The Last Minute Traveller
Guest Author: Carolyn Driver
Ideally travellers should present for pre travel advice about 6-8 weeks prior to departure enabling them to receive full courses of all recommended vaccines and thorough lifestyle advice. In the real world however not only do approximately 50% of travellers seek no advice but of those that do a, proportion will do so at the very last minute.1 How should those of us running a travel health service deal with last minute requests for pre travel advice?
It is easy to feel that last minute travellers are a nuisance and they should have planned better but there are many reasons why a traveller may be leaving imminently - they may be Visiting Friends and Relatives (VFR) responding to a family crisis abroad, urgent overseas business or they could be a member of an emergency team responding to a natural disaster.
We should therefore try to ensure that we have capacity to see these individuals when they seek our advice.
Better that reception staff refer this type of request to a health professional rather than simply informing the traveller that it is too late. If appointments are not available it may still be of value to have a telephone conversation with the individual to elicit important information and encourage them to attend an alternative travel clinic or at the very least collect a prescription for antimalarial medication.
The importance of taking out adequate travel insurance can also be emphasised and checking that they are fully covered for everywhere they intend to go and everything they intend to do. Annual insurance policies are useful for regular travellers especially if they tend to go last minute but it is important that they are relevant for each type of trip they make, for instance, some annual policies do not cover winter sports.
What can be Done for the Last Minute Traveller?
As for any Traveller a Risk Assessment Should Consider:
- Who the traveller is - age, gender, health profile and immunisation history
- Purpose of journey
- Length of trip
- Destination - precise i.e exact area not just the country, is it urban or rural, coastal or high altitude
- Method of transport
- Activities while away.
During the risk assessment consideration can be given to the most significant risks so that their management can be discussed. The majority of risks for most travellers are not vaccine preventable and so risk management will involve educating them about preventive strategies such as:
- Food and water precautions
- Bite avoidance measures
- Climatic challenges
- Road and personal safety
- Consideration of the safety aspects of any activities they may engage in
- Issues pertinent to their own health profile.
In reality the adviser can only alert the last minute traveller to these issues and then encourage them to read further themselves by providing them with take away literature or web links for them to explore themselves.
TRAVAX users can utilise the very useful traveller advice suitcase facility, which enables you to select appropriate information leaflets and email them to the traveller.
Traveller Advice Suitcase
A new feature of TRAVAX. The traveller advice sheets are specifically written for the general public, so are clear, concise and easily understood. They can be found on the fitfortravel site. The Suitcase function allows you to select and save a variety of advice sheets as you progress through the travel consultation and then print or email directly to your traveller. You can also save a note of what you have sent for your own patient or clinic records.
In addition to www.fitfortravel.nhs.uk the following are helpful and can be accessed while abroad so the traveller has on-going access to useful information:
If the risk assessment identifies a significant malaria risk it is never too late to start prophylaxis with either atovaquone/proguanil or doxycycline. Although ideally they should be started 1-2 days before travel the most important time to be taking them is during and after risk of infection so commencing these as late as the day of departure will still be beneficial.
As chloroquine and mefloquine should generally be commenced at least a week before arriving in a risk area they would be less suitable for the very last minute traveller but may be used if other drugs are unsuitable and choices limited. It goes without saying that these travellers should be thoroughly briefed on insect bite avoidance and the importance of prompt treatment.
The Guidelines for Malaria Prevention in Travellers from the UK (available at www.malaria-reference.co.uk ) discuss last minute travellers in section 7.8.
Vaccines for the Last Minute Traveller
All vaccines that would normally be recommended for the destination should be considered in the light of duration of stay and activities planned while there. Other considerations are type of accommodation, season, urban or very remote locations, age and any pre-existing medical conditions.
Once a list of all possible vaccinations has been drawn up then the 'last minute' factor can be brought into the assessment. Future travel plans should also be considered as they may have a bearing on how worthwhile it would be to commence courses of some vaccinations. Boosters of previously received vaccines are generally going to be worthwhile as booster responses occur much more rapidly than primary responses to vaccines.
The incubation period of the infection versus the time taken to respond to the vaccine should also be considered. For instance hepatitis A has a long incubation period of around 28 days so although detectable antibodies are not measurable until approximately 14 days after vaccination it would be worth vaccinating the last minute traveller as they are still likely to gain complete protection.
Typhoid vaccination on the other hand may be less useful to the short tem last minute traveller as it takes about 2 weeks to mount a measureable immune response to the injectable vaccine and the incubation period can be as little as one week. Injectable typhoid vaccine also does not protect against paratyphoid so rigorous food and water precautions are still going to be very important.
If the traveller is leaving in less than 10 days and is going to a country where a yellow fever certificate is mandatory they will need to be advised that this could present them with problems and ideally should delay their trip to comply with the requirement. Travellers who do not have a certificate requirement but who will be travelling to a yellow fever endemic destination also need to consider that they will not be fully protected if they travel in less than 10 days from receipt of vaccine and thus bite avoidance precautions will be all the more important.
Giving just one dose of a product with 2 or more doses in the primary course may not confer much protection in itself so the ability of the traveller to complete the course during long-term travel needs to be considered. Providing them with information about organisations such as:
- The International Society of Travel Medicine (www.istm.org)
- The International Association for Medical Assistance to Travellers (www.iamat.org)
Here, travellers can obtain information about clinics at their destination which may enable them to complete courses while they are away. They must understand that protection will not be complete until they have done this.
It may also be worth starting such courses in short term travellers if they are frequent travellers. Whilst they will not obtain protection for the imminent trip if they continue the course on their return then they will be better prepared for future trips. Having longer than scheduled intervals between doses in a course of injectable vaccines is not detrimental to the long-term benefit. Oral vaccines are less suitable to this approach however.2
In both situations the traveller needs to understand about other preventive strategies and action to take if they are potentially exposed to diseases such as rabies or hepatitis B prior to completing their vaccine schedule.
Promoting Pre-Travel Advice
It is worth considering ways in which the practice can promote the need for pre- travel advice among their practice population. Awareness can be raised through posters in the surgery, notes on prescriptions, by using the local media, especially before specific events such as sporting tournaments, religious pilgrimages etc and even by forming a relationship with local travel agents.
Using text messaging or postal reminders for vaccine boosters so that the traveller doesn't just remember these when they are about to travel again will give further opportunities to discuss the importance of planning well ahead of a trip. All of this may go some way to reducing the number of last minute requests.
Last minute and frequent travel are part of modern life and we need to move away from a culture of focussing on just the next trip and more towards a trend to protecting and educating travellers for the long term.
All members of the practice team need to be aware of the importance of good pre travel advice and that it is never too late.
There will always be situations where it is impossible for the practice to fit someone in and in such cases it is important that all staff know where to refer the individual rather than simply saying you are too late!
1. Nicks BA Travel Medicine and Vaccination. http://emedicine.medscape.com/article/811510-overview. (accessed 25/11/13).
2. Atkinson,WL, Krogar AL, Pickering LK. General immunisation Practices in Eds. Plotkin SA, Orenstein, WA, Offit PA. Vaccines 5th edition 2008, Saunders Elsevier.
RGN RM RHV MSc FFTM RCPS Glas Independent Travel Health and Immunisation Specialist Nurse
Many thanks to Carolyn Driver for writing this guest column for TRAVAX. Carolyn has been a specialist in travel health and immunisation for the last 14 years. Her interest and passion for her special interests were honed during many years experience as a Health visitor and Practice Nurse. Carolyn regularly runs study days on all aspects of travel health and immunisation and is also involved in developing educational projects in addition to writing for professional journals.
Carolyn is currently a member of the travel health sub group of the Joint Committee on Vaccination and Immunisation, the Board of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow and the leadership council of the Nurse Professional Group of the International Society of Travel Medicine. Carolyn is an honorary tutor and examiner on the Glasgow Foundation and Diploma in Travel Medicine courses and is a Fellow of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow.
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