Nalini Brown Nurse Manager/Travel Health Specialist London Travel Clinic

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1 Nalini Brown Nurse Manager/Travel Health Specialist London Travel Clinic

2 TOPICS Why do a travel risk assessment? Vaccines what s new? Advising patients when there is no vaccine Zika virus and Chikungunya and Dengue fever.

3 Why do a travel risk assessment? In 2016 there were 70.8 million visits overseas by UK residents, the highest figure recorded by the International Passenger Survey (IPS). Travel advice should be specific to each traveller who visit countries outside of the UK. As nurses we primarily see the overseas traveller and we need to assess each traveller individually which is where a risk assessment is necessary. It is a compulsory tool in calculating and interpreting the risk to the traveller in order to recommend the appropriate vaccines, medication and health advice they should be given before travelling abroad.

4 The travel risk assessment Name Date of Birth/age Sex Emergency contact name and contact number Destination(s) Type of trip/ pleasure, VFR, business, medical tourism, volunteering, study, sport etc Away from medical help Departure date, length of stay Medical history (e.g. diabetes, immunosuppressed) and surgical history (e.g. removal of thymus, spleenectomy) Current or recent medication Previous vaccine history Any known allergies Any previous serious reaction to a vaccine Any history of epilepsy/or in the family ( can affect what malaria tablets is recommended) Are you pregnant, actual or planned Travel insurance/disclosure of medical conditions

5 Recording the recommended vaccines and medication given

6 LONDONTRAVELCLINIC CONSULTATION FORM FOR OFFICIAL USE Patient name: Travel risk assessment performed: Advised booster: 6 months 12 months TRAVEL VACCINES RECOMMENDED Disease Yes Given Location Route Batch no Date given Declined and Reason Protection Hep A Hep A booster Typhoid Hep B (dose 1) Hep B (dose 2) Hep B (dose 3) Hep B booster Cholera (dose 1) Cholera (dose 2) Tet/Diph/Pol Men ACWY Yellow Fever Rabies (dose 1) Rabies (dose 2) Rabies (dose 3) Jap E (dose 1) Jap E (dose 2) Other Other Other MALARIA PREVENTION ADVICE AND MALARIA CHEMOPROPHYLAXIS Doxycycline Atovaquone + Proguanil/Malarone Mefloquine Other malaria tablets FURTHER INFORMATION AND PACKS e.g. weight of child/batch numbers TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL Food, water and personal hygiene advice Travellers diarrhoea Blood and bodily fluid infection risks Insect bite prevention Animal bites Accidents Insurance Air travel Sun and heat protection Websites SMS vaccines reminder service Travel record card supplied Side effects and dosage explained Other PSD SIGNATURE FOR DR OR PRESCRIBER ONLY Name: Signed: Date: NURSE SIGNATURE Name: Signed: Date: Name: Signed: Date: Name: Signed: Date:

7 Vaccines what s new? National shortages of Hepatitis A and Hepatitis B vaccines Outbreak of Hepatitis A in England Limits on supply of Revaxis Hep B paed and Men ACWY conjugated vaccine now on NHS schedule Dengue fever vaccine (not licensed for the UK) Malaria vaccine (not licensed for the UK) New drug resistant malaria in South East Asia Over the counter malaria tablets Maloff?NHS GP surgeries no longer providing travel vaccines Babies born after 1st August 2017 Infanrix hexa (DTaP/IPV/ Hib/HepB) late September/early October At 8, 12 and 16 wks (Change of Vaccine for routine primary baby immunisation programme)

8 High risk patients who need Hepatitis B

9 Pre and Post exposure Rabies vaccines Pre exposure rabies course 0, 7, 21-28days. Post exposure day, HRIG (up to 7 days) And IM Rabies vacccine on 0, 3, 7, 14, 28 (PHE guidelines) No need to restart the course (very good immune memory response) Only high risk travellers/workers need boosters IM injections as opposed to ID Increasing number of non UK residents attending for post rabies vaccines.

10 Advising patients when there is no vaccine Zika virus and Chikungunya and Dengue fever.

11 Zika Virus Zika virus was first isolated from a monkey in the Zika forest in Uganda in Since 2015, it has been introduced into many countries in South and Central America, the Caribbean, and Oceania (Melanesia, Micronesia and Polynesia). Via bite of an infected Aedes Mosquito Bites predominantly daytime & dusk The dangerous Aedes aegypti mosquito species, whose females carry and transmit debilitating and potentially fatal diseases including Zika, dengue fever, chikungunya and yellow fever, is primarily an urban dweller. It not only prefers to live in and around human habitation, but also thrives and proliferates in these conditions. Aedes aegypti females feed almost exclusively on humans. Sexual Transmission - Oral anal & vaginal sex In Utero from mother to child Incubation period: 3 to 12 days Majority of people infected have no symptoms It can cause a mild, short-lived (2 to 7 days) illness Rash Itching or pruritus Fever Headache Arthralgia or arthritis Myalgia Conjunctivitis Lower back pain Retro-orbital pain

12 Dengue fever Viral disease transmitted by Aedes mosquito Bites from dawn till dusk Estimated 390 million cases per year 96 million Symptomatic/ Incubation period 4-10 days High fever & headache Muscle & Joint pain Nausea & Vomiting Rash Self limiting illness No anti viral treatment /Supportive care only Recovery 3-4 days after rash Severe dengue/dengue haemorrhagic fever Occurs in 1-2% of cases 2.5% fatality rate Rare in travellers

13 Chikungunya fever Viral disease transmitted by Aedes mosquito Bites from dawn till dusk Although Chikungunya only recently appeared in the Americas and the Caribbean >1 million infections within one year The most common symptoms are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash. Chikungunya disease does not often result in death, but the symptoms can be severe and disabling. Most patients feel better within a week. In some people, the joint pain may persist for months. People at risk for more severe disease include newborns infected around the time of birth, older adults ( 65 years), and people with medical conditions such as high blood pressure, diabetes, or heart disease. Once a person has been infected, he or she is likely to be protected from future infections. (CDC)

14 Strict insect bite avoidance Insect repellent 50% DEET Infants >2 months Pregnant women Breast feeding Lasts up to 12 hours Apply to exposed skin over sunscreen

15 Recommended Insect Repellent by PHE apply insect repellent according to instructions on the label rub the repellent into the skin ensuring all skin is covered reapply repellent frequently, especially in hot countries and after swimming apply repellent after sunscreen when using both together (30 to 50 SPF sunscreen should be used to compensate for DEET-induced reduction in SPF) don t use DEET for babies younger than two months use DEET in concentrations up to 50% in pregnant or breast-feeding women, and in infants and children older than two months take supplies with you in case there is a shortage in countries where outbreaks are occurring

16 Training in Travel Health/keeping up to date RCN RECOMMENDATION Attend annual training session on immunisation Attend annual update on anaphylaxis and CPR training Ensure that travel health knowledge is always up-to-date Attend an annual travel health update study session/conference (Nurses should have at least hours training in Travel Health before practicing)

17 QUESTIONS

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