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Travel

Travel health

There were 72.8 million visits overseas by UK residents in 2017, an increase of 3% on 2016 and the highest recorded. The main reason is holidays, both for UK residents visiting abroad and overseas residents visiting the UK.

For the latest holiday destination predictions for 2019 see: Travel Trends 2019. You can register and download the report for free.

The UK Foreign and Commonwealth Office (FCO) provide advice for travellers, including safety and security issues in individual countries, see: Travel Aware. The FCO has updated its site and has an active Facebook Page and useful information on YouTube. Nurses should advise travellers to be aware of this advice and to consult the FCO for the latest information before departure.

Travel health medicine is a fast-growing specialist area of practice, which in the UK is predominantly delivered by nurses. UK travellers of all ages are travelling further afield and becoming more adventurous. Some may present at short notice with illnesses or pre-existing medical conditions requiring specialist advice and support. The art of delivering accurate and current advice to travellers can be complex so nurses should be skilled and competent to undertake the care of travellers.

The updated RCN guidance Competencies: Travel health nursing: career and competence development (2018) provides information on current guidelines and standards of care for travellers and describes the standards of care expected for; a competent nurse, experienced/proficient nurse and a senior practitioner/expert nurse working at that level. For NMC Revalidation purposes, nurses should be aware of their own competence levels and maintain the necessary skills for their level of practice. Royal College of Nursing (2018) Competencies: travel health nursing: career and competence development, London: RCN.

The 2018 version was developed following an extensive audit and evaluation of previous editions. See: Executive summary: perceptions of the RCN Travel Health Competencies.

The Faculty of Travel Medicine (FTM) of the Royal College of Physicians and Surgeons of Glasgow (RCPSG) also produced a position paper, Protecting the health of travellers from the UK and Ireland which acknowledges that injury and illness sustained both during travel and on return, causes a considerable medical and economic burden. High quality pre-travel advice can help to mitigate and reduce this risk. The report recognises that the lack of structure and delivery of travel medicine services in the UK and the absence of a formal training pathway to a recognised professional standard needs to be addressed. See below for General practice indemnity related to travel.

Other related RCN resources / publications

Travel health nursing: Career and competence development. Sample travel risk management form

Travel health nursing: Career and competence development. Sample travel risk assessment form

RCN Library subject guide: Travel Health

RCN public health resource: immunization

Malaria 

Malaria, a preventable but potentially fatal disease, remains an important issue for UK travellers. As a nurse advising travellers, you should make every contact count (MECC) and use every opportunity to engage, especially with those in vulnerable groups likely to return home to visit family in their country of origin (VFRs).

Malaria imported into the United Kingdom 2018: Implications for those advising travellers.

Public Health England (PHE) has published details of malaria cases imported into the UK in 2018 and the implications for those advising travellers. A total of 1,683 cases were reported in the UK, England (1,597), Scotland (52), Wales (23) and Northern Ireland (11), 6.1% fewer than in 2017. London accounts for most cases in England (816/1,597, 51%), a 3% decrease compared to 2017.

Of the 1,098 cases that travelled abroad from the UK, reason for travel was known for 925 (84%). Of these, 783/925 (85%) had visited family in their country of origin (VFRs), 85/925 (9%) travelled for business (including armed forces and civilian air crew) and 57/925 (6%) for a holiday. Countries of travel by count of cases are shown in a useful map. Where travel history is known, most cases were acquired in Africa, 70% Western Africa (774/1,098), 8% Eastern Africa (91/1,098) and 7% Middle Africa (78/1,098).

Consistent with previous years, the majority of cases were caused by P. falciparum. Although the number of P. falciparum cases decreased, the total number remained stable. 

As in 2017, 2016 and 2015, there were 6 deaths, all from falciparum malaria acquired in Western Africa (3), Middle Africa (1), Africa unspecified (1), region of travel not stated for 1 case. The total number of deaths from malaria in 2018 is in line with the annual average of 6 over the last 10 years. Annual deaths from vivax malaria is low or zero. Combined PHE MRL data over 27 years demonstrated that older age is a major risk factor for falciparum malaria and severe vivax, all vivax deaths occurring in those over 50 years. The median age of those who died from falciparum malaria (2000-2018) was 49 years, reflecting the relatively younger age profile of cases.

Of those who had travelled abroad from the UK, where the chemoprophylaxis history was obtained, 663/755 (88%) had not taken chemoprophylaxis. 

Malaria is a notifiable disease carrying a legal obligation to notify authorities. Provisional data show that only 11% of malaria cases reported to MRL in 2018 were officially notified. Clinical and laboratory staff are reminded of their responsibilities to report all cases to the PHE MRL.  Form found at: Public Health England. 

Health messages about the importance of antimalarial chemoprophylaxis are still not reaching groups at particular risk, such as those visiting family in their country of origin, particularly those of Black African heritage and/or born in Africa, or they are not acting on advice. Malaria, an almost completely preventable but potentially fatal disease, remains an important issue for UK travellers. Failure to take chemoprophylaxis is associated with the majority of malaria cases in UK residents travelling to malaria-risk areas and the elderly are at particular risk of dying. Those providing advice should engage with these population groups, including using every opportunity to talk about future travel plans e.g. using MECC. 

Further resources: 

Imported Malaria Deaths in the UK 2000-2018

A summary of the epidemiology of imported malaria in the UK based on data from the PHE Malaria Reference Laboratory. Spreadsheets provide the additional data on:

  • imported malaria cases (including malaria deaths) reported in the UK since 2000 by malaria parasite species
  • imported malaria cases in the UK by species and region of travel for the most recent year
  •  imported malaria cases in the UK by species and reason for travel for the most recent year
 
The World Health Organization (WHO) highlights World Malaria Day each year on 25 April.

The World malaria report, published annually, provides a comprehensive update on global and regional malaria data and trends. See: World Malaria Report 2018

The Public Health England (PHE) Advisory Committee on Malaria Prevention (ACMP) published updated UK Guidelines for malaria prevention in travellers from the UK in 2018. This is an essential tool for nurses advising travellers. The document is updated online and nurses should ensure they are using the latest version. After the major revision of country recommendations undertaken in the 2017 guidelines, fewer changes were necessary for the 2018 publication. The Key changes are listed on Pages 8 and 9 of the document.

As the global incidence of malaria is falling the ACMP undertook a review of country recommendations and accordingly NaTHNaC has produced new malaria maps.

Imported malaria cases and almost all deaths in the UK resulted from visits to Africa. Emphasis should be placed on engagement with travellers planning to visit Africa and relaying the message that the malaria situation is serious there and requires rigorous personal preventive measures. The Visiting Friends and Relatives (VFR) group of travellers who tend to stay for longer periods in endemic areas are more risk of contracting malaria than short term travellers visiting the same location. Once infected the risk of severe or complicated malaria is higher in some groups, e.g. those over 70 years of age, those with co-morbidities or immunosuppression and pregnant women. 

NaTHNaC Malaria Factsheet is regularly updated with current information. 

In Scotland Travax provides malaria information, for registered users or Fitfortravel for the general public. As guidance between the sites can vary, nurses are reminded to use the source of information relevant to their country of practice.

The APPG group on malaria and neglected tropical diseases acknowledges the work of the UK in supporting and strengthening health systems in countries where malaria is endemic and where neglected tropical diseases can be identified and treated. See: All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases Annual report 2017-2018. You can follow them on Twitter.

Hajj, the annual pilgrimage to Makkah (Mecca) in the Kingdom of Saudi Arabia (KSA) occurs between the 8th and 12th day of the twelfth month of the Islamic calendar and is one of the largest mass gatherings in the world. In 2019 it is predicted that Hajj 1440H will take place between 9th – 14th August. NaTHNaC  and TRAVAX

Requirements of the KSA Ministry of Health (MoH) can be found here: Ministry of Health.  

Female Genital Mutilation

Travel health organisations, clinics and health care professionals (HCPs) will find the following resources useful as they highlight how important it is for processes within travel health settings to be reviewed to ensure services provide an effective safeguarding process around FGM.

RCN. Female genital mutilation: RCN guidance for travel health services. This publication acts as a supplement to Female Genital Mutilation: An RCN Resource for Nursing and Midwifery Practice (2016) and focuses on professionals working in travel health services. Travel health organisations, clinics and health care professionals (HCPs) will find it useful as it highlights how important it is for processes within travel health settings to be reviewed to ensure services provide an effective safeguarding process around FGM.
 
RCN. Female genital mutilation: RCN travel health services pathway. This travel health services pathway has been produced as a quick reference tool to help care for girls and women who may be at risk of, or have been, abused through FGM.

Royal College of Physicians and Surgeons of Glasgow’s Faculty of Travel Medicine. Supporting travel health professionals to prevent Female Genital Mutilation (FGM). This free e-learning module aims to examine potential barriers in raising the sensitive subject of FGM in a travel medicine consultation. It gives practical support to doctors, nurses and pharmacists who require to discuss this sensitive subject in practice. 

Barnardos National FGM Centre. The National FGM Centre is a partnership between Barnardo’s and the Local Government Association (LGA) to achieve a systems change in the provision of services for girls and women affected by female genital mutilation (FGM).

Rabies

Rabies is an infectious viral disease and one of the deadliest diseases passed to humans from animals. Rabies is almost always fatal, so travellers need to be aware of rabies in the destination and know what to do in the event of a potential exposure. Nurses should be aware of the latest guidance and competent to advise travellers on the prevention and treatment options available to them.

A pre-exposure rabies vaccine is advisable for those travelling to a high-risk country in, e.g. Africa or Asia, especially if travelling to remote areas, where medical care and rabies post-exposure treatment may not be available. Comprehensive travel health insurance is highly recommended.

In August 2018 Vaccine update (282) published a rabies special edition which included:

  • changes to rabies pre-exposure prophylaxis
  • information on rabies risk from animal bites abroad
  • administration of rabies immunoglobulin
  • advice on how to manage a patient with a bat bite
  • rabies prevention for immunosuppressed patients
  • Rabies and Immunoglobulin Service (RIgS)
  • RIgS contact details for use by health professionals.

In November 2018 NaTHNaC posted a reminder of the global risk of rabies for all travellers from the UK. See: Worldwide rabies risk - reminder for travellers. This information was repeated in May 2019 for travellers and advisers.

Vaccine Update (28 June 2019)  has a feature on the importance of alerting travellers to rabies in the country they are visiting. A leaflet is available for travellers, providing information on bat rabies and emphasising the need to avoid animals. Copies of this leaflet can be ordered for GP surgeries, hospitals, travel clinics or other locations through the Health and Social Care Publications Orderline

Expert advice on post-exposure treatment is available to health professionals in each UK country, see: Rabies: risk assessment, post-exposure treatment, management. 

The Green Book chapter 27 on Rabies was updated in July 2018.

A WHO Factsheet on Rabies is also available.

Zika virus (ZIKV)

Since the first major outbreak of Zika virus (ZIKV) in 2007 and the outbreaks in the Americas in 2015, research has been undertaken to help understand more about the epidemiology and ZIKV infection.

The majority of Zika cases in the UK have travelled to the Caribbean and South and Central America. Four travel-associated cases were diagnosed in 2018. NaTHNaC and Public Health England (PHE) regularly review new evidence and accordingly have updated their guidance for ZIKV (27 February 2019). New information and advice on risk areas and the prevention of sexual transmission was added.

Countries and areas are no longer categorised as “high” or “moderate” risk, but where there is evidence of a current ZIKV outbreak with significant transmission, pregnant women are advised to postpone non-essential travel until after the pregnancy. Pregnant women are also advised to consider postponing non-essential travel until after pregnancy in areas where recent outbreaks have previously been reported, and re-introduction of ZIKV or endemic transmission has occurred. 

Updated guidance on the prevention of sexual transmission:

For those considering pregnancy, consistent use of effective contraception and condoms during and after travel is advised for:

  • 3 months after return or last possible exposure, if both partners travelled to risk areas (previously 6 months)
  • 3 months after return or last possible exposure, if male traveller only travelled to risk areas (previously 6 months)
  • 2 months after return or last possible exposure, if female traveller only travelled to risk areas.

Advice remains the same for pregnant women and their partner: consistent and correct use of condoms for the duration of the pregnancy if both travelled to a ZIKV risk area, or if the male partner only travelled (even if asymptomatic).

Updates have been added to the relevant country pages on:

Other resources:

As more research becomes available information and guidance on ZIKV can change. Nurses should always use the most current information when advising travellers.

Yellow Fever

NaTHNaC (England Wales and Northern Ireland) and Health Protection Scotland's (HPS) TRAVAX (Scotland) are the designated State Parties for Yellow Fever provision in the UK under the WHO International Health Regulations (IHRs).

These parties have designed a mandatory training programme for designated Yellow Fever Vaccinating Centres (YFVCs). Information is on vaccination regularly updated and it is recommended that nurses remain up to date on current advice. On 4 July 2019 TRAVAX issued updated requirements for YFVC’s.  It sets out the conditions of registration for YFVCs in Scotland and provides practical information for those planning to become - or that already are - YFVCs. Health Protection Scotland Designation of Yellow Fever Vaccination Centres Information Pack.

On 4 July 2019 The World Health Organization (WHO) published the updated list of yellow fever certificate requirements and recommendations for 2019. This information is published each year following consultation between the WHO and State Parties, who are asked to confirm or update their requirements for international travellers. NaTHNaC and TRAVAX will review the information and update the country pages accordingly. As well as the annual update, additional country yellow fever recommendations and certificate requirements may be published as they become available.

NaTHNaC sought advice from the World Health Organization (WHO), following The Federal Government of Nigeria’s announcement of their intention to phase out and replace the Yellow Card (yellow fever certificate (YFC)) with an e-Yellow Card version with effect from 1 July 2019. Clarification has been received and posted on Travel Health Pro.

Please note that also as of 1 July 2019, the YFC requirement for travellers to Nigeria changed and a YFC is now required for all travellers aged 9 months or over. 

On 14 July 2018, Public Health England (PHE) published a revised version of Chapter 35: Yellow fever, in Immunisation against infectious disease (Green Book). An updated section on yellow fever vaccine indications for patients with immunosuppression and/or HIV infection has been added. Although related to travellers from the USA, the CDC website contains useful current information and updated yellow fever maps. See also, the CDC Yellow Book. NHS Wales users can gain free access to TRAVAX resources via the NHS Wales website Health in Wales.

Note that the Yellow Fever Map for the Americas is currently being updated on the NaTHNaC Factsheet. Due to the Yellow Fever outbreak in Brazil refer to the European Centre for Disease Prevention and Control map.

please see: Vaccine recommendations

The Medicines and Healthcare products Regulatory Authority (MHRA) has posted an alert following two fatal adverse reactions to yellow fever vaccine and emphasised the importance of a detailed individual risk assessment before administering the vaccine, especially for those who may be immunocompromised or aged 60 years and older. 

Leaving the EU, NaTHNaC posted information for Yellow Fever Vaccine Centres 

The Green Book is continually updated, nurses advising travellers should use the most current information.

Vaccine Update provides notification of new or amended information so sign up to email alerts.

For NaTHNaC clinical and administrative resources for healthcare professionals running or managing a YFVC, see the Yellow Fever Zone with news and quick links to Key YFVC resources, including The NaTHNaC Training Portal. See also: Country requirements for an international certificate of vaccination or prophylaxis (ICVP): key changes for 2018.

MMR

Measles is an ongoing global problem. Before travelling abroad, all travellers should be reminded that they should be fully protected against measles, either through a known history of infection or with a record of two doses of a measles containing vaccine. Please see: Measles reminder.

General practice indemnity related to travel

The Clinical Negligence Scheme for General Practice (CNSGP) in England and a similar scheme, the General Medical Practice Indemnity (GMPI) in Wales, were introduced from 1st April 2019. The schemes covers clinical negligence liabilities arising in general practice and related to incidents that occurred on or after 1 April 2019. 

The schemes essentially provide fully comprehensive indemnity for all NHS work in general practice. The schemes do not cover for private work including travel vaccines given privately. 

In summary:

Travel Advice - (which includes consent) on all travel vaccinations and immunisations – regardless of whether the patient pays or not – is covered by CNSGP 
Travel vaccinations - funded by the NHS (no charge) are covered under CNSGP
Travel vaccinations - for which patients have to pay a charge are not NHS services and therefore not covered under CNSGP.

The RCN have extended the indemnity scheme for members to cover nurses administering private vaccinations and providing private prescriptions for malaria chemoprophylaxis. 

If you are new to Travel Medicine a video on how to navigate TravelHealthPro is available. TravelHealthPro eBook updates for November 2018 include: 

  • Travelling with mental health conditions
  • Malaria
  • Diabetes
  • Sun protection
  • Season influenza.

The World Health Organization's International Travel and Health 2017 (ITH) (also known as “the green book”) contains useful information for nurses. It is a must for YFVCs but valuable to everyone advising travellers. 

Prior to the Asia Pacific Travel Health Conference (APTHC) in March 2018, the WHO convened a one-day meeting with the aim to understand the key needs and challenges of the travel health community with regards to health advice for travellers. The group identified 9 top priorities for immediate update of the ITH book: deep vein thrombosis, malaria prophylaxis and stand-by treatment, Japanese encephalitis, altitude sickness prevention and treatment; jet lag; rabies prevention; insect repellents; hepatitis A prevention; and dengue vaccines. Be aware of changes to come and read the report.

As a nurse, you should stay alert to current information and the possibility of the risk of exposure to other diseases. For travellers returning ill from affected areas a full travel history should be taken before appropriate referral.

Travel resources, courses and study days

NaTHNaC

The National Travel Health Network and Centre (NaTHNaC) continually update their website. Recent changes include changes to the Country pages:

  • the ability to download each complete country page to enable viewing offline or printing a hard copy 
  • new antimalarial recommendations added for some countries
  • quick access to the country page index.

Changes to the World overview:

  • quicker search results
  • multiple outbreaks or for a specific location, outbreaks with exact location data
  • search options by day, week, month, 6 month or year.

 TravelHealthPro eBook:

  • all TravelHealthPro factsheets are contained in one eBook
  • opportunity to subscribe to email alerts for eBook updates.

Health Protection Scotland (HPS) Travax

TRAVAX is an interactive NHS website providing up to date health information for UK health care professionals who advise the public about avoiding illness and staying healthy when travelling abroad. Registration is required.

Fitfortravel

Fitfortravel is a free, interactive, public access website providing up to date health information for the UK public on avoiding illness and staying healthy when travelling abroad.

The Faculty of Travel Medicine (FTM)

The Faculty of Travel Medicine at the Royal College of Physicians and Surgeons of Glasgow (RCPSG) offers lifelong learning, which includes educational courses and examinations to support travel health professionals throughout their careers. See: FTM courses. Nurses can also join the FTM as Affiliate Members and benefit from access to publications and reduced fees for conferences.

The Liverpool School of Tropical Medicine (LSTM)

The Liverpool School of Tropical Medicine (LSTM) has launched a part-time and fully online Professional Diploma in Travel Health, educational programme, jointly developed with the National Travel Health Network and Centre (NaTHNaC) and with LSTM’s Well Travelled Clinics (WTC).

The diploma consists of four modules: Travel Vaccination Principles and Practice; Governance and Safety in Travel Health; Malaria Prevention in Travel Health; and Hazards in Travel Health. Developed and presented by doctors and nurses with extensive and diverse experience in travel health, this unique educational programme offers an opportunity for both new and experienced practitioners to advance or enhance their knowledge, skills and competencies in the discipline. Full details of each module and how to apply for either standalone modules or the diploma are available on the LSTM website.

A new ‘current aspects of travel health’ course, will be held in Liverpool on 15-16 August 2019. The course will run over a full day and a half (morning). Designed around common questions to the NaTHNaC advice line for health professionals, latest developments from research and guidelines will be included. Aimed at health professionals already working in the field but suitable for those with an interest in providing travel health services in the future. 

Migrant Health Guide

If you are involved in caring for travellers from the non-UK-born population, especially those who are likely to return to their home country to visit friends and relatives (VFRs), the PHE Migrant Health Guide provides comprehensive and relevant information. See also: Travel to visit friends and relatives: migrant health guide.

For advice and guidance for health care practitioners on the health needs of migrant patients please see: PHE NHS entitlements: migrant health guide.

eLearning courses are increasing. Other organisations that offer courses, include:


Workshops

New Vaccinology workshops in Stockport have been announced for 2019

Nursing, medical or related professional health workers involved with immunisation are invited to attend.

For more information, contact: Medical Education Centre, Pinewood House, Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, SK2 7JE, 0161 419 4684/5,  jan.good@stockport.nhs.ukStockport NHS Foundation Trust.

Forthcoming travel health conferences

RSPSG Travel Medicine Roadshow

Half-day events in various UK locations from April to September 2019 

Faculty of Travel Medicine (RCPSG) Annual Symposium -Travel Medicine into the Future

9 October 2019
Royal College of Physicians and Surgeons of Glasgow

The 8th Northern European Conference on Travel Medicine (NECTM8)

3-5 June 2020
De Doelen Rotterdam, The Netherlands


Asia Pacific Travel Medicine Society 

18-21 March 2020
Auckland, New Zealand 

Pan African Travel Medicine Conference


14-17 October 2020
Kruger National Park South Africa

CISTM17 

19-23 May 2021
Kuala Lumpur, Malaysia


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Page last updated - 16/07/2019