Travel health update

The big news this month is that the 2017 malaria prevention guidelines have just been published, PLUS from feedback at recent conferences, it seems that what to do about rabies vaccination is far from clear – Jane Chiodini has the details

MALARIA

Public Health England (PHE) has published the long-awaited Guidelines for malaria prevention in travellers from the UK: 2017,¹ which include some significant updates.

For some time now there have been rumours of ‘the new malaria guidelines’ so the news that it has at last been made public is very welcome. Some of the changes will make it easier for us to manage delivery of the required advice to our travellers.

The key points are listed in the Executive summary, which explains that the world malaria situation has improved significantly in some regions in recent years. The World Health Organization World Malaria Report (2015) states that 88% of global malaria cases originate in the WHO African region. This pattern is also reflected in data from the Public Health Laboratory Malaria Reference Laboratory (MRL) that collects and collates all information on this notifiable disease, which show that almost all of the malaria deaths in travellers returning to the UK originate from Africa.

It is therefore vital that we engage our travellers travelling to malarious areas of Africa, impress upon them the seriousness of this parasitic infection and the need to vigorously follow the prevention advice given.

The Advisory Committee for Malaria Prevention (ACMP) undertook an in-depth review of malaria risk for travellers to Southeast Asia, South America, parts of the Caribbean and south Asia, which resulted in substantial changes to the recommendations. Many of these areas have now been judged to be below the threshold to advise chemoprophylaxis. This doesn’t mean that there is no malaria risk at all, but the risk is sufficiently low that malaria tablets are not now advised for some destinations. (The full methodology is explained in appendix 1D, pages 92-93).

However, for all malarious countries, the advice regarding awareness of risk, bite prevention and prompt diagnosis remains extremely important. In addition, the guidance explains that travellers visiting friends and relatives long term (i.e. going for 3 months or longer) run a higher risk of contracting malaria than short term travellers to the same locations. The risk of developing severe or complicated malaria in those infected is higher in certain groups such as the elderly (over 70 years), the immunosuppressed and those with complex co-morbidities, and pregnant women. This does not meant that these groups should be offered antimalarials routinely for destinations where bite avoidance only is now recommended, but antimalarials can be considered in exceptional circumstances. Of course, expert advice can also be sought in these situations from the MRL fax service, NaTHNaC and TRAVAX. The guidance states that the final decision whether or not to advise chemoprophylaxis rests with the travel health advisor and traveller after an individual risk assessment has been carried out.

Bite avoidance

Over 30 countries have had change of advice to ‘bite avoidance only’ where the previous guidance advised chemoprophylaxis. These include countries such as Brazil, Cambodia, Costa Rica, China, Dominican Republic, Ecuador, Honduras, Laos, Pakistan, Peru, Thailand and Vietnam. The full list is found on pages 39-47 of the guidance and this information is then also found on the TravelHealthPro website. To complement this change, NaTHNaC have substantially revised and re-designed their malaria maps with a new colour coding as well to reflect the different levels of risk from ‘No’ to ‘High risk’. A news item at https://travelhealthpro.org.uk/news/263/presenting-nathnac-malaria-maps-2017 explains how the maps were created and how the seasonal variation was dealt with. They have not produced maps for countries where the advice is the same for the whole country and all the maps provided show the malaria prevention advice (including chemoprophylaxis if relevant) for different areas within a country. They are based on the best available information and often follow regional boundaries, altitude limits, or river basins.

There is an important statement in the guidance (on page 8), which is that: ‘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 and Northern Ireland are advised to use the ACMP guidelines as the preferred source of guidance for malaria prevention’.

The new guidelines have had all the malaria maps from TravelHealthPro included at the back of the document and all sections can be accessed quickly by clicking on the hyperlinks in the index of the publication. The guidelines are a very important and essential document for travel health advisors and it is important for all GPs and pharmacists also to be made aware of the revised recommendations.

RABIES

I’ve recently created a page on my website for the various online resources I’ve made at http://www.janechiodini.co.uk/education/online-learning/ . The third educational module on the contents list is a new one on rabies. This includes all the relevant information you need to be aware of to manage rabies pre- and post-exposure in one unit. Made for World Rabies Day which is always held on 28 September, it provides information about the global issues for rabies (this section also has a fascinating link to the history of Louis Pasteur); details about pre-exposure protection for occupational risk as the PHE guidance for ordering vaccine in England changed in August;2 rabies and the travellers pre-exposure; details for first point of contact for a traveller and for post-exposure advice; and lastly, further rabies information resources. Remember chapter 27 of the Green Book provides guidance for rabies.³ At risk groups are divided into ‘continuous’ – laboratory workers routinely working with rabies virus; ‘frequent’ – people who handle bats, imported animals (e.g. at quarantine centres); and ‘infrequent’. Travellers fall into the infrequent risk group. Those travelling to rabies enzootic areas can be offered a primary course of three doses of vaccine, on days 0, 7 and 21-28 days, especially if post-exposure medical care and rabies biologics at the destination are lacking or in short supply, if they are undertaking higher risk activities such as cycling or running, or they are living or staying in the area for more than one month. A booster dose of vaccine can be considered at 10 years post-primary course if travelling again to a high-risk area.

YELLOW FEVER

NaTHNaC, which administers yellow fever vaccination centres in England, Wales and Northern Ireland, has just posted information about a change to policy for the reissuing of the International Certificate of Vaccination and Prophylaxis (ICVP). Where the original ICVP has genuinely been lost or misplaced, badly damaged (illegible), or is subject to name change (e.g. due to marriage, divorce, gender re-alignment and verified by appropriate documentation) and where an accurate medical record of the previous vaccination can be seen, a health professional at a Yellow Fever Vaccination Centre (YFVC) can issue a replacement ICVP and now it is acceptable to write the term of validity as ‘life of person vaccinated’. When replacing an ICVP subject to name change for whatever reason (name must match that on current passport), it is also acceptable to write ‘life of person vaccinated’. Details can be found in the reissue section at https://nathnacyfzone.org.uk/factsheet/5/international-certificate-of-vaccination-or-prophylaxis-icvp

AND FINALLY…

Congratulations from all at Practice Nurse to Jane who has just been elected as Dean Elect of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow. This is a high honour especially in a medical Royal College, and the first time a nurse has held this position. Jane becomes the Dean in October 2018.

REFERENCES

1. Public Health England. Guidelines for malaria prevention in travellers from the UK: 2017, October 2017. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/652892/Guidelines_for_malaria_prevention_in_travellers_from_the_UK_2017.pdf

2. Public Health England. Guidelines on requesting rabies pre-exposure prophylaxis, August 2017. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/637681/PHE_guidelines_on_rabies_pre-exposure_prophylaxis.pdf

3. Public Health England. Immunisation against infectious diseases. Chapter 27 – Rabies. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/85762/Green-Book-Chapter-27-v3_0.pdf