Travel health update

New guidance on prophylaxis for travellers’ diarrhoea prompted by need to tackle antimicrobial resistance, plus make sure your have indemnity cover for private travel health work as the new state-backed scheme won’t cover you

TRAVELLERS’ DIARRHOEA

The TravelHealthPro factsheet on travellers’ diarrhoea was updated in March, https://travelhealthpro.org.uk/factsheet/53/travellers-diarrhoea and upon reading, this seems to be because of change in the guidance for the use of standby antibiotic treatment adopted by NICE and Public Health England. As anti-microbial resistance (AMR) becomes an increasingly serious concern, these government bodies updated their guidance with a document entitled Summary of Antimicrobial Prescribing Guidance – Managing Common Infections from PHE in October 2018 which reviewed a number of papers on the subject and makes for interesting reading. https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care This link also leads you to another update republished in February 2019 from NICE and PHE where a table is provided setting out the guidance.

It says that for travellers’ diarrhoea, prophylaxis is rarely, if ever, indicated and to consider standby antimicrobials only for patients at high risk of severe illness or visiting high-risk areas. For this azithromycin 500mgs once daily for 1 to 3 days is advised. Ciprofloxacin is not advised at all now. For prophylaxis and treatment the NICE/PHE table advises bismuth subsalicylate (BSS), 2 tablets QDS for 2 days. In the UK the most common symptomatic treatment for TD has been antimotility agents such as loperamide. We have used bismuth subsalicylate less commonly although it has been the management of choice in the USA for some time. The NaTHNaC factsheet states ‘BSS can be recommended for mild diarrhoea and is helpful in reducing nausea. Such preparations are available over the counter for use in adults and children over 16 years of age. However, loperamide has been shown to be more effective in controlling diarrhoea and cramping and works more quickly.’ I only found one BSS product on the Electronic Medicines Compendium, a liquid preparation, but on an online search, it’s also available in chewable tablet format in many of the larger pharmacy chains.

INDEMNITY INSURANCE AND PRIVATE TRAVEL PROVISION

NHS Resolution is operating a new state-backed indemnity scheme for general practice in England called the Clinical Negligence Scheme for General Practice, which came into effect from 1 April 2019. This covers clinical negligence liability for NHS work you may carry out as a practice nurse in a GP surgery, but not for any private work. This could be important for you if you give any of the private travel vaccines (yellow fever, rabies, Japanese encephalitis, tick borne encephalitis and Men ACWY for travel puposes, but also consider hepatitis B if you charge for it).

A good travel consultation should also include malaria prevention advice and sometimes a private prescription may be required. This would also constitute private work although the GP may be issuing the prescription. Additional indemnity cover may well be needed, and medical defence organisations who would have originally not charged for the practice nurses to be added on to a package that GPs subscribed to, will now be charging because the premiums they receive will be lower due to the new government scheme. I’ve written a blog on the subject because the information is complex and to my mind not fully understood yet. Links to key resources are included so please have a look at http://janechiodini.blogspot.com/2019/03/indemnity-in-general-practice.html

YELLOW FEVER INFORMATION RESOURCES

I’ve been a fan of the NaTHNaC yellow fever information leaflet for travellers for some time but was challenged when printing it out, I couldn’t manage to print it in a leaflet format that didn’t end up upside down at some point! This publication has now been reformatted and renamed. The file name ‘flip on short edge’ gives a clue when you come to set your printer! Access at https://nathnacyfzone.org.uk/media_lib/mlib-uploads/full/nathnac-yf-information-print-duplex-flip-on-short-edge.pdf

NaTHNaC has a new poster at https://nathnacyfzone.org.uk/factsheet/67/poster-yellow-fever-vaccination-valid-for-life to remind travellers not to throw away their old certificates, explaining that one yellow fever vaccine is all that is required for most travellers and the certificate is now valid for life, even if it looks like it’s not. And the poster states ‘See your travel health advisor for further information’.