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Where do we get our travel health information from?

Jane Chiodini
MSc RGN RM
Travel-Health Specialist Nurse
Chair
RCN Travel Health Forum
Personal Adviser
Diploma of Travel Medicine Course
University of Glasgow

The past decade has seen great advancements in the field of travel medicine, not just because of the increase in the number of travellers to more exotic destinations, but also in the development of new vaccines and the scope of available information sources. For these reasons, it is most important that the travel health adviser remains up to date and knows how to access such information.
In 1987 there was an outbreak of group-A meningococcal meningitis associated with the Hajj, and since 1988 the Saudi Arabian government has required all pilgrims to be immunised against the disease.(1) Last year, an outbreak of Neisseria meningitidis W135 infection was also associated with the Hajj, and up to the end of December 2000 there had been 45 reported cases and eight deaths in the UK alone. UK health departments now recommend use of the quadrivalent meningococcal polysaccharide vaccine, which provides protection against strains A, C, W135 and Y, as being more appropriate.(2) Currently one licensed product is available. ACWY Vax (SmithKlineBeecham Vaccines) is indicated for children and adults over 2 years of age. For those aged 5 years and over, the vaccine provides immunity for up to 5 years, but children under 5 when vaccinated should be considered for revaccination after 2-3 years if they remain at risk. An A4 poster from www.doh.gov.uk/ traveladvice/ hajj.htm with information for the public about this recommendation can be downloaded in Arabic, Bengali and Urdu, as well as in English.
There were 2,069 cases of malaria imported into the UK in 2000, and of these 1,576 were caused by the most dangerous species, Plasmodium falciparum, including 16 deaths (Malaria Reference Laboratory; personal communication, 2001). Of those who died, the majority had taken either inappropriate chemoprophylaxis or none at all.(3) Choice of chemoprophylaxis is complicated when the traveller is visiting a number of areas where there is chloroquine resistance; some regions of the world now have mefloquine resistance as well. For the latter, doxycycline is now licensed for malaria chemoprophylaxis. This drug is very effective, but prescribers must ensure the correct administration. The medication should always be taken after food with a large glass of water, and the traveller should be instructed not to lie down for 30 minutes afterwards to avoid severe oesophagitis.
A new agent, Malarone(TM), an anti-protozoal biguanide (GlaxoSmithKline), has been used to treat malaria for some time but gained its licence for chemoprophylaxis in the USA in July 2000. Licensing for prophylaxis in the UK was granted in May 2001. A study comparing Malarone(TM) with mefloquine concluded that, for malaria chemoprophylaxis in non-immune travellers, Malarone(TM) was better tolerated and recipients had fewer drug-related adverse events, fewer neuropsychiatric side-effects and fewer moderate or severe adverse events. Malarone and mefloquine were similarly effective for falciparum malaria prophylaxis in non-immune travellers.(4)
Other benefits of Malarone(TM) are that it needs only to be taken for 1-2 days before entering the malarious area, and for 1 week after leaving. This will help increase compliance in those who find tedious the 4-week period of administration that applies to all other regimens after leaving a malarious area. Prescribers must take care to  prescribe Malarone(TM) correctly and not to inadvertently prescribe Maloprim (a sulphone/diaminopyrimidine;GlaxoSmithKline), which currently has limited use. Of course, bite prevention should still be discussed with travellers as this remains as important as chemoprophylaxis.
Administration of vaccines within a travel consultation occurs in many cases under a group protocol, but there has been no statutory obligation to have one in place, leaving nurses vulnerable. However, the NHS Executive document issued in August 2000 on Patient Group Directions (England only) was welcomed, as it stipulated what had to happen to legalise a practice that had been undertaken by nurses for a long time. A Patient Group Direction (PGD) refers to a drug, allowing a doctor to delegate responsibility for the nurse to administer it without a specific prescription being written beforehand, as long as certain criteria are met.(*) PGDs should now be in place in surgeries, and failure to comply with the law could result in a criminal prosecution under the Medicines Act.(5) Those who have not yet seen the health service circular can download it from www.doh. gov.uk/ coinh.htm

*PGDs have now been rolled out in Wales and Scotland. There is more information on PGDs on the RCN website: www.rcn.org.uk/pgdirections/index.htm

It is vital for the health professional to keep up to date when advising on travel health. The Department of Health publishes two essential reference books, popularly known as the "yellow" and "green" books. The "green" book is essential for immunisation information, and the "yellow" book - Health Information for Overseas Travel - provides invaluable guidance on country-specific disease risks, vaccine requirements, malaria chemoprophylaxis preferences and travel-related problems. A new edition of this book is expected imminently and copies will be distributed to all GPs and, for the first time, practice nurses.
While this is an essential reference source, any printed material risks becoming outdated very rapidly. This is why use of an online database is so beneficial. Travax is such a system and is compiled by the Scottish Centre for Infection and Environmental Health, the NHS in Scotland. Disease outbreaks are entered into the system, ensuring that the latest information is always available. In addition to the outbreak index, Travax has a large and informative A-Z index with country-specific advice for all countries in the world. There are also pages devoted to advice for different types of travellers and travel situations (for example, diabetics, cruise-ship travel and air travel). Other pages are devoted to vaccine information, conferences, books and literature, useful weblinks, and education and training. Patients can be given printouts of their country destination with the the latest information. The true value of such a resource can be appreciated only by studying the site. Travax is available free of charge to GPs in Scotland and for £50pa for surgeries in England and Wales, although some health authorities have purchased the service for all their practices for a nominal amount. A public site is also available on www.fitfortravel.scot.nhs.uk

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References

  1. Department of Health. Immunisation against infectious disease. London: HMSO; 1996.
  2. Department of Health. Immunisation for pilgrims travelling to Saudi Arabia for Hajj or Umrah. London: HMSO; 2001. (www.doh.gov.uk/cmo/cmo01_03.htm)
  3. Public Health Laboratory Service. Imported malaria cases to the United Kingdom for 1999. London: PHLS; 2000.
  4. Overbosch D, Schilthuis H, Bienzle U, et al. Malarone versus mefloquine for malaria prophylaxis in non-immune travellers. Poster presented at "New challenges in tropical medicine and parasitology" conference. Oxford: 18-22 September 2000.
  5. NHS Executive. Patient Group Directions. HSC 2000/026. Leeds: NHSE; 2000.

Further reading
Centers for Disease Control and Prevention. Health information for the international traveler 2001-2002. Atlanta, GA: US Department of Health and Human Services; 2001.

Kassianos GC. Immunization - childhood and travellers' health. 4th edn. Oxford: Blackwell Scientific Publications; 2001.

Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F, editors. Travel medicine and migrant health. Edinburgh: Churchill Livingstone; 2000.

World Health Organisation. International travel and health - vaccination requirements and health advice. 2001 edition. Geneva: WHO; 2001.