Flying squad: occupational health advice for business travellers

Doctors’ surgeries were traditionally the first port of call for travellers seeking health advice, but with the increase in international travel, this advisory role has now been extended to school nurses, private clinics and occupational health staff. On-site clinics in corporate settings can be an effective way of providing comprehensive travel medicine services.¹

With the ongoing development of new vaccines, constantly changing disease outbreaks and distribution, and ease of travel into areas previously considered as remote, it is important that health professionals who are being asked to provide this healthcare service have access to guidelines and reliable sources of information.

In 2005 there were 800 million international tourist arrivals worldwide with business travel accounting for 16% of the total.² Travel medicine has become recognised as a specialist area of healthcare, with organisations such as the International Society of Travel Medicine promoting research and awarding academic qualifications.³ The UK has always been at the forefront of this development and in 2006 the first Faculty of Travel Medicine was established by the Royal College of Physicians and Surgeons of Glasgow.⁴

This article highlights the travel health documents developed by the Royal College of Nursing (RCN) and discusses the importance of risk assessment protocols in a travel health consultation.

Guidelines and competencies

In June 2005 the RCN produced a guidance document, Delivering Travel Health Services,⁵ for nursing staff who were being asked to take on the role of travel health adviser.  It emphasises the need for basic or further education, dependent on the responsibilities or level of advice given, and suggests courses and qualifications.

A more comprehensive document, Competencies: An Integrated Career and Competency Framework for Nurses in Travel Medicine was published earlier this year. This concise framework is designed to give a more detailed breakdown of expected skills and the knowledge base for nurses practising at all levels. It also provides a chapter highlighting the importance of pre-travel risk assessment.

Risk assessment

There are very few absolute rules when providing travel health advice or recommending vaccines, but guidance can only be given following thorough risk assessment of each traveller. It is impossible to presume that two travellers going to the same country will require the same advice or vaccine recommendations, and reliance on a wallchart showing vaccines for different countries is outdated and poor practice.

In a perfect world, OH would see travellers well in advance of their trip, as a reasonable timescale is crucial to the efficient and effective delivery of advice. However, this is not always possible and, if there is insufficient time for complete vaccine schedules, complementary education and advice becomes increasingly important. Providing relevant and comprehensive guidance requires not only information about the traveller and their itinerary, but also an understanding of the actual disease, transmission and treatments, bearing in mind that for most health risks we can offer no vaccine. 

It is impossible to carry out a travel health consultation without referring to an atlas, as regional or climatic variations are important factors to consider. A recognised online database (giving UK-based guidelines) is also an essential reference source for health professionals providing advice.

A complete risk assessment requires knowledge of the traveller, their itinerary, their destination, the potential health risks and diseases, and if appropriate, the available vaccines or chemoprohylaxis.

Personal and travel details

The most concise way to approach risk assessment is to consider personal and travel details. In many instances the health professional may have no information about their client so some basic details are required. It is useful to have a structured form, which can be designed to suit each clinic or workplace. Some of the key risk assessment issues are summarised below:

Age

• The traveller may have been born prior to implementation of many current national schedule vaccines
• Older travellers have reduced immune systems
• Young children may not have complete UK schedule vaccines

Current medications

•  Potential interaction with vaccines or anti-malarial drugs
•  In the case of long-term travel, will the traveller have sufficient supplies
•  Consider the safe storage of drugs and possible restrictions for carrying medication and equipment

Medical history/current state of health

• Those with ongoing medical problems may require specialist advice
• A history of epilepsy, psoriasis or depression is relevant when discussing malaria chemoprohylaxis
• Consider the health insurance implications of pre-existing conditions, such as diabetes or heart disease, which increase the risk of requiring medical attention abroad
• If the traveller has a compromised immune system it may affect vaccine efficacy or recommendation

Pregnancy
Not a contra-indication to travel – but high risk when considering malaria; little data on the use of certain vaccines and increased risk of requiring medical attention abroad

Previous vaccines

• In general most travellers will not remember their previous vaccine history
• If history is incomplete you may have to restart a schedule
• Always provide a patient-held record card – this makes life easier in the future

Allergies

• Relevant if the traveller has an allergy to recommended vaccines/components or medications
• An issue if the traveller is allergic to foodstuffs and visiting a country where labelling and awareness will not be subject to the same guidelines as the UK

Destination

• An atlas is an essential reference source
• Advice and recommendations will vary with seasonal and geographical variations
• Stopovers may have an impact on recommendations – particularly for yellow fever vaccine requirements

Departure date

• Last-minute travellers may not have time for complete vaccine schedules and may have limited choices when considering anti-malarial medication

Length of stay

• A two-day business trip to a high-risk destination has different implications compared with a long-term contract living abroad as an ex-pat with family
• With longer stays, seasonal risks become more relevant
• Will adherence to malaria chemoprohylaxis be an issue?

Type of accommodation

• Good quality air-conditioned accommodation will decrease overall health risks, but outside this environment many health issues will apply
• For those staying in basic facilities, the need for mosquito bite awareness and food/water risks will increase

Planned activities/purpose of travel

• This will include everything from the backpacker adventure traveller to the person on short, regular business trips or the ex-pat living abroad for many years
• They may all have a similar destination but the information and advice given will vary considerably
• In areas where there is a high carrier rate of hepatitis B, the traveller will be at risk following sexual contact and if receiving medical treatment
• Will there be close contact with the local population? Is the traveller attending, say, the Hajj pilgrimage?

Access to medical facilities

• May be of particular relevance to those with pre-existing health problems and a factor on whether certain vaccines (eg rabies) would be recommended

Previous travel

• Does the traveller have previous travel experience? What level of advice do they require?

With the risk assessment completed, the next stage in the travel health consultation is to determine the most appropriate advice and, if relevant, to recommend any vaccines or anti-malarial drugs.

This is an area of care that can range from general to specialised, but as recommended by the RCN, health professionals who are expected to provide this service should take a basic course. Access to reliable information is crucial, with some of the best and most up-to-date sources of information provided on online databases.

Sheila Hall RGN RM MSc is an independent travel health adviser and director of TREC Travel-Health Related Education & Care

Travel health education

• TREC – Travel-Health Related Education & Care
  Two-day courses organised in venues throughout the UK. Designed as a common sense approach to travel health education. Suitable for health professionals new to travel health or those wishing to update current knowledge. Tel 01360 770829
• London School of Hygiene and Tropical Medicine
  Five-day course based in London – organised annually.
• Health Protection Scotland
  Distance learning courses – six-month foundation and 12-month diploma course. In collaboration with RCPSG. 
• NaTHNaC – Yellow Fever Training National Travel Health and Network Centre
  Organises the compulsory training day for clinics providing yellow fever vaccination
  
  Sources of information
• The Green Book – an essential reference source for anyone providing travel or national schedule immunisations. Department of Health (2006) Immunisation against infectious disease (3rd Ed.) London: DH. Updates available online.
• The UK Malaria Guidelines – important guidelines and advice specifically for travellers from the UK
  Health Protection Agency (2007) Guidelines for malaria prevention in travellers from the UK London: HPA. Available online. 
• World Health Publication – World Health Organisation (2007) International travel and health, Geneva; WHO. Available online.
  
  Useful websites
• TRAVAX – an online database for health professionals, run by Health Protection Scotland, updated daily. For registered users only. Charge made to non NHS users. For more information call 0141 300 1164
• Fitfortravel – free access site for general use. Also run by Health Protection Scotland. Less detailed than TRAVAX.
• National Travel Health and Network Centre provides information for health professionals and general public. Free access.
• Medical Advisory Services for Travellers Abroad is a privately-run database that incorporates online ordering facilities for vaccines etc.  For registration details tel 0113 238 7500
  
  References
  
      1.   Prince T, Spengler S, Collins T (2001) Corporate Travel Medicine: Benefit Analysis of On-Site Services. Journal of Travel Medicine, 8:163-166
      2.   World Tourism Organisation Tourism Highlights 2006
      3.   International Society of Travel Medicine
      4.   Royal College of Physicians and Surgeons Glasgow
      5.   Royal College of Nursing Delivering Travel Health Services (2005)
      6.   Royal College of Nursing (2007) Competencies: An integrated career and competency framework for nurses in travel health medicine. www.RCN.org.uk/publications