Travel health update
This month’s big news is the publication of updated malaria prevention guidance, which all nurses offering travel health services should familiarise themselves with. Plus news that fake rabies vaccine may be in circulation is one more good reason to consider pre-exposure prophylaxis
MALARIA UPDATE
Public Health England published new guidelines for malaria prevention in travellers from the UK (2018) at the end of last month (31 January 2019). Key changes are discussed on page 8 of the document, available at https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellers-from-the-uk but for day-to-day practice here is a summary of some of the items I think are important.
A number of changes to chemoprophylactic drugs include news that the SmPC for mefloquine has been updated and insomnia has been added to the list of psychiatric symptoms that have to be regarded as prodromal for a more serious event. The full updated list is insomnia, abnormal dreams/nightmares, acute anxiety, depression, restlessness or confusion. The malaria guidelines document that those taking mefloquine are more likely to have these symptoms during travel than those who take atovaquone-proguanil or doxycycline.
Regarding atovaquone-proguanil, an abbreviated regimen for use in travellers after leaving a malarious-endemic area is not advised. Increased information regarding use of this drug in pregnancy is described on pages 61/62. The Advisory Committee for Malaria Prevention (ACMP) does not currently advise the use of atovaquone/proguanil for antimalarial chemoprophylaxis in pregnancy due to sparse data. However, they say, if there are no other appropriate options, its use may be considered in the second and third trimesters after careful risk assessment. In these circumstances, 5mgs folic acid should be used daily.
There have been some changes to recommendations in the country table and these have been transferred to the databases NaTHNaC on TravelHealthPro and selected ones onto TRAVAX so it is important each time you risk assess a traveller you check the latest guidance online for the specific country. Clarification as to which database should be used is further explained on page 12, where it states: ’We recommend health professionals stick to using one resource for country specific malaria recommendations to optimise consistency of advice. Whilst we recognise that other sources of advice are available, healthcare professionals working in England, Wales or Northern Ireland are advised to use the ACMP guidelines as their preferred source of guidance for malaria prevention. They are also available on the NaTHNaC website, https://travelhealthpro.org.uk. Separate guidance is produced in Scotland for Scottish health professionals by the Scottish Malaria Advisory group.’
A new feature on the malaria maps is available on TravelHealthPro as some have become ‘interactive’ i.e. the maps for Bangladesh, Bolivia, Brazil, Ethiopia, India, Kenya, Pakistan, and Tanzania. Advancing technology now means the map with an overlay of Google maps enables you to zoom in on a specific destination within the malaria country map or to search a destination within the country and find the exact malaria risk. The static maps are also included at the end of the guidelines and – as a tip – are easier to print out!
SAFEGUARDING
A new intercollegiate competencies framework has been published by the RCN. This is the 4th edition of Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff. Clinical staff in primary care all have to have safeguarding training to level 3 now. I’ve written a blog about this subject in relation to travel health practice, which also explains that pharmacists would also need level 3 training if seeing child travellers in a travel clinic. The new document also references the RCN Female Genital Mutilation: RCN guidance for Travel services. See http://janechiodini.blogspot.com/2019/01/safeguarding-children-and-young-people.html for further details.
FAKE RABIES VACCINE
A Medical Product Alert published by the World Health Organization last month related to falsified Verorab® vaccines that have been identified in the Philippines. Two vaccines have discovered so far and the details, including images, have been posted at: https://www.who.int/medicines/publications/drugalerts/drug_alert-1-2019/en/. Such news is of concern especially for our travellers visiting the Philippines requiring post exposure treatment, but even more so if they have had no pre exposure prophylaxis (PrEP). Perhaps this is another compelling reason why travellers need to seriously consider having a course of PrEP if their travel assessment suggests a risk of rabies. To refresh your learning on this subject, see https://rise.articulate.com/share/EdkDXQzl66fK05sJL7mp04w6S6mun4Zw#/