Travel health

The RCN guidance document Travel Health nursing: career and competence development has been published. This updated (2023) edition provides information on current guidelines and standards of care expected from nurses advising travellers from the UK. Travel advice can be complex, and this update continues to build on previous editions by defining the standards of care expected for a competent registered nurse, experienced/proficient nurse, and a senior. A sample travel risk assessment form (pages 57-58) and a travel risk management form (pages 59-60) are available in Appendix 1.

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.

A GP mythbuster 107 for pre-travel services in England has been published by the Care Quality Commission (CQC). Focus is also on the importance of governance and training within travel health and the evidence CQC expects to find on inspection. 

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 2019: Implications for those advising travellers.

Public Health England (PHE) has published data on malaria imported into the United Kingdom (UK) in 2019, mostly based on figures reported to the PHE Malaria Reference Laboratory (MRL). A total of 1,719 cases of imported malaria were reported in the UK, 2.1% higher than reported in 2018. 

Consistent with previous years, the majority of cases were caused by P. falciparum. The number of P. falciparum cases increased in 2019, while the proportion of P. vivax cases decreased. Cases caused by other species remained similar. 

In 2019, 15 deaths were reported, which is an increase compared to the previous 10 years with an annual average of 6 deaths. Fourteen deaths were from falciparum malaria, acquired in Africa. The remaining death was from vivax malaria acquired in Southern Asia. 

Reason for travel was known in 11 cases; 5 travelled for holiday, 3 to visit friends and relatives (VFR), and 3 were foreign visitors to the UK. The UK region was known in all cases; 7 deaths were in cases presenting in London, and 9 presented outside London. History of malaria prophylaxis use was known in 7 cases; 5 took no prophylaxis, and none of the 7 cases took an effective regimen with full adherence. In the 8 cases where time from onset of symptoms to initiation of treatment was known, median time was 4 days. Four patients did not receive any treatment for their malaria infection; 3 were found dead at home. “Numbers are too small to draw definite conclusions from these data, but the higher case fatality rate seen in tourists and those born outside Africa, as well as in those presenting in areas of the UK where malaria is less commonly seen, reflect published data from a large observational study of UK malaria deaths"  (BMJ, 2012).

Please note that Public Health England (PHE) is now known as The UK Health Security Agency (UKHSA). 

The UKHSA Malaria Reference Laboratory (MRL) provides an Email Service for healthcare professionals. A risk assessment form can be downloaded. The form can be completed electronically and emailed to: phe.malproph@nhs.net. The MRL will reply within three working days.

If not diagnosed and treated promptly, P. falciparum can progress to severe and life-threatening illness, including cerebral malaria. Travellers returning from malaria risk areas should seek urgent medical advice, including a same-day result malaria blood test, for any symptoms, especially fever, during their trip or in the year following return home. Treatment guidelines and algorithms for clinicians are available from the British Infection Association.

Malaria remains an important issue for UK travellers with failure to take chemoprophylaxis associated with the majority of cases in those visiting-risk areas. Cases in holidaymakers are small but associated with greater mortality. Those of African or Asian ethnicity who are non-UK born and travelling to visit friends and relatives are at increased risk of malaria, as well as other infections. Older travellers are at particular risk of dying from malaria. Those providing advice should engage and discuss future travel plans with these population groups using MECC.

Further resources:

The World Health Organization (WHO) highlights World Malaria Day each year on 25 April.

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 (2020). This publication acts as a supplement to Female Genital Mutilation: An RCN Resource for Nursing and Midwifery Practice (2019) and focuses on professionals working in travel health services. Travel health organisations, clinics and health care professionals 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 guidance for sexual health care (2020). This publication acts as a supplement to Female Genital Mutilation: An RCN Resource for Nursing and Midwifery Practice (2019) and focuses on professionals working in sexual health services such as sexual health clinics, genitourinary medicine clinics and children’s services.

Royal College of Physicians and Surgeons of Glasgow. Female Genital Mutilation - eLearning module. The Royal College of Physicians and Surgeons of Glasgow provides travel health e-learning modules for healthcare professionals. Those providing pre-travel consultations should routinely consider the risk of FGM for female travellers. National guidance states that a question about FGM should be included in all routine pre-travel risk assessment questionnaires. This eLearning module helps healthcare professionals identify those at risk of FGM, and sets out practical ways to discuss this sensitive subject with patients. The module is now open access and free for all to undertake.  

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

The following is for information. Nurses in the UK should continue to follow guidance from the Green Book.

The Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report 6 May 2022, published new recommendations from the Advisory Committee on Immunization Practices (ACIP) on pre-exposure rabies vaccination (PrEP).

Reference: Rao AK, Briggs D, Moore SM, et al. Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:619–627.
DOI: http://dx.doi.org/10.15585/mmwr.mm7118a2external icon

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.

As part of this management, guidance for health professionals on how to administer post-exposure rabies vaccination with rabies immunoglobulin was recently added. Aimed at health professionals whose patients require a course of post-exposure rabies vaccination with rabies immunoglobulin (RIG). It provides critical information on the correct administration of RIG, and should remain with the product.

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:

• NaTHNaC. Zika virus (ZIKV) update to guidance
• TRAVAX. (login required) Zika Virus: Updated Guidance for Travellers
• Fitfortravel.(public access) 
• For current information on outbreak surveillance search NaTHNaC. Outbreak surveillance.

Other resources:

• Zika risk assessment: updated 27 February 2019 
• Public Health England: Zika virus: clinical and travel guidance

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 Public Health Scotland (PHS) TRAVAX 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 on vaccination is 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. Public Health Scotland Designation of Yellow Fever Vaccination Centres Information Pack. NaTHNaC has updated and revised the format for yellow fever training. For options see the NaTHNaC training portal.  

The World Health Organization (WHO) published the 2020 updates to country yellow fever recommendations and certificate requirements. The country list is a compilation of key information to facilitate safe international travel, including country requirements and WHO recommendations for yellow fever vaccination and malaria prophylaxis. International Travel and Health and Annex 1 International Travel and Health. 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 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. The Association of British Travel Agents (ABTA) has published a free resource for UK travellers. Restarting travel – a guide for customers, includes information for both domestic and international travel. The situation on overseas travel remains dynamic with advice likely to change at short notice.

The Foreign, Commonwealth and Development Office (FCDO) continues to advise on overseas travel for British nationals. Advice varies between the four UK countries. Refer to COVID-19 box for information. For international travel and demonstrating COVID-19 status for travel from each UK country see: International travel and demonstrating COVID-19 status.

During 2021 the clinical team at NaTHNaC hosted regular lunchtime sessions on Zoom to help with COVID-19 related travel health issues. New dates have been released.

WHO publishes the latest public health information on resuming international travel. Make sure the most current update is accessed.

On 13 January 2020 Chapter 35: Yellow fever, in Immunisation against infectious disease (Green Book) was updated to reflect the recommendations of the Commission on Human Measures (CHM) to strengthen measures to minimise the potential risk of rare but serious and fatal adverse events associated with yellow fever vaccination (in those with weakened immune systems, those aged 60 years or older and anyone who has had their thymus removed). 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.

On 11 March 2021, NaTHNaC launched a new portfolio of yellow fever vaccination recommendation maps. More will be added, so make sure the most current information is accessed. The NaTHNaC Factsheet and disease information are frequently updated so check details regularly.

In April 2019, the Medicines and Healthcare products Regulatory Authority (MHRA) 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. 

Yellow Fever vaccination: Important new guidance for health professionals

Public Health England published guidance for health professionals managing clinical incidents or adverse vaccine associated events related to yellow fever vaccination. Health professionals working in UKYFVCs should read this guidance in its entirety, ensure the information is disseminated widely to the clinical team and applied in clinical practice. See: Yellow Fever Vaccination.

On 21 November 2019 the above item was updated. Following a review of these serious adverse events after yellow fever vaccination, new recommendations for clinical practice include strengthened measures to minimise the risk of serious and fatal reactions post vaccinations have been published. The MHRA, Public Health England (PHE), NaTHNaC and HPS circulated a joint letter to inform health professionals of the recommendations of a Commission on Human Medicines (CHM) review of serious and fatal reactions following administration of yellow fever vaccine. Specific recommendations are contained in the letter.  

The Green Book Chapter 35, Yellow Fever, and NaTHNaC and TRAVAX resources were amended accordingly.

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. 

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

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.

On 18 November NaTHNaC updated advice on Measles vaccination for infants from six months to under 12 months of age travelling overseas. Following risk assessment, in some circumstances, vaccination should be considered in this age group.

On 8 July 2020 TravelHealthPro, posted a reminder for measles vaccination during the COVID-19 pandemic. 

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 CNSGP (England)  
• The GMPI (wales)  

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.

Now that the RCN indemnity scheme has been extended to cover paid-for travel vaccinations, most members employed in General Practice settings will find that all their professional needs are met by their RCN membership.

• See the podcast by Roz Hooper - RCN head of legal services
• All vaccines should be given in line with the guidance in ‘Immunisation against infectious disease’ (The Green Book) 
• See the RCN guidance Competencies: Travel health nursing: career and competence development (2018) for current guidelines and standards of care for travelers and the standards of care expected for; a competent nurse, experienced/proficient nurse and a senior practitioner/expert nurse working at that level
• The BMA focus on travel provides further useful information. 

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.

The World Health Organization’s (WHO) Road Map NTD 2021-2030 was launched on 28 January 2021. January 30th is the second annual World Neglected Tropical Disease Day. Ambitious targets include ensuring that 100% of NTD endemic communities can access basic water and sanitation services by 2030. 

Travel resources, courses and study days

Royal College of General Practitioners LGBT Health Hub

In July 2017, the Government Equalities Office launched a national survey of LGBT people which was open to anyone who identified as having a minority sexual orientation, gender identity or had variations in sex characteristics. It asked questions about people’s experiences of living in the UK and in accessing public services and received more than 108,000 responses, an unprecedented number.

NaTHNaC

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

• 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.

NaTHNaC has an e-learning course on risk assessment and risk management in the travel health consultation. The course is aimed at health professionals new to the travel health consultation or those more experienced looking to refresh their knowledge.

The NaTHNaC telephone advice line number has changed from the non-geographic 0845 number to 0207 383 7474.

Initially an auto-divert function will be available for callers who ring the old number.

The advice line is for health professionals who have queries about travel scenarios that involve complex itineraries or travellers with special health needs.

The advice line is open Monday, Tuesday, Thursday and Friday 13.00-1500 and Wednesday 13.30-15.30

Further information for callers is available on the Contact Us page.

Public Health Scotland (PHS) 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.

Changes to Travel Health Service Provision in Scotland

On 01 April 2022, the process to access travel health services in Scotland changed:

• Fitfortravel is now the national entry point for travellers seeking to access the free travel advice and vaccines provided by NHS Scotland

The changes apply only to travellers living in Scotland.

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 join the FTM as Affiliate Members and benefit from access to publications and reduced conference fees.

Professional Development Certificate in Travel Medicine

The Royal College of Physicians and Surgeons of Glasgow, Faculty of Travel Medicine, is offering a Professional Development Certificate (PDC) in Travel Medicine. The course is designed to enhance the knowledge and skills of doctors, nurses and pharmacists working within Travel Medicine. Other relevant healthcare professionals with an interest in this area may be considered.

The standard timeframe for this course is six months, but individuals have the flexibility of working at their own pace. The course has four core modules:

1. Pre-Travel Risk Assessment & Management
2. Travel Related Infections
3. Malaria and Mosquito Borne Diseases
4. Immunology and Immunisations.

On successful completion, a Professional Development Certificate (PDC) in Travel Medicine will be awarded by the Royal College of Physicians and Surgeons of Glasgow (RCPSG).

Applications are open. The second and third cohorts will begin in September 2021 and January 2022 respectively.

Post Graduate Diploma in Travel Medicine

The Royal College of Physicians and Surgeons of Glasgow, Faculty of Travel Medicine, is offering a Post Graduate Diploma in Travel Medicine. The course is designed to develop and support healthcare professionals in their role as travel medicine practitioners. The course consists of eight postgraduate modules delivered over 18 months.

1. Epidemiology, Immunology and Travel Risk Assessment
2. Vector Borne Infections
3. Non-Vector Borne Infections
4. Environmental Factors and Travel
5. Advanced Research Methods
6. The Complex Traveller – Pre and Post Travel
7. Medical Conditions and Travel
8. Governance, Legal and Ethical Considerations.

Those who successfully complete the course will be eligible for admission to Membership of the Faculty of Travel Medicine MFTM RCPS(Glasg).

Successful candidates will also have the opportunity to articulate into the Masters in Advanced Practice with Glasgow Caledonian University (approval pending).

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.

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

Forthcoming travel health conferences    

CISTM18

21-25 May 2023
Basel, Switzerland

The 9th Northern European Conference on Travel Medicine (NECTM9)

22-24 May 2024
Tivoli Hotel and Congress Centre, Copenhagen Denmark