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Travelling with the family: vaccination advice

Carolyn Driver
RGN RM RHV FPCert MSc(TravelMed)
Independent Travel Health Specialist
Cheshire

The annual summer holidays are fast approaching, and many practice nurses will be advising families who are travelling to the great variety of destinations that are now on offer to British tourists. While most people are motivated to seek advice in order to establish whether or not they need any vaccinations, it is important that the adviser does not focus purely on vaccinations but also considers the many other lifestyle issues that are equally significant.

Risk assessment
All travel consultations should start with a risk assessment, which should involve obtaining relevant details about the travellers, journey, destination and planned activities. Up-to-date resources should then be used to advise appropriately about recommended vaccinations, malaria prevention, food and waterborne infections, other insectborne infections, climatic risks and general lifestyle risks. Books and charts are no longer felt to be the most appropriate resource as they cannot be absolutely up to date, and it is therefore essential that the nurse has access to the internet (see side panel for the best online resources).

Vaccinations
Once the risk assessment has been performed the recommended vaccinations can be discussed. This is a very good time to establish if the UK national schedule has been completed or, in the case of children, is up to date for their age. If the destination is a developing country where appropriate post­exposure treatment for a tetanus prone wound may not be available then a booster should be considered for those who last received a tetanus-containing vaccine more than 10 years ago. Similarly, if the destination is one where polio is still endemic and polio was last received more than 10 years ago then a booster should be given. In either case, Revaxis is the vaccine of choice for those over 10 years of age. Children under 10 who are not up to date with the National Schedule should be given whichever vaccines are outstanding. It is worth reminding parents that measles is highly endemic in many developing countries and children who have missed out on MMR can be offered the vaccine at this time.

Diphtheria is a risk for those who are not up to date and who will be spending lengthy periods in close contact with the local population in eastern Europe and developing countries.

Families wishing to travel to developing countries with very young children need to consider the vaccination and malaria recommendations and their implications. They should be discouraged from taking babies abroad until they have received their initial primary series of vaccines.

Hepatitis A - food and waterborne viral infection
For all destinations outside Europe or USA, hepatitis A would be recommended to all members of the family over one year of age. Two doses confer long-term immunity of at least 20 years. Ideally, the two doses should be given 6-12 months apart, but there is good evidence that a delay significantly longer than this does not affect the response to the second dose.  Children should be given the dose appropriate to their age when they present.
 
As hepatitis A has a very long incubation period it is well worth giving this vaccine to last-minute travellers as the vaccine has an opportunity to stimulate an immune response during the incubation period.

Typhoid - food and waterborne bacterial infection
Most of the UK imported typhoid cases originate in the Indian subcontinent, and thus any traveller to India, Nepal, Pakistan, Bangladesh or Sri Lanka should be offered vaccination.  Holidays in good-quality accommodation in other parts of the world carry much less risk, especially where the traveller can take adequate precautions with food and water. The typhoid vaccine contains a pure polysaccharide antigen that does not induce a good immune response in children under two, and does not promote good immune memory in any individual, thus vaccination needs to be repeated every three years in those who travel frequently to risk areas. The vaccine does not protect against paratyphoid, and as there are also many other food and waterborne infections it is important that the traveller also receives advice on general food and water precautions.

Yellow fever - insectborne viral infection endemic in sub- Saharan Africa and Amazonian South America
This is a potentially fatal infection transmitted by mosquitoes, and all travellers to endemic areas are advised to receive the vaccination. Yellow fever vaccine is a live vaccine that can be used from nine months of age onwards. It is contraindicated in anyone who is immunosuppressed or those who have an anaphylactic reaction to egg protein, and is used with caution in pregnancy.
 
Yellow fever vaccination certificates are issued under the International Health Regulations laid down by the World Health Organization and are a requirement of entry by certain countries. The certificate requirement should not, however, be used as a guide to recommendation of the vaccine, as many countries where the disease exists will allow travellers from Europe entry without a certificate. This is because the purpose of the certificate is to control the spread of the infection rather than to protect individuals. Yellow fever does not occur in Europe, thus a European traveller is not likely to import the infection - however, if their destination is an infected country the European traveller will be at risk.

Yellow fever vaccination can only be given by registered yellow fever centres because of the International Health Regulations; in the UK registration is carried out by the National Travel Health Network and Centres (NaTHNaC). Practices wishing to become yellow fever centres can obtain information from the NaTHNaC website (see Box 1), or those who wish to refer patients to a centre can find details of their nearest centres. The site also contains important information about yellow fever and elderly travellers as well as risk maps.

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Other vaccines
Vaccination against rabies, Japanese encephalitis, meningitis ACWY, hepatitis B and tickborne encephalitis is less likely to be recommended for short family holidays. However, their mode of transmission and preventive measures against these diseases should still be discussed, and if the risk assessment identifies a particularly high risk then vaccination can be offered. All travellers should understand the urgent need for postexposure treatment for rabies following an animal bite or scratch that draws blood, in any country outside western Europe.

Malaria 
The risk assessment should establish whether the destination carries a risk of transmission. Good online resources are essential here as risk can vary significantly within an individual country and thus a website such as Travax, which contains colour-coded risk maps, becomes invaluable.

The risk and prophylactic options should be discussed with the travellers so that they understand why and for how long they must take their medication. The recommendations of the UK Malaria Advisory Committee on Malaria Prevention should be followed (see Box 1). Parents should understand how serious malaria can be in children and that the prophylaxis will involve persuading their child to take tablets either weekly or daily depending upon the chosen regime. All malaria tablets should be taken with food, and for children the tablets can be crushed. They are not soluble and thus should not be added to drinks. As they are quite bitter they are best added to a small quantity of a strong-tasting food that the child likes. Chocolate spread and peanut butter are reported to be quite useful for this purpose.

Bite avoidance
In addition to discussing malaria prevention, the travellers should be advised about the importance of avoiding insect bites as there are many infections spread in this way. Dengue fever, chikungunya fever, West Nile fever, leishmaniasis, filariasis, sandfly fever and many others may occur in tropical destinations. A good insect repellent should be used day and night. Preferably this should contain DEET - a proven repellent - or Mosiguard, which is a natural product that has undergone stringent testing. Unless in air-conditioned accommodation travellers should sleep under a mosquito net and also keep windows and doors screened, use knock-down fly sprays and plug-in vaporisers. Clothing acts as a good barrier to insects, and the more of the body that is covered the less opportunity for bites - this is especially important at dusk and dawn, which are peak activity times for most species of mosquito.

Lifestyle risks
Many infections are transmitted by droplet infection or direct contact. Thus personal hygiene is very important, and frequent handwashing can help to cut down transmission of many pathogens. Where access to water may be problematic, alcohol-based gels can be carried in travel sizes and kept in a pocket or backpack.

Careful choice of food, avoiding uncooked foods or food that has been sitting uncovered for any length of time, plus drinking only boiled or bottled water, can all help. Advice should also be given on management of diarrhoea, especially in children as it can be hard to avoid this problem (see Box 1).

The effects of the climate should also be discussed - avoidance of both sunburn and heatstroke involve sensible exposure and timing of activities and increasing fluid intake.

General safety issues should also be discussed - reminding the traveller with children that safety features we take for granted at home may not be present abroad. Care on hotel balconies, around swimming pools and in motor vehicles should all be mentioned.

Summary
There is much to discuss with the prospective traveller, especially if they are travelling with a young family. This requires both time and access to the most up-to-date resources so that the best advice can be given. Follow-up literature should be used as, with the best will in the world, the nurse can only give the traveller a flavour of the issues they should consider and it is then up to them to follow these up with their own reading. There are now good websites for the public that the nurse can refer their patients to in addition to using leaflets available from the DH literature line.

References

  1. Department of Health. Immunisation against infectious diseases. Available from URL: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/GreenBook
  2. Health Protection Agency. Foreign travel associated illness. England, Wales and N. Ireland - annual report 2005. London: HPA; 2005.

Resources
NaTHNaC
W:www.nathnac.org
Recent news and links to more detailed
information sources
T:0845 602 6712
(09.00-12.00, 14.00-16.30, Mon-Fri)

Travax
W:www.travax.nhs.uk
Free to all in Scotland, Wales and N Ireland through NHS intranet -
practices in England can subscribe for £100. PCTs can subscribe for £500

HPA
W:www.malaria-reference.co.uk
Links to UK Malaria Advisory Committee guidelines and FAQs
T:020 7636 3924
(09.00-16.30, Mon-Fri)

Immunisation against infectious diseases
W:www.dh.gov.uk/Policy AndGuidance/
HealthAnd SocialCareTopics/GreenBook
Draft versions of new chapters now available - nurses should no longer use the 1996 version but refer to the new chapters on this site

Public access websites

Fit for Travel
W:www.fitfor travel.scot.nhs.uk

NaTHNaC
W:www.nathnac.org

International Association for Medical Assistance to Travellers W:www.iamat.org
Useful directory of approved, English- speaking doctors around the world

Malaria Hotspots
W:www.malaria hotspots.co.uk
Educational site on malaria

Further reading
DH health advice for travellers:
Think Malaria
Travel Safe (re HIV)
Available free from: DH Publications Orderline
PO Box 777
London SE1 6XH
T:0870 155 54 55 F:0162 372 45 24