childhood and travel health. 4th ed. Oxford: Blackwell Science; 2001.
5. Department of Health. FHSL (95)7: Malaria prophylaxis regulation permitting GPs to charge for
prescribing or providing anti-malarial drugs. London: DH; 1995.
6. Health Protection Agency. Guidelines for Malaria Prevention in Travellers from the United Kingdom. London: HPA; 2006. Available from: http://www.hpa.org.uk/web/hpawebfile/hpaweb_c/1203496943523