What's new in travel medicine

Changes in travel patterns and re-emerging diseases have increased the demand for travel health advice, reports Sandra Grieve.

Statistics show travel abroad by UK residents is on the rise. Greater availability and speed of travel, and the increasing numbers of travellers visiting remote areas have created a new tier of health provision and a complex area of practice.

Travellers can arrange personal itineraries, often to participate in high-risk activities, and age is no barrier. This means advice for all individuals is equally important.

Keeping up-to-date
Failure to accommodate and prepare travellers may lead to an escalation in imported illness, which would increase demands on the health service.

A recent Health Protection Agency (HPA) report, on foreign travel-associated illness provides an overview of the global epidemiology of travel-associated infections and a summary of illness. It highlights the need for improved surveillance of imported illness and emphasises the recording of travel histories from those who contract infectious diseases abroad.

Health professionals need to be adept at communicating the risks and benefits of vaccination based on current research and evidence. They need to become familiar with vaccine preventable disease in travellers and be able to conduct a thorough risk assessment.

This year, several new publications and resources have become available to help health professionals advise travellers. All practitioners working in travel medicine should have ready access to these documents and an up-to-date atlas.

Full history
The Green Book has been updated. Since the last edition, published in 1996, the UK immunisation programme has seen changes, as well as a debate on vaccine safety and efficacy.

Public awareness and attitudes to immunisation have changed and vaccination schedules altered.

Childhood immunisation forms the basis for travel vaccine recommendations. In Britain's multicultural society it is important to collect information on a person's childhood vaccination schedule and where it was administered.

Patient specific directions and patient group directions are now included in the Green Book, because these were not in place previously.

There is an emphasis on policies, procedures and responsibilities in primary care and immunisation clinics. Training for everyone involved in vaccine administration is essential.

Emerging issues
The WHO's International Travel and Health is a core text in travel health medicine and it now includes emerging problems such as avian influenza and chikungunya, as well as health risks for long-haul air travel and travel by sea.

Other additions include information on environmental factors and infectious diseases that may affect travellers and the worldwide distribution of major infectious disease.

Individual country information outlines the requirements for mandatory or recommended yellow fever vaccination, as well as the malaria situation and prevention advice.

Malaria guidelines
HPA figures for malaria imported into the UK during 2006 were similar to those for the previous year. The potentially fatal Plasmodium falciparum species was responsible for 79 per cent of cases. Where reasons for travel were known, 57 per cent of cases occurred in people visiting friends or foreign relatives.

Failure to take appropriate chemoprophylaxis is a major factor in contracting malaria. Malaria can kill, but death and illness are avoidable. A travel risk assessment can determine an individual's itinerary and their likelihood and projected level of exposure.

HPA malaria guidelines for long-term travellers has been revised and combined into a practical booklet and user-friendly web format. The guidance, which includes advice on children's dosages and standby treatment, is intended for UK-based travellers.

Since chemoprophylaxis is not 100 per cent effective, bite prevention is of paramount importance. The HPA Advisory Committee on Malaria Prevention (ACMP) strongly recommends DEET-based insect repellants. The HPA also recommends that antimalarials should be purchased before departure, as overseas products may be counterfeit.

Advice for travellers
Travellers should be made aware of the symptoms of malaria, which can be vague and flu-like, and the need to seek medical advice promptly. Malaria should be considered in every ill patient who has returned from the tropics in the previous year, especially in the first three months.

The HPA ACMP has recently published detailed advice on treating malaria in the UK, which is complemented by a malaria treatment algorithm.

Yellow fever vaccination
Yellow fever vaccine administration is regulated under the WHO international health regulations, which are intended to protect host countries and travellers, and to prevent disease spread internationally.

The revised regulations have a broader scope, encompassing new and re-emerging diseases such as SARS and pandemic influenza, and non-infectious diseases with potential international health concerns.

Yellow fever is currently the only disease for which vaccination is required under the WHO regulations. An international certificate of vaccination or prophylaxis may be requested from individuals entering certain countries.

As of 15 June 2007 the model international certificate of vaccination or prophylaxis replaced the international certificate of vaccination or revaccination against yellow fever.

The National Travel Health Network and Centre for England, Wales and Northern Ireland and Health Protection Scotland are responsible for the administration of designated Yellow Fever Vaccinating Centres.

Sandra Grieve is chairwoman of the RCN Travel Health Forum.

This article is based on a talk to be presented at the MASTA Travel Medicine Study Day, to be held on 30 November at the Royal College of Physicians, London. For details visit www.masta.org/studyday.

Travel vaccination advice

References

  • HPA. Foreign travel associated illness, England, Wales, and Northern Ireland. 2007 report. August 2007.
  • RCN. Competencies: an integrated career and competency framework for nurses in travel health medicine. 2007.
  • Salisbury D, et al (eds.). Immunisation against infectious disease - 'The Green Book'. London: DoH; 2007.
  • HPA. National minimum standards for immunisation training. June 2005.
  • WHO. International travel and health. Geneva: WHO 2007: http://whqlibdoc.who.int/publications/2007/9789241580397_eng.pdf.
  • Chiodini P, et al. Guidelines for malaria prevention in travellers from the United Kingdom. London: HPA; 2007. Available from: www.hpa.org.uk/publications/2006/Malaria/Malaria_guidelines.pdf.
  • British Infection Society, HPA. Malaria - algorithm for initial assessment and management in adults. 2007. www.britishinfectionsociety.org/documents/Malariaalgorithm07.pdf.
  • WHO. International health regulations. Geneva: WHO; 2005. www.who.int/csr/ihr/en/.
  • NaTHNaC. Designation of yellow fever vaccination centres. January 2007. www.nathnac.org/pro/documents/YFInfoPackRevision3Jan2007.pdf.
  • HPS. Yellow fever vaccination centres. www.hps.scot.nhs.uk/yellowfever/index.aspx.

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