Travel health update

In a change from Jane’s usual review of what is new in travel health, this month’s update focuses on meeting the needs of the ‘complex traveller’. Read the case study, reflect on what you would advise, and then read Jane’s summary of the advice that should be offered

CASE STUDY – THE ‘INVINCIBLE’ YEARS

A 24-year-old man intends to backpack around India for 6 months; unsure of itinerary but travelling in rural areas; on a tight financial budget. He has epilepsy controlled on carbamazepine, history of severe depression but not currently on medication. He used to have a drug addition but is now clean; he is HIV-positive, asymptomatic with a CD4 count of 500. He leaves in 2 weeks’ time.

Travel vaccine history

• All national programme vaccines including MMR x 2
• Course of Twinrix on 0, 1 and 6 month schedule in 2009
• Typhoid 2009
• Rabies course completed 2009
• Revaxis at school in January 2006

KEY POINTS

On first reading, the information can seem overwhelming, but breaking it down into bite sized pieces will help. This traveller has the following issues: concern over general health due to HIV status; potential HIV restrictions at destination; mental health issues which could be exacerbated when away; long term travel with some vaccine requirements; malaria prevention needed at the destination and chemoprophylaxis issues in relation to health status. Within the time restraints it would be impossible to advise him on all aspects of care and some he could research himself by providing links to online resources, for example, Fit For Travel, NaTHNaC and useful social media sites, such as the Foreign & Commonwealth Office (FCO).

HIV status and vaccines required He is well and with his current CD4 count has limited immune deficits so he could receive vaccines required according to Green Book guidance and travel risk assessment. These would include a booster dose of hepatitis B, a typhoid vaccine, a Revaxis booster slightly early as he will be away when the 10 year protection expires, and recommendation for a course of Japanese encephalitis vaccine, given on the new 0 and 7 day schedule. Cholera could also be considered. TRAVAX provides a good chart for vaccination in HIV infection. The Global Database on HIV-specific travel and residential restrictions reveals there are no restrictions for travel to India. Taking sufficient HIV medication is essential and aspects of this care may require referral back to his HIV specialist. It would not be expected that the practice nurse would have the competence to address all care related to HIV in this situation.

Malaria It depends where he is going: chemoprophylaxis is not now recommended in general for much of India. However, if he were to get malaria, the illness could make him more vulnerable and/or his HIV status could deteriorate, so it may be sensible in this situation for him to take something during the trip. The UK Malaria guidelines state doxycycline is the simplest chemoprophylaxis against malaria for most people on antiretrovirals. However, information in this area is accumulating rapidly and the travel health adviser should check the manufacturer’s SPC and the BNF on an individual agent basis and discuss the options for chemoprophylaxis with the traveller’s own HIV physician who should make the decision on choice of agent. Regarding his epilepsy and the fact he is taking carbamazepine which can reduce the half-life of doxycycline, the UK malaria guidance would advise increasing the dose to 100mgs twice a day.

Mental health An excellent FCO publication, published last month, states Lack of familiar support systems, disrupted daily routines, language barriers, culture shock and unexpected situations can intensify stress levels rather than alleviate them. This booklet provides a checklist for planning prior to travel, tips on provision of medication while away, obtaining drugs in different countries, and consideration of deterioration of mental health while away.

Safety Road traffic accidents are the most frequent cause of death in people aged 15-29 and injuries can also occur in activities people take part in abroad such as adventure sports. A report by the FCO found that fewer than half (45%) of young Brits surveyed checked that their insurance covers risky pursuits despite 4 out of 5 (82%) admitting to taking part in more adventurous behaviours when on holiday. Raising awareness of risk and stressing the importance of taking out good travel insurance, including repatriation, is key. The FCO Know Before You Go campaign provides excellent information.

While this is only a quick review, it raises important points to be considered and provides information to undertake more research. Resources to help with this case study can be found at http://www.janechiodini.co.uk/education/conference/bpin