Advising travellers who have special risks.

The aim of an effective travel health consultation is to provide advice that is tailored to the individual traveller; this is particularly the case when advising travellers with special health needs. This article discusses the general principles of identifying travellers with special risks and tailoring travel health advice accordingly. This is the second in a three-part series looking at the principles of travel health.

Preventing malaria in travellers: an overview.

Malaria is a common, potentially fatal infection found in more than 100 countries. Nurses play an important role in advising travellers about the risk of malaria, methods of prevention and in recognising the disease in returning travellers. This article provides an overview and outlines key areas of knowledge that are essential for nurses involved in giving pre- and post-travel malaria advice.

Travel risk assessment and risk management.

Risk assessment and risk management are fundamental to travel health consultations. Undertaking a comprehensive risk assessment involves gathering information on the traveller and their proposed journey. This information, as well as identifying specific travel-related hazards, should ensure risk-management advice and strategies are appropriate for individuals. This article outlines the principles of risk assessment and risk management in the context of travel health consultations.

Health advice for older people travelling overseas.

Old age should not prevent people from venturing to foreign climes for their holidays, but some of the hazards associated with travel are of more concern for older tourists. Nurses caring for older people in community, acute and residential settings should know where to direct them for pre- and post-travel health advice. Risk assessment and management are important parts of travel health consultations. This article provides a summary of the dangers of overseas travel and the general principles of health advice applicable to the specific needs of the older traveller.

National review of reported Yellow fever vaccine incidents in the UK.

BACKGROUND: Yellow fever (YF) vaccination is the single most important preventative measure against YF infection, however the live attenuated vaccine has associated serious adverse events. All YF vaccinations in England, Wales and Northern Ireland (EWNI) are administered in YF Vaccination Centres and comply with National Travel Health Network and Centre (NaTHNaC) Conditions of Designation and Code of Practice, including reporting of vaccine incidents to NaTHNaC. In this study we evaluated the number and type of YF vaccine incidents in EWNI to identify areas for improvement. METHODS: NaTHNaC's telephone advice line database was retrospectively searched from 1st January 2016 to 31st December 2018 for YF vaccine incidents. Calls were categorised and analysed according to incident type. RESULTS: Seventy-eight YF vaccine incidents were reported from a total of 17250 calls. The commonest incident was incorrect timing of measles, mumps and rubella vaccine in relation to YF vaccine, where the recommended 28-day interval was not observed (n = 21). Other incidents included accidental partial vaccination (n = 11), inappropriate vaccination (n = 5) and invalid vaccination due to expiry or cold chain breach (n = 4). Inadvertent vaccination in contraindicated individuals occurred in two travellers with thymectomies (resulting in one death), and five immunocompromised travellers. CONCLUSIONS: YF vaccine incidents represent a small proportion of total calls. Similar incidents likely occur with other vaccines, but YF vaccine incidents are of particular concern; whilst most incidents were not harmful, vaccination in contraindicated individuals resulted in one death. These findings helped to inform new guidance and update training for staff in YF vaccination centres.

Quality improvement in travel medicine: a programme for yellow fever vaccination centres in England, Wales and Northern Ireland.

BACKGROUND: The National Travel Health Network and Centre (NaTHNaC), a United Kingdom public health body, is responsible for designating nearly 3500 Yellow Fever Vaccination Centres (YFVCs) in England, Wales and Northern Ireland (EWNI). In 2005, NaTHNaC established a programme of registration, training, clinical standards and audit for YFVCs following the mandate of International Health Regulations (IHR, 2005). ASSESSMENT OF PROBLEM: Administration of yellow fever (YF) vaccine is complex because of the changing epidemiology of YF and the risk of rare, severe adverse events following vaccination. Additionally, there is little formal assessment of providers of travel medicine, particularly in the area of YF vaccination. In 2004, prior to introducing their programme, NaTHNaC sent a questionnaire to all YFVCs in England to assess their practice. This highlighted a need for training and institution of standards to reinforce best practice in vaccination and knowledge about YF. STRATEGIES FOR CHANGE: In 2005, NaTHNaC introduced its programme for all YFVCs. It was expected that training, adherence to standards and access to resources would lead to increased confidence and consistency of practice by YF vaccine providers. EFFECTS OF CHANGE: In 2009, a questionnaire was sent to all YFVCs in EWNI to evaluate the impact of the NaTHNaC programme. Among respondents who attended NaTHNaC training 95.8% of respondents indicated that it improved their confidence about YF vaccination. Furthermore, 68.5% of centres made changes to their practice, and improved adherence to core standards was observed. NEXT STEPS AND LESSONS LEARNED: The NaTHNaC programme has led to improved standards in YFVCs and increased confidence in health professionals who administer the YF vaccine. Although this has not been tested, it is expected that this will translate to more consistent and better care for the international traveller. Elements of the NaTHNaC programme could be a model for improvement of clinical standards and for other countries as they seek to implement IHR (2005) and improve the practice of travel medicine.

Travel health: routine, recommended and required vaccines.

Vaccines are an important public health measure and may be the prompt for travellers to attend for pre-travel health advice. Nurses involved in the provision of travel health advice require a sound knowledge of available vaccines together with the diseases they prevent and other risk management strategies. Travel vaccines should always be administered following a travel health consultation and risk assessment, taking into account the informed choice of the traveller. This paper discusses vaccine preventable disease in the context of travel health, and the appropriate use of routine, recommended and required pre-travel vaccines, which can be considered following individual risk assessment.

Pre-travel malaria enquiries to the United Kingdom national travel advice line 2016: Advice mainly needed on malaria maps and risk groups.

BACKGROUND: Malaria prevention in travellers can be complex and requires consideration of a number of factors. UK healthcare professionals providing pre-travel malaria advice can access specialist support from the National Travel Health Network and Centre (NaTHNaC) telephone advice line. The aim of this study is to characterise queries to the NaTHNaC telephone advice line regarding pre-travel malaria advice. METHOD: Telephone calls received to NaTHNaC's advice line are recorded using an online data capture form. All calls relating to malaria advice during 2016 were selected and data extracted. Analysis was undertaken using Microsoft Excel and STATA. RESULTS: During 2016, 1803 malaria-related calls were received; the majority from general practice and calls were from across the UK. The most common type of pre-travel malaria query was country-specific followed by travellers with special health needs. Many queries related to pregnant and breastfeeding travellers, children under 5 years and travellers over 60 years. CONCLUSIONS: This review presents a large and exceptional dataset and reflects the ambiguity amongst some healthcare professionals regarding malaria advice. We have identified potential knowledge gaps, and as a result will strengthen future guidance, enhance existing malaria maps, and inform the development of future clinical educational activity.

Amplification of perceived risk among users of a national travel health Web site during the 2013-2016 West African Ebola virus outbreak.

Timely outbreak information was paramount to public health bodies issuing travel advisories during the 2013-2016 West Africa Ebola virus outbreak. This article explores the potential for a syndromic system/Shewhart control chart based on the online interaction with a national travel health Web site in comparison with searches on the Google UK search engine. The study showed an amplification of perceived risk among users of a national travel health Web site months before the World Health Organization declared the outbreak a Public Health Emergency of International Concern and the initial surge in public interest on Google UK in August 2014.

Access to yellow fever travel vaccination centres in England, Wales, and Northern Ireland: A geographical study.

BACKGROUND: More than 700,000 trips were made by residents in England, Wales, and Northern Ireland (EWNI) in 2015 to tropical countries endemic for yellow fever, a potentially deadly, yet vaccine-preventable disease transmitted by mosquitoes. The aim of this study was to map the geographical accessibility of yellow fever vaccination centres (YFVC) in EWNI. METHODS: The location of 3208 YFVC were geocoded and the average geodetic distance to nearest YFVC was calculated for each population unit. Data on trips abroad and centres were obtained regionally for EWNI and nationally for the World Top20 countries in terms of travel. RESULTS: The mean distance to nearest YFVC was 2.4 km and only 1% of the population had to travel more than 16.1 km to their nearest centre. The number of vaccines administered regionally in EWNI was found correlated with the number of trips to yellow fever countries. The number of centres per 100,000 trips was 6.1 in EWNI, which was below United States (12.1) and above the rest of Top20 countries. CONCLUSIONS: The service availability was in line with demand regionally. With the exception of remote, rural areas, yellow fever vaccination services were widely available with only short distances to cover for the travelling public.

Early detection of perceived risk among users of a UK travel health website compared with internet search activity and media coverage during the 2015-2016 Zika virus outbreak: an observational study.

OBJECTIVES: The Zika virus (ZIKV) outbreak in the Americas in 2015-2016 posed a novel global threat due to the association with congenital malformations and its rapid spread. Timely information about the spread of the disease was paramount to public health bodies issuing travel advisories. This paper looks at the online interaction with a national travel health website during the outbreak and compares this to trends in internet searches and news media output. METHODS: Time trends were created for weekly views of ZIKV-related pages on a UK travel health website, relative search volumes for 'Zika' on Google UK, ZIKV-related items aggregated by Google UK News and rank of ZIKV travel advisories among all other pages between 15 November 2015 and 20 August 2016. RESULTS: Time trends in traffic to the travel health website corresponded with Google searches, but less so with media items due to intense coverage of the Rio Olympics. Travel advisories for pregnant women were issued from 7 December 2015 and began to increase in popularity (rank) from early January 2016, weeks before a surge in interest as measured by Google searches/news items at the end of January 2016. CONCLUSIONS: The study showed an amplification of perceived risk among users of a national travel health website weeks before the initial surge in public interest. This suggests a potential value for tools to detect changes in online information seeking behaviours for predicting periods of high demand where the routine capability of travel health services could be exceeded.

Yellow fever vaccination: is one dose always enough?

In March 2013, the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunisation (SAGE) considered a number of issues in order to update the WHO Position Paper on Yellow Fever (2003). A key conclusion of this review was that a single dose of yellow fever (YF) vaccine appears to confer life-long protection against YF disease, and that a booster dose of YF vaccine is not needed to maintain immunity. While the efficacy of YF vaccine in the majority of vaccine recipients is not in doubt, the WHO announcement is somewhat surprising as there are some limitations in the evidence base, but more importantly, this announcement is not accompanied by any imminent change in the International Health Regulations 2005. The tension between what is considered best clinical practice and the law will be difficult to reconcile for many health professionals, travellers, and the travel industry, in an area of travel medicine that is already subject to debate and confusion. This commentary reviews the recent WHO announcement, and considers the practical implications for health professionals providing YF vaccine to international travellers.

Evaluation of travel medicine practice by yellow fever vaccination centers in England, Wales, and Northern Ireland.

BACKGROUND: The National Travel Health Network and Centre (NaTHNaC) introduced a program of registration, training, standards, and audit for yellow fever vaccination centers (YFVCs) in England, Wales, and Northern Ireland (EWNI) in 2005. Prior to rolling out the program, NaTHNaC surveyed YFVCs in England. OBJECTIVES: To reassess the practice of YFVCs in 2009, 4 years after the institution of the NaTHNaC program, to identify areas for ongoing support, and to assess the impact of the program. METHODS: In 2009, all YFVCs in EWNI were asked to complete a questionnaire on type of practice, administration of travel vaccines, staff training, vaccine storage and patient record keeping, use of travel health information, evaluation of NaTHNaC yellow fever (YF) training, and resource and training needs. Data were analyzed using Microsoft Excel® and STATA 9®. RESULTS: The questionnaire was completed by 1,438 YFVCs (41.5% of 3,465 YFVCs). Most YFVCs were based in General Practice (87.4%). In nearly all YFVCs (97.0%), nurses advised travelers and administered YF vaccine. An annual median of 50 doses of YF vaccine was given by each YFVC. A total of 96.7% of nurses had received training in travel medicine, often through study days run by vaccine manufacturers. The internet was frequently used for information during travel consultations (84.8%) and NaTHNaC's on-line and telephone advice resources were highly rated. Following YF training, 95.8% of attendees expressed improved confidence regarding YF vaccination issues. There was excellent adherence to vaccination standards: ≥ 94% correctly stored vaccines, recorded refrigerator temperatures, and maintained YF vaccination records. CONCLUSIONS: In the 4 years since institution of the NaTHNaC program for YFVCs, there has been improved adherence to basic standards of immunization practice and increased confidence of health professionals in YF vaccination. The NaTHNaC program could be a model for other national public health bodies, as they establish a program for YF centers.

Analysis of yellow fever vaccination practice in England.

BACKGROUND: Prior to initiation of a program of registration, training, standards, and audit for yellow fever vaccination centers (YFVCs) in England, the National Travel Health Network and Centre (NaTHNaC) assessed the current practice and resource needs of these centers. METHODS: A questionnaire was sent to all YFVCs on the English Department of Health (DH) database in November 2004. It surveyed type of practice, administration of travel vaccines, training and duties of staff, vaccine storage and record keeping, access to travel health information, and resource and training needs. RESULTS: The questionnaire was completed by 69% (2,933 of 4,242) of YFVCs on the DH database. Nearly all (94%) YFVCs were part of general practice; centers were widely distributed throughout England. A median number of 35 doses of yellow fever vaccine (YFV) were given every year, with 75% of centers giving less than one dose per week. Nurses administered YFV more frequently than physicians (96% of nurses vs 49% of physicians, p < 0.0001). More nurses in YFVCs had received travel health training compared with physicians (95% vs 57%, p < 0.0001). Study days run by pharmaceutical companies were the most frequent source of training. Most YFVCs properly refrigerated vaccine and maintained vaccination records. Of the centers that reported using Internet resources for every patient, the Travax (Health Protection Scotland) (64%) and DH (England) (48%) Web sites were most frequently accessed. YFVCs cited training opportunities, information for travelers, and specific travel medicine advice as resources that would be most helpful to them. CONCLUSIONS: The NaTHNaC program of registration, training, standards, and audit should help to meet important needs in practice settings and contribute to an improvement in travel health.