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Travel medicine update: issues and education

Eric Walker
MB ChB FRCP FRCGP
Consultant in Travel Medicine at the Scottish Centre for Infection and Environmental Health (SCIEH) Glasgow
Honorary Consultant Physician
Department of Infection and Tropical Medicine
Gartnavel General Hospital
Glasgow
Honorary Senior Clinical Lecturer
University of Glasgow

The increase in international travel continues unabated. During the 1960s there were around 10 million individual trips abroad made from Britain annually; today that figure looks likely to exceed 60 million (Figure 1).(1) While most of these travellers go to Europe and North America, about 15% go to destinations, or are intending to be involved in activities, that warrant individualised health advice before departure.

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Important developments during 2001
The UK Expert Panel on Malaria Prevention for Travellers from Britain distributed new guidelines during 2001 emphasising that chloroquine and proguanil are no longer adequate firstline drugs for most of subSaharan Africa.(2) The choice for these drug-resistant areas includes mefloquine and doxycycline, which is now fully licensed for malaria prophylaxis, and the new combination drug, Malarone (atovaquone plus proguanil). Malarone is expensive, but needs to be taken for only one week after exposure and so is useful for short visits into high-risk areas, such as game parks and rainforests.
Travellers with special travel health needs, such as migrants, refugees and asylum seekers, need particular attention. After initial port health screening, their healthcare usually falls within the remit of  primary care. We need to be aware of the infections common in their home countries and keep in mind that many will have suffered psychological trauma and stress. 
Like many governments throughout the world, the UK is setting up processes for rapid response to infections caused by bioterrorism. The enhanced surveillance systems required will involve developing the established methods already used for monitoring imported infections. Prompt response is dependent upon a heightened awareness of the possibility of bioterrorism by those at the frontline of healthcare, such as GPs, and prompt reporting to public health authorities.

Deep vein thrombosis (DVT) and air travel
This has attracted much media attention recently.(3) There is little evidence that air travel predisposes to thrombosis more so than any situation where mobility is difficult. A major World Health Organization study is underway to try to clarify the issues involved.

Be aware of predisposing risk factors
Predisposing factors for DVT (in addition to the possible effects of prolonged immobility while travelling) are endothelial vascular lesions, hypercoagulability of the blood and thrombophilia (including hereditary forms such as factor V Leiden). Risk factors include being  over 60 years of age, a smoker, having had a previous (especially recent) DVT or pulmonary embolus, having recently undergone surgery or injury, being pregnant or less than two months postpartum, having a malignancy, cardiorespiratory disease or other chronic illness, taking oestrogen medication, or having deep varicose veins. Symptoms can be delayed for several weeks after the flight. Cases of DVT usually have an average of three of these factors.

Possible advice for those at minimal risk (no or one predisposing factor)
Exercise the legs when possible, maintain hydration and limit alcohol consumption.

Advice for those at low or moderate risk (two or three predisposing factors)
Exercise in the aircraft cabin wherever possible, maintain hydration and limit alcohol consumption, consider using below-knee compression stockings. Possibly consider a daily dose of aspirin while at risk (if aspirin is not contraindicated). The effective dose is unclear - perhaps 75-300mg.

Advice for those at high-risk (more than three predisposing factors)
Exercise, compression stockings, maintain hydration and limit alcohol consumption. Possibly consider subcutaneous injections of "Minihep" (sodium heparin 5,000IU twice daily) or low molecular weight heparin (eg, dalteparin 2,500IU daily or enoxaparin 40mg daily) while at risk (so long as anticoagulation is not contraindicated).

Fear of flying
This problem has been highlighted since the terrorist events in New York in 2001. In Britain an estimated nine million people suffer anxiety about flying and may miss out on professional and personal opportunities. There is no single personality type prone to fear of flying, but there may be a link with problems at work or home.
Fear may develop from a bad experience - a rough flight, or after a news report of a highjacking or crash. Panic attacks are common (sudden intense anxiety, sweating and trembling). The sensation is often so frightening that the sufferer may refuse to fly from then on.

Advice for the traveller who is afraid of flying

  • Explain that fear of flying is common and ­emphasise that flying is safer than road or rail travel in most developed countries.
  • Try distraction by talking with other passengers, watching inflight films, eating or reading.
  • Tell the cabin crew. Reassurance about strange sounds can help.
  • A visit to the doctor before travel can provide reassurance about general fitness for air travel.
  • Consider a tranquilliser before departure. It should be stressed that these drugs do not mix well with alcohol.
  • Cognitive behaviour and/or hypnotherapy may be helpful for more severe cases. The person ­identifies what they actually fear, and then learns different ways of overcoming it.
  • Courses and counselling are available on fear of flying. Aviatours provide courses at Heathrow and Manchester airports.

Risk assessment
This concept is common to much of preventive medicine. Dogmatic advice on when to vaccinate and use other preventive measures is often wrongly given. This may result from relying on simplified wall charts commonly presented in magazines and journals. There is no shortcut to a taking a good case history based on all of the following:

  • What is the traveller's intended destination(s) and lifestyle? Are there any regional and ­seasonal ­differences in incidence of disease risks, and are there any current local epidemics?
  • How serious could the illness be for this traveller? Pre-existing health conditions may make an illness more severe.
  • Are there any potential public health risks should the traveller return home with an infection?
  • How does the risk of contracting an illness weigh up against the effectiveness, cost and possible side-effects of available preventive measures?

It may be perfectly reasonable after a consultation to select different, but appropriate, vaccinations or malaria prophylaxis for travellers going to the same destination and even on the same trip. The travelling public and doctors should not be led to believe that travel advice is simply a case of looking at a country-by-country chart and if individual advice varies then it must be wrong .(4)

Travel medicine education

Diploma, MSc and foundation courses in travel medicine
This diploma is a one-year distance learning course run by the Scottish Centre for Infection and Environmental Health (SCIEH). The diploma is awarded by the Royal College of Physicians and Surgeons (Glasgow). An MSc with the University of Glasgow is run in collaboration. The diploma consists of an introductory residential week followed by written assignments, and is aimed at GPs and practice nurses with a special interest in the subject. A second residential week includes workshops. A mini research project is carried out over the final three months. The foundation course includes four short modules and a two-day workshop. Details from SCIEH, Clifton House, Clifton Place, Glasgow G3 7LN, or email TMdiploma@scieh.csa.scot.nhs.uk

Diploma in travel health and medicine
This one-year day-release diploma from the University of London is based within the Academic Unit of Travel Medicine and Vaccines and supported by the Department of Microbiology and of Primary Care and Population Science. Contact: The Academic Unit of Travel Medicine and Vaccines, Royal Free and University College Medical School, Rowland Hill St, London NW3 2PF, or email rftm0005@rfhsm.ac.uk

Travel medicine certificated course
This course runs over six months and offers an opportunity for healthcare professionals to further their knowledge and skills in travel health and medicine. The course is a combination of distance learning, workshops and tutor-led sessions. For more information contact: Linda Sharpe, Registry (postprofessional), St Martin's College, Bowerham Road, Lancaster LA1 3JD.

Travel-health related education and care
These courses are designed for practice nurses who are new to the field of travel medicine, or those who wish to update and expand their current knowledge. These courses are approved and supported by the SCIEH. Regular courses are organised throughout the year. For more information contact: Sheila Hall, TREC, 6 New City Row, Blanefield, Glasgow G63 9JB, or email sckhall@TRECare.co.uk

The Magister Home learning course
Because most UK travellers will seek advice from their general practice it is likely that practice nurses will need to develop a level of competency in this subject in order to provide a safe service. The cost of the course does not include assessment. For more information contact: Louise French, Magister, Doral House, 2b Manor Rd, Beckenham, Kent BR3.
 
Travel medicine societies and associations
The British Travel Health Association (www.btha.org) has 500 members. It organises national scientific conferences and publishes a newsletter and a journal. The association's aims include support and education for the health adviser, establishing guidelines and setting standards, and developing education and research initiatives.
Most EU countries have travel medicine associations or societies, and the EU is encouraging collaboration between these societies and other bodies monitoring and preventing travel-related illnesses.
The International Society of Travel Medicine (www.istm.org) is committed to addressing the health problems of travellers, supporting high standards of travel medicine practice, research and publications, education and exchange of information between professionals at an international level.

References

  1. Transport, travel and tourism - national UK statistics. Available from URL: http://www.statistics.gov.uk/statbase
  2. Report of the Malaria Prevention Advisory Body for UK 2001. Available from URL: http://www.phls.co.uk/ facts/malaria.htm
  3. Walker E, McIntosh I. Travellers' thrombosis - a literature review. Br Travel Health J 2001;2:10-4.
  4. Risk assessment for travellers. Available from URL: http://www.travax.scot.nhs.uk

Resources
Department of Health - health information for overseas ­travel
W:www.archive.official-documents.co.uk/document/doh/hinfo/index.htm
TRAVAX
Professional site
W:www.travax.scot.nhs.uk
Public site
W:www.fitfortravel.scot.nhs.uk 
World Health Organization
W:www.who.int/ith
British Foreign Office and Health Departments
Safety Information from the British Foreign Office
W:http://193.114.50.10/travel/countryadvice.asp
International Association for the Assistance of Travellers
W:www.iamat.org 
World Tourism Organization
W:www.worldtourism.org

Events
5th Conference of the British Travel Health Association
11 April 2003
Edinburgh E:btha@scieh.csa.scot.nhs.uk