Recommendations for the practice of travel medicine

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Summary

Travel Medicine has emerged as a distinct entity over the last two decades in response to a very substantial increase in international travel and is now forging its own identity, remit and objectives for care of the traveller.

Crucial to the formation of any speciality is the definition of recommendations for its practice. This is particularly important and needed for travel medicine as it overlaps with and forms part of day-to-day work in a number of different medical specialities.

This document defines a set of recommendations for the practice of travel medicine from the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow.

Their objective is to help raise standards of practice and achieve greater uniformity in provision of services, better to protect those who travel.

As travel medicine moves towards applying for speciality status, these standards will also contribute to that process.

Introduction

Travel Medicine focuses on the health and well-being of international travellers. Also known as Travel Health or Travel Health Medicine, Travel Medicine has emerged as a distinct entity over the last two decades in response to a very substantial increase in international travel. Most frequently practised part-time by health professionals in a variety of fields, notably primary care and infectious diseases, recent years have seen the emergence of full time practitioners at Consultant level. We now see travel medicine forging its own identity, remit and objectives for care of the traveller. At the time of publication Travel Medicine is not a speciality as recognised under UK legislation (as listed in the General and Specialist Medical Practice (Education, Training and Qualifications) 2010 order). Therefore, this set of recommendations should be seen in that light.

Its core practice is risk assessment and risk management, not only of communicable diseases but also conditions resulting from the natural environment (eg extremes of temperature; altitude), local circumstances (eg road traffic hazards; risks to personal security) and underlying illness in the traveller which might be affected by the circumstances of travel.

Travel medicine also considers the influence of travel on the country visited. Mass tourism can have a considerable effect on the people, environment and economy of the host country.

Crucial to the formation of any speciality is the definition of recommendations for its practice. This is particularly important for travel medicine as it overlaps with and forms part of day-to-day work in a number of different medical specialities.

In recent years there has been a move to improving standards of travel health advice in the UK and internationally. The Royal College of Nursing (RCN) has published Travel Health Nursing: Career and Competence Development which is endorsed by the Faculty of Travel Medicine (FTM) of the Royal College of Physicians and Surgeons of Glasgow (RCPSG). The National Travel Health Network and Centre (NaTHNaC) has mandated standards of training and practice in the administration of Yellow Fever Vaccine at centres across England, Wales and Northern Ireland. Health Protection Scotland has similar authority for centres in Scotland.

Training has traditionally been supported by the appropriate medical Royal College. In line with this the FTM aims to support education and professional development in travel health and strives for improvement in the quality of care provided by its practitioners.

This document defines a set of recommendations from the Faculty of Travel Medicine for the practice of travel medicine in the UK. Their objective is to help raise standards of practice and achieve greater uniformity in provision of services, in line with generally agreed criteria. As travel medicine moves towards applying for speciality status, these standards will help in the production of a draft training syllabus. With that in mind, they have been mapped to the curriculum for the MFTM examination of the RCPSG (available via the College web site http://www.rcpsg.ac.uk/) which was itself mapped against the General Medical Council's publication Good Medical Practice. The MFTM examination is designed for those health professionals aspiring to the standard of an independent practitioner in travel health. It is recognised that certain sections of this document include specialised recommendations which may be outside the expertise of many general travel health practitioners. In those situations the recommendations relate to the advice a traveller should receive from the appropriate specialist, to whom referral may be made. Nurses undertaking general travel health practice should follow the RCN Guidelines.

The Infectious Diseases Society of America has published its own set of guidelines which should be consulted by those practising in North America.

Section snippets

Statutory regulations and/or information sources relevant to all sections

In the UK, the principal resource for travel health professionals is the “Yellow Book” Health Information for Overseas Travel, Prevention of illness in Travellers from the UK. National Travel Health Network and Centre, London UK 2010.

https://connect3.communisis.com/NHS/Public/Catalogue.aspx

Other important resources (listed alphabetically) are:

Standards of practice

Provision of a travel medicine service to include:

  • Infrastructure: buildings, consulting rooms, information technology, suitable storage and medical equipment

  • Health and Safety

  • Staffing/time

  • Professional registration

  • Protocols and Patient Group Directions/Patient Specific Directions

  • Continuous Professional Development (CPD) for all staff in travel health

  • Record keeping including risk assessment forms, advice leaflets etc.

  • Accounts

Measurable outcomes

  • Provision of a service meeting general professional standards laid down

Standards of practice

  • Applies working knowledge of world geography to permit recognition of travellers' destinations

  • Understands the effects of geographical location on the safety of travel including: altitude; weather/seasons; desert; flood risk; tsunami risk etc

  • Understands the effects of geography on population distribution

  • Understands the effects of geography on disease distribution, e.g. vector distribution.

Measurable outcomes

  • Uses an up-to-date atlas or online maps to identify relevant geographical areas and global destinations

  • Uses

Standards of practice

  • Knows how to undertake risk assessment effectively

  • Performs a comprehensive risk assessment

  • Interprets the risk assessment and applies critical analysis to manage the risk by accessing the latest recommendations for travel health advice, immunisations required and malaria chemoprophylaxis appropriate to the risk assessment for the journey

  • Identifies those with special risks to enable tailored risk management advice

  • Recognises own limitations in relation to complex travel health issues

  • Supports and

Standards of practice

  • Provides advice to the individual traveller reflecting their particular needs

  • Communicates information effectively to explain:

    • The risk of non-vaccine preventable infections e.g. Chikungunya, schistosomiasis, many sexually-transmitted infections

    • Other travel-related risks e.g. accidents, personal safety and security

    • The risk of vaccine preventable infections

    • Vaccine recommendations and malaria prevention advice appropriate to the risk assessment

    • General risk management advice relevant for all

Standards of practice

  • Understands the issues of informed consent in relation to travel health and acts accordingly

  • Understands Gillick competence in UK law for those under 16 years of age.

Measurable outcomes

  • Obtains and documents valid informed consent for the procedures involved in the travel health consultation.

Practitioner knowledge, understanding and skills

  • Understands the issues of informed consent in relation to travel health.

  • Understands the issues relating to minors and adults who do not have competence to consent.

Attitudes and behaviours

  • As for Section 1

Statutory regulations and information sources relevant to this section see second page and in addition:

  • British Medical Association – Consent tool kit

Standards of practice

  • Demonstrates ability to order, store and handle vaccines to prevent wastage and keep vaccines in optimum condition prior to administration

  • Balances the risks and potential benefits of immunisation in the context of risk of exposure to vaccine preventable disease at destination/s

  • Demonstrates knowledge of the vaccine preventable diseases and the vaccines used to prevent them

  • Schedules vaccinations in an appropriate way

  • Checks if childhood immunisation schedules are up-to-date according to the

Standards of practice

  • Demonstrates education of the traveller regarding accident risks whilst abroad

  • Demonstrates identification of key risks associated with roads, water, sports and accommodation

  • Provides appropriate advice to the traveller on the effect of alcohol and drugs on accident risks

  • Provides appropriate advice on adequate insurance cover and advises regarding potential invalidation of insurance cover depending on behaviour/activity.

Measurable outcomes

  • The traveller's documentation shows that the above-mentioned Standards of

Standards of practice

  • Explains the nature of the organisms which cause gastrointestinal infections

  • Explains the route of transmission of gastrointestinal infections

  • Explains the principles of food, water and personal hygiene measures

  • Explains the methods available for water purification

  • Advises the use of vaccines where appropriate for the prevention of gastrointestinal infection, whilst emphasising that most such infections are not currently vaccine preventable

  • Advises on the use of antibiotic or other prophylaxis for

Standards of practice

  • Demonstrates understanding of malaria and its transmission

  • Demonstrates understanding of the geographic distribution and degrees of malaria risk

  • Demonstrates understanding of the methods for personal protection and malaria chemoprophylaxis

  • Demonstrates ability to undertake a risk-benefit assessment for malaria prevention measures

  • Advises the traveller on the effective use and safety of antimalarial prevention measures.

Measurable outcomes

  • Record that a risk-benefit assessment has been performed and advice communicated

Standards of practice

  • Demonstrates awareness of biting patterns of the vectors of arthropod-borne infections

  • Demonstrates awareness of barrier methods to protect against arthropod bites

  • Demonstrates awareness of available insect repellents, their duration of action, side effects and contraindications

  • Demonstrates awareness of available insecticides for use in dwellings, on clothing and on bed nets.

Measurable outcomes

  • The traveller's documentation clearly articulates the advice the individual is given is appropriate and specific to the

Standards of practice

  • Demonstrates ability to assess different skin types

  • Demonstrates ability to advise travellers on the recognition, treatment and prevention of sunburn and heatstroke

  • Demonstrates ability to recognise skin lesions suspicious of melanoma or other skin cancers and refer for further assessment.

Measurable outcomes

  • Documented evidence that the consultation adequately covers the competencies listed

  • Traveller satisfaction surveys.

Practitioner knowledge, understanding and skills

  • Knowledge of the effect of ultra violet (UV) light exposure on the skin

  • Understands the use of sun

Standards of practice

  • Demonstrates ability to advise the traveller on potential risks when they plan to swim, snorkel or scuba dive

  • Demonstrates understanding of the effects of water immersion on human physiology

  • Demonstrates understanding of the mechanisms of fresh water and salt water drowning

  • Demonstrates understanding of the risk factors for the development of cramp whilst swimming

  • Demonstrates ability to explain the safety aspects of the act of diving into water

  • Demonstrates ablilty to perform a medical assessment

Civilian

  • Demonstrates awareness of those conditions which contraindicate flying or can be made worse by flying, and an ability to take a relevant medical history

  • Demonstrates ability to advise patients with medical, psychiatric or other conditions on the advisability of flying and what actions can be taken to make flying possible and safe, including carriage of personal medications in hand luggage where relevant

  • Demonstrates familiarity with fear of flying and other psychological issues

  • Demonstrates an

Standards of practice

  • Demonstrates ability to recognise those who have risk factors for the development of mental illness

  • Demonstrates ability to take a psychiatric history

  • Demonstrates ability to recognise psychiatric illness in different cultural groups

  • Demonstrates ability to advise on specific issues such as fear of flying, the effects of environment, culture shock and language barrier and how these may impact on adult and child travellers

  • Demonstrates the ability to recognise psychological issues related to recent

Standards of practice

  • Adheres to appropriate national vaccination schedules

  • Identifies additional vaccine requirements

  • Advises on child-specific issues relating to malaria prevention

  • Understands the non specific features of malaria and the speed with which death may occur in young children with malaria

  • Pays special attention to prevention of diarrhoea and other faecal-oral diseases, dehydration and heatstroke

  • Advises on personal hygiene issues, especially for infants

  • Advises on personal security especially prevention of

Standards of practice

  • Advises on safety and security issues especially for women travelling alone

  • Advises on cultural and local custom awareness eg appropriate clothing

  • Advises on management of menstruation

  • Advises on management of contraception especially for long term travel and access to a continued supply of contraceptives.

  • Advises on vaccination and malaria chemoprophylaxis in relation to contraception, pregnancy and breast feeding

  • Advises on HIV, blood-borne viruses and sexually-transmitted infections (STIs) and

Standards of practice

  • Takes a full medical, social and drug history

  • Determines the relevance of pre-existing health problems to the traveller's itinerary/destination and tailors risk assessment and risk management advice accordingly

  • Considers the potential influence of malaria chemoprophylaxis, other drugs or vaccines on the traveller's underlying medical condition

  • Explains how treatment schedules for underlying conditions may need to be modified or monitored during travel and whilst in the country of destination

Standards of practice

  • Demonstrates awareness of special risks to VFRs (as compared with tourists) e.g. accommodation; activities; contact with local population and gives pre-travel advice accordingly

  • Demonstrates awareness of VFRs' perception of the need for pre-travel advice and potentially different economics of travel

  • Demonstrates awareness of the additional risk to second and third generation VFRs (health, culture shock)

  • Demonstrates awareness of communication issues and language barriers

  • Demonstrates awareness of

Standards of practice

  • Demonstrates ability to work with interpreters and patient support groups

  • Demonstrates understanding of problems of access to health services

  • Demonstrates understanding of psychiatric/psychological issues

  • Demonstrates understanding of post traumatic stress disorder

  • Demonstrates understanding of health issues relating to poverty

  • Demonstrates understanding of cultural differences between migrant groups

  • Demonstrates awareness of different healthcare experience in home country e.g. immunisation schedules

Standards of practice

Pre-travel

  • Conducts a risk assessment and provides advice specific to the long term traveller with special reference to duration and type of exposure

  • Demonstrates ability to assess psychological profile and previous psychiatric history

  • Demonstrates ability to perform a risk assessment for the development of psychiatric/psychological illness

  • Demonstrates ability to advise on the principles of access to medical care in the host country

  • Demonstrates ability to advise on availability of regular

Standards of practice

  • Demonstrates ability to determine the underlying condition for which treatment is being sought

  • Demonstrates ability to assess the effects of the condition on fitness to travel (mobility; the need for treatment or medical support during the journey) for both pre-and post procedure travel

  • Demonstrates ability to assess the possible effects of travel on the underlying condition

  • Assesses the travel health needs of the medical tourist, including malaria chemoprophylaxis and necessary vaccinations

Standards of practice

  • Demonstrates ability to assess fitness for cruise travel

  • Pre-travel demonstrates ability to identify specific risks such as history of claustrophobia; propensity to sea sickness; the elderly; lack of mobility (risk of accidents); chronic medical conditions; recent infectious illness

  • Demonstrates ability to provide advice on how to minimise cruise-related risks.

Measurable outcomes

  • The traveller's documentation shows that the above-mentioned Standards of Practice have been followed and clearly records the advice the

Standards of practice

Pre expedition

  • Provides advice to expedition leaders, members and expedition medical staff about precautions required prior to an expedition departure, including psychological profile and physical fitness

  • Advises on malaria prevention and vaccination recommendations and requirements specific to the trip

  • Advises on special requirements for very remote travel eg elective appendicectomy, drugs and equipment required for medical support to an expedition

  • Advises on the need for first aid training for

Standards of practice

Cold

  • Demonstrates ability to advise the traveller who will be exposed to extreme cold and potentially extremely remote locations

  • Demonstrates ability to understand the effects of exposure to cold on human physiology

  • Demonstrates ability to understand wind chill factor

  • Demonstrates ability to understand the principles of prevention of heat loss

  • Demonstrates ability to advise the traveller on nutritional and fluid requirements for those exposed to cold environments

  • Demonstrates ability to advise the

Standards of practice

  • Demonstrates ability to advise the traveller intending to travel to a high altitude destination

  • Demonstrates awareness of the effects of living at high altitude on human physiology – acute and chronic

  • Demonstrates awareness of the symptoms and signs, prevention and acute management of acute mountain sickness; high altitude pulmonary oedema; and high altitude cerebral oedema

  • Demonstrates familiarity with the correct use of a portable hyperbaric chamber

  • Demonstrates ability to advise the traveller on

Standards of practice

Demonstrates an understanding of the advantages and disadvantages of tourism including:

  • Economic growth

  • Risk of over dependence on tourism

  • Risk of local inflation

  • Social unrest due to tensions between tourists and the local population

  • Exploitation, including sex tourism

  • Environmental issues – over-development, destruction of wildlife habitats, pollution.

Measurable outcomes

  • Records reflect discussion of responsible tourism issues throughout the consultation and provision of links to information sources to enable the

Section 27|The returned traveller

As well as physical ill-health, psychological ill-health is common, including bereavement responses to the loss of place, depression, and Post Traumatic Stress Disorder, particularly in long term travellers.

It is recognised that many travel medicine practitioners concentrate on providing pre-travel services and may have little exposure to illness in the returning traveller, whereas others may devote most of their time to the practice of infectious and/or tropical diseases, of which the

GP

  • Demonstrates ability to suspect malaria in an unwell returned traveller and arrange an urgent malaria test or immediate admission to hospital if appropriate

  • Demonstrates an awareness of the potential implications of recent travel when assessing an ill patient

  • Demonstrates ability to undertake basic syndromic assessment of the unwell returned traveller, eg fever; diarrhoea; skin disease; respiratory symptoms

  • Demonstrates ability to identify psychological ill-health and arrange for appropriate

Section 28|Research methods, critical analysis and presentations

This section is directed primarily at the specialist travel health practitioner.

Standards of practice

  • Assists in the collation and development of audit in travel health clinical practice

  • Uses expert knowledge to inform protocol development in relation to travel health and guides others in this process

  • Audits travel health documentation to ensure appropriate standards and guidance are maintained.

Measurable outcomes

  • Documented evidence of undertaking clinical audit in travel health practice and acting on findings to develop and improve standards of care

  • Current up-to-date protocols for safe effective travel healthcare

Section 30|Teaching

This section is specifically for those who undertake teaching in travel medicine.

Standards of practice

  • Ensures that travel health knowledge is always up-to-date

  • Evaluates own travel healthcare practices against accepted standards and guidance

  • Ensures that any relevant guidelines on CPD/revalidation (e.g. Faculty of Travel Medicine, General Medical Council) are adhered to.

Measurable outcomes

  • Uses recognised online databases on a frequent and regular basis to ensure the latest national recommendations are always followed

  • Reads appropriate travel medicine journals

  • Reads update information to ensure awareness of issues

Conflict of interest

None.

Dedication

These recommendations are dedicated to the memory of Dr Darryl Robert DipTravMed RCPS(Glasg).

Acknowledgements

The Faculty is pleased to acknowledge and thank the following organisations for their comments on the draft document. The Faculty of Travel Medicine remains responsible for the content.

Academic Unit of Travel Medicine and Vaccines, Royal Free and University College Medical School.

British Global and Travel Health Association.

Department of Health.

Health Protection Scotland Travel Unit.

Liverpool School of Tropical Medicine.

Medical Advisory Service for Travellers Abroad.

National Travel Health

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