Independent Travel Health and Immunisation Specialist Nurse Travel Health Update Carolyn Driver Independent Travel Health and Immunisation Specialist Nurse March 2008

Aim of Session Look at RCN Competencies Malaria Update Last minute travellers Extended stay travellers

Risk assessment in Travel Health Travel Health is an Important but time consuming clinical area Appropriate time must be allocated for a full risk assessment Reliable resources should be available to the healthcare professional offering the service Informed consent must be obtained for all vaccines administered Correct identification of malaria prophylaxis and explanation of regime must be given at the consultation Staff who are expected to run a travel health service should be encouraged to attend training courses http://www.rcn.org.uk/__data/assets/pdf_file/0006/78747/003146.pdf

Risk Assessment HAZARD vv RISK The presence of a disease in a country or region does not necessarily imply that the traveller is at risk of developing the disease A disease may be low hazard but high risk e.g. an upper respiratory infection many travellers will develop it but it will not cause much harm A disease may be high hazard but low risk, e.g. rabies It is a very dangerous disease but few travellers will develop it

Information required for a Risk Assessment Characteristics of traveller Previous history (medical & immunisations) Departure date & length of stay Destination & full itinerary Mode of travel Budget & accommodation All planned activities

Activities Exposure to heat & sun Exposure to cold Water activities & other high risk sporting & leisure activities Alcohol & drugs Health care Voluntary workers Sex tourism

www.nathnac.org

Malaria Need to know exactly where in a country the traveller is going to establish risk Use good resources to then advise the traveller about appropriate preventive measures Must regularly check live (internet) resources for any changes that may have recently occurred. www.malaria-reference.co.uk

Plasmodium Knowlesi recently identified in humans in Malaysia and Thailand - previously only thought to occur in monkeys Preventive strategies are the same as for the other 4 types of malaria

The Late Presenter It is never too late to give advice Ensure that Patients aren’t turned away when planning a last minute break. Boosters work very quickly so it is appropriate to give boosters even on day of departure. Hepatitis A is also effective at the very last minute. Vaccines that normally require a 3 dose course – if 2 doses can be given probably worthwhile – if only one –may be better to give preventive advice rather than one vaccine unless they can continue the course whilst away – or can complete course between journeys

Malaria and the late presenter Both Doxycycline and Malarone can be started just a day or so before departure. Someone who has taken Mefloquine before without problem need only start a week before departure – if they present less than a week before and this is their drug of choice – could still be used as long as they agree to use good bite avoidance measures and are alert to any potential malaria symptoms a week after they have arrived at their destination. Similarly Chloroquine and Proguanil are ideally started a week before travel but the most important time is during and after a potential exposure. So if this is the drug of choice and the individual accepts the slightly increased risk of breakthrough infection – it can be used in late presenters.

Extended Stay Travellers Problems with long stay travellers in high risk environments: Greater potential exposure to pathogens More insect bites More chance of relationships with local population More chance of need for medical intervention More risk taking activities Increased likelihood that they will become complacent about preventative strategies Need to ensure they have an appropriate insurance policy

Extended Stays Vaccines – Clearly they should be encouraged to have all the vaccines recommended for their destination/s Also need to consider any other travel they may plan to undertake while away Even if Staying in a city – worth considering rabies and (if living in SE Asia) Japanese Encephalitis as they will have opportunity to travel more remotely when on leave etc.

Extended Stays Psychological issues Have they thought about; isolation/communication with home/culture shock/boredom Females – contraception/menstruation/pregnancy Marie Stopes, IPPF, travel stores such as Nomad –have advice and equipment that could be useful .

Malaria and Extended Stays

Extended Stays Before they go Dental Check up Smears/Family planning check etc If on regular medication chick availability at destination and take adequate supply for initial period.