Abstract
Managing the health of our globetrotting population is a challenging yet fascinating aspect of general practice. Overseas travellers may return from journeys with symptoms as exotic and unheard of as their far-flung destinations. Pre-travel health can also be a mystery as this tends to fall under the remit of practice nurses in most surgeries. Yet, GPs are expected to have at least some knowledge of travel health, particularly in our increasingly globalized world.
The GP curriculum and travel health
Travel health is not specifically mentioned in the GP curriculum. However,
understand the principles of immunization and vaccination be aware of the configuration of public health, epidemiology and preventive health care, including working with public health authorities and notifying appropriate infectious diseases know how to promote health through health promotion or disease prevention programmes
This paper seeks to provide an overview of the approach to pre-travel assessment, using fictional case studies to provoke thought and encourage application of knowledge to particular topics. It does not provide a detailed discussion of travel health, or the management of illness in the returning traveller, as these topics have been comprehensively tackled in previous editions of InnovAiT (Jones and Simon, 2010; Meharli, 2010).
Pre-travel advice
Travellers are often concerned about contracting an exotic disease while in foreign lands. The risk of this happening depends on the country visited and might not be insignificant; yet, exotic disease is rarely the greatest threat to travellers' health. Far more travellers suffer problems such as injuries, sunburn, insect bites, sexually transmitted infections or gastrointestinal upset. The most significant risk to life is posed by accidents (mainly road traffic incidents) or exacerbations of pre-existing ill health. The greatest cause of death among overseas travellers from the UK is myocardial infarction.
Advice about avoiding both the mundane and the more unusual problems associated with foreign travel should be provided in a pre-travel appointment, at which potential risks can be assessed and appropriate prophylaxis arranged. Often, practice nurses provide these ‘travel clinic’ appointments within the practice. Separate dedicated travel health clinics also exist in many urban areas; these are sometimes the only places travellers can obtain specialist vaccines, such as the yellow fever vaccine or the quadrivalent meningitis C vaccine required by those making the Hajj pilgrimage to Saudi Arabia.
It is generally advisable to book pre-travel appointments at least 8 weeks before travel, to allow for vaccinations to be administered or subsequent assessments to take place. However, patients may sometimes need to make an urgent unplanned trip (see Case Study 1). In such instances, GPs should provide pre-travel care and advice to the best of their ability, within the limited time constraints.
Case Study 1
Somayya, a 24-year-old woman of Indian origin, calls you for advice. She is currently 29 weeks pregnant with twins. There has been a sudden death in her family and she urgently needs to fly back to India for the funeral.
What is the guidance about air travel in pregnancy?
What other health issues may be relevant in this case?
If Somayya is travelling to a malarial area, what advice should she be given regarding chemoprophylaxis?
Issues to be discussed during a pre-travel appointment
Current general health
Travel may be inadvisable if the current state of health is poor. This may be especially relevant if the patient plans to travel by plane (see Box 1). Particular attention may be required for special cases, for example pregnancy (Case Study 1) or patients who have known significant morbidity (Case Study 2).
Fitness to fly.
Determination of a patient's fitness to fly should include consideration of:
the impact of mild hypoxia and decreased cabin air pressure (it is normal for oxygen saturations to drop to 90% in a healthy person). As a general rule, if a person can climb a flight of stairs without severe dyspnoea, they are likely to tolerate cabin pressure the impact of sustained immobility the mental and physical stress of airport transfers the need to take regular medication (timing may be difficult on long-haul flights) how the patient's medical condition may affect the welfare of other passengers
Guidance has been published to assist practitioners in the assessment of patients' fitness to fly (see further information). This specifies the medical contraindications to flying, such as unstable angina, as well as suggesting support which may be needed to assist those with medical conditions to fly. Airlines have their own fitness to fly policies and patients should always be advised to contact them to ensure that they comply with the necessary medical regulations. They may need to complete a medical information form (MEDIF) to provide the airline with information about their condition. This will help ensure that they receive the assistance (e.g. inflight supplemental oxygen) that they require.
Flight-related problems can also affect previously healthy individuals. These include motion sickness, jet lag or deep vein thrombosis (DVT). The latter is more common in those with predisposing factors. Advice should be provided about simple prophylactic measures, such as using over the counter medications for motion sickness, and to keep well hydrated and mobile during flights to avoid DVT. Individuals at higher risk of DVT may require aspirin, support stockings or — in the most vulnerable individuals — injections of low-molecular weight heparin.
Specific health risks posed by the patient's destination
Plans for accommodation and the purpose of travel should be ascertained as this may affect the risks to which the patient is exposed.
Case Study 2
Eric, an 82-year-old gentleman who has congestive cardiac failure and stage 3B chronic kidney disease, would like to travel to Australia for the wedding of his great granddaughter. His New York Heart Association (NYHA) score is III (breathless on minimal activity). He has a biventricular pace maker fitted and he takes several medications, including bisoprolol 10 mg once daily, ramipril 5 mg once daily, furosemide 20 mg once daily and spironolactone 25 mg once daily. He tells you that he plans to stay in Australia for an additional 4 months after the wedding.
Describe how you would assess Eric's fitness to travel.
What issues are raised by Eric's plan to stay in Australia for an additional 4 months?
Previous travel history
Previous travel may be relevant and will help to tailor the advice and prophylaxis required. A more seasoned traveller may have immunity conferred by previous vaccination to diseases such as yellow fever or hepatitis. Experienced travellers may also have better awareness of health risks or be able to inform you of problems encountered in the past (e.g. side effects from antimalarials), guiding your advice for the current trip. However, people returning home to malarial areas are at higher risk of malaria as they may not appreciate the need to take appropriate malaria prophylaxis because their natural immunity will have waned.
Immunization status
Vaccination requirements vary by country and the duration of protection afforded by different vaccines also varies. It is important that current immunization status is checked before travelling as new vaccines or boosters may be required. Up-to-date guidance for vaccinations is available through sources such as the National Travel Health Network and Centre (NaTHNaC) website (see further information).
Malaria prophylaxis
If the area to which the patient is travelling is known to be malaria-endemic, the patient will require provision of appropriate antimalarials. These must usually be obtained on a private prescription, although chloroquine and proguanil are available over the counter. In addition, general advice should be provided about avoiding mosquito bites, such as wearing clothes to cover the skin after dusk and using suitable repellants and permethrin-impregnated mosquito nets. Patients should also be warned of the symptoms to look out for that may suggest malaria infection and given guidance on what to do should these occur.
Travel health insurance
Advise patients to ensure that they have adequate health insurance cover for their trip. Most standard insurance policies do not cover illness or injury resulting from ‘extreme activities’ such as white-water rafting, bungee jumping or high-altitude climbing; patients will need to arrange additional cover. Those who are planning a more unusual expedition may need to obtain insurance from specialist companies. Patients should also be advised to inform their insurance company of any changes to their health that may affect their cover before they travel.
First aid
It may be useful to provide patients with guidance about items to carry in a first aid kit, particularly if they are travelling to more remote destinations. The contents should be tailored to individual need but usually include the equipment and medication needed to manage pre-existing medical conditions, prevent travel-related illness and treat incidental minor health problems. Box 2 details some typical items to consider.
Typical contents of travel health kit
Medication and equipment (e.g. catheter bags) for pre-existing medical conditions Destination-related medication, e.g. antimalarials Paracetamol or ibuprofen to reduce pain or fever Medication to manage stomach upset or diarrhoea, such as loperamide, antacids and oral rehydration salts Treatment for respiratory or allergic ailments, such as decongestants or antihistamines (EpiPen for those with anaphylaxis) Motion sickness medication Simple first aid items, such as gloves, bandages, antiseptic and plasters Thermometer
For travellers to some destinations, it may be advisable to carry a commercial suture, syringe or intravenous (IV) line kit. These can be purchased at many pharmacies or outdoor sports shops or via online suppliers.
A further useful tip is for travellers to carry an alert card that provides information about pre-existing medical conditions, next of kin and travel insurance details.
Pre-existing conditions
Patients taking medication for pre-existing conditions should be advised to carry enough supplies for the duration of their trip, plus a small extra supply. Medications should be carried in original containers with the patient's name and the dose clearly displayed. An official letter from the doctor is often helpful to confirm that the medication has been supplied to that patient. It is worth advising patients that some countries do not allow the import of certain medications that are legally prescribed (or even purchased) in the UK, such as codeine. In particular, there are often restrictions on the quantity of some controlled drugs (e.g. morphine) that are permitted for import; patients who take these drugs will need to apply to the Home Office for an import/export licence if they plan to be abroad for over 3 months. The controlled drugs section of the British National Formulary (BNF) provides helpful guidance on this matter.
Managing ill-health while away
GPs should have an idea of the pertinent issues involved in managing illness while abroad as they may need to provide advice to their patients prior to travel. Most ailments among previously well travellers, such as insect bites or viral infections, are relatively mild, self-limiting and can be managed with simple measures and advice. However, more serious illness can occur, requiring medical attention while overseas. This includes illnesses unique to travel, such as altitude sickness (Box 3) and infections like malaria or severe travellers' diarrhoea (Box 4). It may also include complications of pre-existing illness.
Altitude sickness
This condition will not be encountered in the UK as it only occurs at altitudes of over 2500 m above sea level, at which the body is physiologically compromised. However, travellers to high altitude in other countries are vulnerable. GPs providing pre-travel advice should therefore be aware of the problems caused by altitude and how they can be prevented.
It is possible for the body to function normally at altitudes of over 2500 m, but only if it has time to acclimatize. This generally means ascending by no more than 300m a day at altitudes above 3000 m, with a rest day for every 1000 m of ascent. If this does not happen, altitude sickness — with symptoms such as headache, disorientation and nausea — may ensue. Severe cases may progress to pulmonary and cerebral oedema. Medications, such as acetazolamide, may help to prevent onset of altitude sickness but are no substitute for acclimatization. Should symptoms occur victims must be advised to rest, hydrate and descend to a lower altitude. Severe cases may be life threatening; oxygen and dexamethasone may be needed and rapid descent is imperative.
Most GPs in the UK are not specifically trained to manage the health of others while overseas. However, some choose to spend time working abroad (as an expedition doctor for example) and others are themselves intrepid travellers, who could find their medical skills unexpectedly called upon to assist a fellow tourist (see Case Study 3).
UK doctors do not have a legal duty to provide medical attention if not at work. However, many feel ethically obliged to offer their services if needed. UK medical defence organizations usually cover members for claims that might arise out of ‘good Samaritan acts’ worldwide; it is worth checking your level of cover with your insurance provider prior to travel.
Traveller's diarrhoea.
30–70% of travellers experience diarrhoea, usually due to ingesting contaminated food or water. Most cases are mild and last between 3 and 5 days, although 1 in 10 patients may suffer symptoms for a month or longer.
Mild cases can be managed with advice to maintain fluid intake and use oral rehydration salts. Antidiarrhoeal agents should be avoided if possible and are contraindicated in children or in the presence of fever or blood in the stool. Fever and bloody stools, along with systemic upset or the persistence of symptoms for over 72 hours, suggest more severe illness and are indicators to seek medical advice. Investigations such as a fresh stool sample and antibiotic treatment may be required.
Pathogens may be viral, bacterial or protozoal. Most known travel-related cases are due to Salmonella species, but this is probably because travel history is more often recorded in this group of patients; milder illness may go unreported.
Rarer causes of severe illness include amoebic dysentery, caused by Entaemoeba histolytica, which results in severe bloody diarrhoea. Cholera also causes severe illness, with profuse watery stool, vomiting and rapid dehydration after a short incubation period. This mainly occurs in outbreaks in endemic countries and is unlikely to be seen in the UK. All severe infections of this kind are likely to need hospital management with intravenous fluids and antibiotics.
More insidious symptoms with incubation of over 2 weeks, watery explosive diarrhoea, weight loss but no fever or vomiting suggests infection with the protozoan Giardia lamblia. Stool culture may find ova or parasites but can be negative. If suspected, giardiasis can be treated with a course of metronidazole 2 g daily for 3 days.
Case Study 3
You have joined a group of tourists making the trip to Everest Base Camp (altitude 5364 m above sea level) in Nepal. Morris, a 19-year-old gap-year student, is in the party. He has been working in Nepal for the past 6 months. In the last 2 months of his stay, he has developed loose bowel motions with occasional cramping abdominal pain. He is concerned because during the trek, his symptoms have worsened and he has also developed a headache and vomiting.
Outline your differential diagnosis for Morris' complaints.
What would your management involve and how may this be affected by your situation (consider availability of health care, cultural issues and language barriers)?
When providing assistance, make an assessment of the patient's present complaint and the severity of their condition, alongside a review of past medical history and usual medications. Check compliance with medication (regular and prophylactic) as poor compliance may have led to the current problem. If the condition warrants further medical intervention, this should be sought locally where possible, although in some cases, repatriation may be required. The traveller's insurance company will usually meet the costs of repatriation, providing that they have taken out a comprehensive policy. The insurance company should be contacted as soon as it becomes apparent that a claim will be made.
In cases where the traveller is seriously unwell and requires hospital admission, the relevant British Embassy, High Commission or Consulate should be contacted. Staff there can provide further support and information. In the event that a traveller should die while overseas, they will work with the UK Foreign and Commonwealth Office to guide and support relatives.
The returning traveller
This article does not deal with management of the unwell returning traveller; however, this is an important topic particularly in our globalized world where you never know if the next feverish patient may be ailing with dengue fever caught in Bali rather than a simple bout of influenza contracted in Bognor Regis. It is also an area in which most GPs are likely to feel outside their comfort zone, particularly if unusual pathogens are involved. In such cases, a specialist referral is often required and discussion with the local Health Protection Agency (HPA) may also be helpful. The local authority Medical Officer for Environmental Health, who is often based with the HPA, will need to be informed in cases of notifiable disease. This is required under the Public Health (Control of Disease) Act 1984. InnovAiT has previously published a comprehensive article about ‘Illness in returning travellers’ (Jones and Simon, 2010); readers are advised to access this text to find out more.
Taking things further
Although most travel medicine is nurse led in the UK, doctors are still required to fulfil certain roles and if you have an interest in this area, there are plenty of opportunities to get involved. Some doctors find work providing travel advice to employees of organizations that send workers overseas. Others prefer more hands-on roles, such as working with travel insurance companies (who need doctors to assist clients overseas), being the doctor for a cruise ship or overseas expedition or accompanying unwell passengers on flights or other journeys abroad. The training required for these roles will vary; a list of useful links to some relevant courses is provided in Box 5.
Travel medicine courses
A list of courses can be found on the British Travel Health Association website: www.btha.org/courses_and_conferences.asp. Links to some specific courses are listed below.
2-day Travel Health course—Travel Health-Related Education and Care: www.trectravelhealth.co.uk/courses.html
Certificate of Travel Health—International Society of Travel Medicine. www.istm.org
Foundation and Diploma in Travel Medicine courses—Royal College of Physicians and Surgeons of Glasgow: www.travelcourses.hps.scot.nhs.uk/home.aspx
Travel Health and Expedition Medicine Course—Liverpool School of Tropical Medicine: www.lstmliverpool.ac.uk/learning-teaching/lstm-courses/short-courses/tc01—travel-expedition-medicine-course
Travel Medicine short courses—London School of Hygiene and Tropical Medicine: www.lshtm.ac.uk/study/cpd/stm.html
Key points
An increasing number of UK residents are undertaking foreign travel. While pre-travel health care is often provided by nurses or specialized clinics, GPs should also be able to provide pre- and post-travel care When providing pre-travel care, consider factors that increase risk. These may be patient-related or associated with the destination itself Sometimes GPs may be called upon to provide health care while overseas. They should also be able to advise patients on how to manage ill health while away A wide range of high-quality information is available to assist health care providers in giving pre-travel advice and managing travel-related illness Courses and opportunities exist for those who wish to expand an interest in travel medicine