The Last Minute Traveller

1. The Last Minute Traveller BAHSHE, York, 6th July 2012 Adrienne Willcox PhD, RN info@talent4health.co.uk

2. Why are some travellers and travel consultations so complicated?

3. ChallengingTravellers • Chronic conditions – diabetes, respiratory disease, history of embolisms… • Stage of life – the very young and the very old. • Destinations – high risk, few facilities. • Activities – high risk; unknown or unstated. • Mode of travel – long-haul flights, coach journeys. • Timescale – it’s Friday afternoon, you’ve no free appointments, they travel tomorrow… • They come back ill…

4. What is ‘last minute’ travel? The traveller presents: • One month before travel? • Too late to defer unsuitable travel if they’ve booked and paid, but enough time for vaccines and all anti-malarials. • Two weeks before travel? • Too late for full rabies, Jap encephalitis, Hep B. • One week before travel? • Too late for YF (Certificate), mefloquine and full protection from Hep A, Typhoid, TBE, Men. ACWY. • One day before travel? • Too late for chloroquine and proguanil.

5. Why do people travel at the last minute? • Busy lives • Poor organisation skills • Suddenly have some free time or money • Spot a last-minute bargain • It’s the nature of their work or study • Responding to family events abroad • Marketing and other influences on lifestyle

6. Managing last minute travellers • They’re here to stay – service provision needs to recognise this. • There’s always something that can be done to assist the last minute traveller, who may be at increased risk of travel-associated illness. • Follow the risk assessment and advice as for any general traveller. • Can they legally travel? • Time: 20 minutes is the RCN (2007) and NaTHNaC (2010) recommendation. • Provide written advice: good quality leaflets that are personalised and ‘gifted’ to the traveller. • Do start vaccines and anti-malarials.

7. Vaccines • What’s the risk of catching this disease? • How long is the trip and what are the activities – and therefore exposure to infection? • How much time is needed to develop an immune response to the vaccine? • What adverse reactions to the vaccine are likely and will they happen during travel? • What’s the vaccine schedule and can it be accelerated without a sub-optimal immune response? • Should the vaccine be started if it can’t be completed? • How many vaccines can I give this traveller today?

8. Malaria • Atovaquone and proguanil (Malarone) and doxycycline can be started 1-2 days before travel, or even on day of travel. • Chloroquine + proguanil need 1 week before travel. • Unless it’s been tolerated previously, mefloquine (Lariam) is not suitable for last-minute travel because a 3 week/dose trial is recommended. • Emphasise all • anti-bite strategies.

9. Other advice • Insurance. • Personal safety – see the Foreign and Commonwealth Office website for services such as Locate, Know Before You Go, and the free leaflets for young travellers. • NaTHNaC Travellers and Fit For Travel are both evidence-based websites aimed at the lay public.

10. Putting these principles into practice • Emma presents to you four days before she travels to Cambodia. Her friend Ashleigh is going out to stay with her parents for the holidays and has asked Emma to join her. Emma’s flight is booked – she’s going!

11. Conclusions • Basic principles apply – start with a thorough risk assessment. • Give vaccines and anti-malarials as indicated. • Empower the traveller by directing them to trustworthy resources.

12. References and resources • NaTHNaC (Health Information for Overseas Travel (2010) is known as the ‘Yellow Book’) www.nathnac.org • Joint Committee on Vaccination and Immunisation (Immunisation Against Infectious Disease is known as the ‘Green Book’) www.dh.gov.uk/greenbook • Health Protection Agency (Malaria Guidelines due to be updated October 2012) www.hpa.org.uk

13. The Ill Returning Traveller BAHSHE, York, 6th July 2012 Adrienne Willcox PhD, RN info@talent4health.co.uk

15. Some words of reassurance • You do not have to become an expert in diagnosing tropical diseases • But you are well able to take a travel history... • ...and refer a symptomatic patient on to the most appropriate person or facility.

16. A vision of services in the future • Strategically located centres of expertise • Closing the loop of pre-travel and post-travel healthcare • Proactively caring for travellers most likely to experience travel-related illness • Emphasis on travel health, not just travel medicine • Joined-up policy and practice

17. Freedman et al (2006) Spectrum of disease and relation to place of exposure among ill returned travelers. New Eng.J. of Medicine, 354(2):119-130. • 8% travellers to developing world require medical care. • Diagnosis and treatment can be guided by destination. • The top three presentations are systemic fever without localised findings, diarrhoea and dermatological problems. • The top three diagnoses are malaria, dengue and rickettsial infections. • Diarrhoea is often parasitic.

18. Health Protection Agency (2007) Foreign travel-associated illness, England, Wales, and Northern Ireland. • Travel history reporting is poor and improvement is essential. • 4000 deaths of UK citizens abroad a year required FCO intervention – probably an underestimate. • Accidents a major cause of morbidity and mortality. • Heterosexuals with newly diagnosed HIV: at least half acquired abroad, especially Thailand and Africa. Source: www.hpa.org.uk/publications

19. Accidents • The most common cause of mortality & morbidity in younger people abroad • Different standards of motor safety apply • Inexperience of life and travel • Alcohol & ? drugs play their part • Liminal space theory

20. But right now... • An update on some tropical diseases • Guidance on what to do in practice • Resources for finding out more

21. Diseases of poor hygiene • Hepatitis A • Typhoid • Polio • Tetanus • Spectrum of traveller’s diarrhoea • Leprosy? • Fungal infections • Cholera

22. Diseases of contact • Hepatitis B • TB • Diphtheria • Meningitis • ‘Flu • Leprosy? • Sexually acquired infections, inc. HIV

23. Diseases from insects and animals • Yellow fever + VHFs • Dengue • Plague • Rabies • ?Leprosy • Japanese encephalitis • Tick-borne encephalitis • Chikungunya • Rift Valley Fever • Malaria • Leishmaniasis • Schistosomiasis • Parasites and infestations, e.g larva migrans

24. “New” health issues • Long-term travellers, ex-pats: alcohol, depression and STIs • Culture shock and reverse culture shock, inc. VFRs • Medical and health tourism • Drug “mules” • Voluntourists and chadventurers

25. Malaria: the scale of the problem • 90% of malaria occurs in sub-Saharan Africa; also in Asia, central and South America. • 1.5 - 3 million deaths a year; a child every 30 seconds. • 2000 cases of malaria brought into the UK each year resulting in 2-12 deaths. • Plasmodium falciparum is on the increase. Accounts for 75% of imported malaria but P. vivaxhas increased recently. • VFRs particularly at risk – often inner city dwellers.

26. The experience of one emergency department • Ill & injured travellers made up 0.18% of the dept. workload, & 0.14% of admissions – small but preventable. • Two travellers had Salmonella infections – notifiable. But burden of work is underestimated by current reporting systems. • 76% injuries: limb fractures and soft tissue damage. • 24% illness, including 3 flight-related problems. Source:Vardy et al, (2007) Attendance to Emergency Departments by Ill or Injured Travelers Returning from Abroad. J.Travel Med. 14(3):200-202.

27. But… • Travellers present with signs and symptoms, not a confirmed diagnosis. • Asking about recent travel should become a routine part of history-taking in the consultation. • Common, self-limiting conditions are far more likely than rare tropical infections… • …but fever in a returned traveller is malaria until proven otherwise.

28. Nurse, I’ve got... • a temperature • Delhi belly, Rangoon runs, Spanish squits, Turkey trots, Cancun quickstep • a nasty discharge • a cough/ cold/ earache/ sore throat • this funny rash

29. Taking a travel history • Travel details: destination, dates, duration, mode of travel. • Environment abroad: accommodation, altitude, climate, activities. • Lifestyle: diet, e.g raw or unpasteurised products, sex (who/how/how many?), health care, piercings, tattoos etc. • Medical history, inc. vaccination status, pre-existing conditions, anti-malarial measures used….honest answers please!

30. Examination & investigations • Examination, e.g. anaemia, enlarged lymph nodes, liver or spleen? • Investigations: weight, TPR, BP, urine. • Bloods: malaria films, culture, FBC, LFT, U&Es, serology e.g. schistosomiasis. Check with microbiologist if unsure. • Other specimens as appropriate. • CXR if risk of TB. • Care plan: refer?(GP, GUM, Specialist infectious disease unit), or self-care & safety net?

31. Dermatology

32. What to do in practice • Discuss management of post-travel illness within the department and draw up policy or protocols. • Routinely ask about recent travel when taking a history. • Promote the taking of a travel history if relevant. • Know how, when and where to refer on. • Make friends with your microbiology team! (then the dermatologists)

33. Further resources • WHO (2012) International Travel and Health.Geneva:WHO. Main site: www.who.int/ith Weekly epidemiological record: www.who.int.wer • Health Protection Agency www.hpa.org.uk • NaTHNaC – Yellow Book, Section 4 www.nathnac.org • Lab Tests Online www.labtestsonline.org.uk • Willcox, A; Ellis, M. and Allen, J. (2006) Travel health: a practical approach to post-travel consultations. Primary Health Care. 16(3):43-50. • Immunisation, Influenza and Travel Health Training www.access2education.co.uk