Key learning points:
– Vaccination is a small part of the pre-travel health consultation
– A knowledge of diseases and other health risks for travellers is necessary to determine which vaccines to give
– Practitioners need a source of up-to-date advice on which vaccines to give
In the UK, specialist travel health clinics and pharmacists are increasingly offering pre-travel advice and vaccination, but the majority of patients still seek these services in primary care, from the practice nurse.1
Pre-travel health risk assessment is a wide subject, but this article will focus on the importance of vaccination and the sources for determining which vaccines are appropriate for particular destinations. Individual vaccines and diseases will not be discussed.
Why are vaccines important?
Vaccination is a way for an individual to generate a protective immune response to a disease without direct exposure. This is achieved at a population level through the national immunisation programme2 with additional specific vaccines administered for travel purposes depending on area of travel.3
A number of the commonly recommended vaccines (for instance, hepatitis A and typhoid) are against diseases that pose a public health risk to a population of unvaccinated people. If any traveller were to return to the UK with either of these diseases there is potential to infect close friends and relatives. So it is important for the health professional to know the incubation period of diseases.4
What does the nurse need?
Before administering any vaccine the nurse should have completed training and regular updates in accordance with the National Minimum Standards for Immunisation Training5 and Supporting the Delivery of Immunisation Education quality framework.6 As with any drug, it is important that the nurse is familiar with what they are administering before they give it to the patient.7 Figure 1 is a series of questions to check knowledge of travel diseases.
Find the answers in relevant disease literature; see Resources section.
When to vaccinate?
In the ideal world, patients would make contact four to six weeks before their trip.8 This would allow time to plan and schedule any recommended vaccines. Ideally all travellers would be vaccinated, including those who consider their travel to be within ‘safe areas’ with minimal disease exposure. If this happened, the consultation could also be an opportunity to bring travellers up to date with routine UK-schedule vaccinations4,8 and vaccinations could be tailored to their intended activities. For example, those walking or cycling in forested areas of Austria might be exposed to tick-borne encephalitis, which is preventable by vaccine.9
In reality, it is more likely that patients present when they have been advised to by their travel agent, a friend or family member because they are heading to exotic regions or somewhere with a reported or perceived risk. Even if a traveller arrives within a very short time of departure, it is always worth providing malaria prophylaxis and advice based on a risk assessment.8
Which vaccine do I give?
Each patient will need an individual assessment to determine which vaccines they require. Online resources contain the most contemporary advice. Printed material may be out of date. The two primary resources are Travel Health Pro and TRAVAX, and access varies according to region. There is some difference between their recommendations, so the health professional should note which one they consulted to support their decision-making.
Vaccinations administered to travellers generally fall into three categories:
– Those that are updating in line with the UK schedule.
– Those that are recommended.
– Those that are mandatory.
Generally, mandatory travel-associated vaccines are not available for free from the NHS, so the discussion with the patient will most likely centre around the cost. In rare cases the patient might refuse to be vaccinated.
Most travel-related vaccines are listed as ‘recommended’ or ‘advised’. In that case, the traveller generally asks “what would you do?” This can be used as an opportunity to discuss the disease, risk and potential impact on their trip. Patients also tend to ask ‘what do I get for free?’, so the nurse needs to be aware of the rules and advise the traveller accordingly. Unless the practice has opted out of vaccine provision (and this would also include opting out of UK schedule vaccines as practices cannot opt out of travel vaccine provision only),10 the vaccines listed as free should be administered if recommended. For recommended vaccines that incur a charge, if the practice stocks them, there should be a list of charges displayed. The patient should be informed of the charge before they are given the vaccine. If the practice does not stock the vaccine there should be a protocol for next steps. This may be a referral to a private clinic, or issuing a private prescription so that the patient can source the vaccine at a pharmacy and return to have it administered.
Yellow fever is the vaccine most likely to be mandatory for entry into a country. It is largely required for sub-Saharan Africa and Latin America, and is on the recommended list for some other destinations (refer to country-specific information on your preferred online resource).
To administer yellow fever the clinic must be a registered centre, so that the International Certificate of Vaccination can be issued. If the traveller requires yellow fever as mandatory, they will also require malaria prophylaxis and advice about bite prevention to reduce exposure risk for both diseases. Even if a practice is not authorised to administer yellow fever vaccine, the nurse needs to have knowledge of the disease and know where to refer the patient. If advice has been given on how to access a registered yellow fever centre, this should be recorded in the patient notes, as well as the advice given on bite prevention and malaria prophylaxis.7
If meningitis ACW135Y vaccination is administered as part of the UK vaccine schedule it is free, but if it is administered for travel a fee is payable.10 Meningitis ACW135Y is mandatory for visa applications for entry into the Kingdom of Saudi Arabia (KSA) for travellers visiting to attend Hajj or Umrah.11 The Hajj in 2016 is due to start on 9 September, and travellers should have their vaccine administered between 10 days and three years before arrival in KSA.11
The vaccine is only recommended, so what do you do?
To advise a traveller fully the health professional must know the percentage of risk. This will vary according to what they are doing, where they are staying and what they are eating. In addition, a patient might say they intend to do one thing and end up doing another.12 In practice, most health professionals just advise the traveller according to the online recommendation.
In recent years the recommendations for typhoid vaccine have changed, with fewer countries now listing it as a recommendation. The number-crunchers have factored in some of the ‘actual risk’ and determined that the ‘average’ UK tourist on a two or three-week holiday of ‘normal’ activities has a lower risk of contracting the disease than the local population who may have daily exposure or the long-stay traveller whose eating and drinking habits may increase their exposure risk. This is why India and the Indian subcontinent continue to have typhoid.13 The only way to determine what to give is to know about the disease and provide sufficient information for the patient to make an informed choice.
We cannot be expected to be experts in travel vaccines but we need some understanding. Patients also need to take some responsibility and refer to suitable resources themselves (see Resources for information sources for patients).
Travel vaccination advice is not as simple as saying “this is what we have and this is what is recommended”. Decisions must be based on risk assessment and discussion. Nurses have a professional duty to not administer any drug without knowing the disease it is for and how it is contracted – as well as knowing about the drug. It’s also essential to have access to up-to-date resources and robust protocols that facilitate safe and effective practice.
Relevant disease literature:
Public Health England. The Green Book, 2014 – gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
Electronic Medicines Compendium. Summary of Product Characteristics, 2016 – medicines.org.uk/emc/
In the case of vaccines the SPC may be superseded by any more recent update in the Green Book.
Travel health sources for healthcare professionals:
Travel Health Pro (England and Wales) – travelhealthpro.org.uk/
TRAVAX (Scotland) – travax.nhs.uk/ (login required)
Public Health Agency (Northern Ireland) – publichealth.hscni.net/directorate-public-health/health-protection/immunisationvaccine-preventable-diseases
NathNac – nathnac.net/
Information sources for patients:
NHS choices – nhs.uk/
Travel Health Pro – travelhealthpro.org.uk/
Fit for Travel – fitfortravel.nhs.uk/home.aspx
– Chiodini J, Boyne L, Stillwell A, Grieve S. Travel health nursing: career and competence development, 2012. rcn.org.uk/__data/assets/pdf_file/0006/78747/003146.pdf (accessed 28 April 2016).
– Chiodini J, Anderson E, Driver C, Field V, Flaherty G, Grieve A, Green A, Jones M, Marra F, McDonald A, Riley S, Simons H, Smith C, Chiodini P. Recommendations for the practice of travel medicine. Travel Medicine and Infectious Disease 2012a;10:109-128.
– Driver C. How to do a travel health risk assessment. Nursing in Practice 2007:20. 22-23.
– Lockie C, Walker E, Calvert L, Cossar J, Knill-Jones R, Raeside F. Travel Medicine and Migrant Health, eds. Churchill Livingston, 2000.
– Steffen R, Connor B. Vaccines in Travel Health: From Risk Assessment to Priorities. Journal of Travel Medicine 2005;12:26-35.
1. Royal College of Physicians and Surgeons. Faculty of Travel Medicine Executive Board position paper. Protecting the health of travellers from the UK & Ireland, 2015. rcpsg.ac.uk/the-college/policy-media-and-publications/policy/travel-health.aspx?cookieCheck=true (accessed 28 April 2016).
2. Public Health England. The routine immunisation schedule. gov.uk/government/uploads/system/uploads/attachment_data/file/510450/PHE_2016_Complete_Immunisation_Schedule_A4_17032016.pdf (accessed 14 April 2016).
3. Travel Health Pro (2016b). Country Information. travelhealthpro.org.uk/country-information/ (accessed 14 April 2016).
4. Public Health England. Green Book (Immunisation against infectious diseases), 2014. gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book (accessed 14 April 2016).
5. Health Protection Agency (now PHE). National Minimum Standards for Immunisation Training, 2005.
gov.uk/government/publications/immunisation-training-national-minimum-standards (accessed 14 April 2016).
6. Royal College of Nursing. Supporting the delivery of immunisation education, A quality framework to support the implementation of national standards and guidelines on immunisation training, 2015. www.rcn.org.uk/-/media/royal-college-of-nursing/…/2015/…/005335.pdf (accessed 14 April 2016).
7. Nursing & Midwifery Council. The Code for nurses and midwives. nmc.org.uk/standards/code/ (accessed 28 April 2016).
8. Travel Health Pro. Fact sheets, general advice for travellers. travelhealthpro.org.uk/general-advice-for-travellers/ (accessed 14 April 2016).
9. Travel Health Pro (2016a). Austria. travelhealthpro.org.uk/locations/austria/#Vaccine_recommendations (accessed 14 April 2016).
10. British Medical Association. GP Practices Focus on Vaccination and Immunisation. bma.org.uk/support-at-work/gp-practices/focus-vaccinations (accessed 14 April 2016).
11. Travel Health Pro (2016c). Hajj and Umrah. travelhealthpro.org.uk/hajj-and-umrah/ (accessed 14 April 2016).
12. Steffen R, Connor B. Vaccines in Travel Health: From Risk Assessment to Priorities. Journal of Travel Medicine 2005;12:26-35.
13. Public Health England. Enteric fever (typhoid and paratyphoid) England, Wales and Northern Ireland: 2014. gov.uk/government/uploads/system/uploads/attachment_data/file/488395/Enteric_fever_annual_report_2014_FINAL_.pdf (accessed 14 April 2016).