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

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

3. 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

4. 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

5. 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

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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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.

14. 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 .

15. Malaria and Extended Stays

16. 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.