Rationale

Australians are keen travellers. In 2014–15, 9.2 million Australian residents departed Australia for short-term travel. The most popular destinations were New Zealand, Indonesia, the US and the United Kingdom. Thailand, China, Fiji and India were also included in the top 10 destination countries during this time period.1

Travel-related consultations are common in general practice. For registrars, these occur at an estimated rate of 1.6 per 100 encounters.2 Unfortunately, evidence suggests that the majority of individuals travelling overseas do not access medical advice before travelling. A 2013 study demonstrated that 20.2% of general practice patients had travelled abroad in the previous two years, and that 60.7% had visited at least one ‘at risk’ country, with the most common risks being hepatitis B, typhoid, hepatitis A, rabies, malaria and yellow fever. Of these individuals, 52.3% had not sought any medical advice, while 39.7% had sought advice from a general practitioner (GP).3

GPs are well placed to provide opportunistic advice to individuals who present for other issues and who are travelling overseas in the near future, and to individuals who present specifically requesting travel advice. The holistic continuity of care GPs provide for families can enable an easy route to accessing family members who may not present routinely for pre-travel vaccinations and advice. The capacity to provide quality pre-travel advice, as well as high-quality care when an individual arrives home unwell, relies on a good foundation in the core skills of general practice.

The provision of effective pre-travel advice involves good communication skills, a patient-centred approach that acknowledges the health beliefs of the individual, and a solid understanding of disease epidemiology, principles of transmission and preventive measures for a variety of diseases endemic in a variety of destinations. Important issues to cover in pre-travel consultations may include the following.4

  • Prevention of communicable diseases through vaccination, using evidence-based best practice guidelines.  This involves having a solid understanding of vaccination requirements. For example, it requires an understanding of all travellers and individuals who are particularly at risk of exposure, such as those who may be working while overseas in health or with animals (eg with potential risks of exposure to blood-borne viruses or rabies), and an understanding of relevant processes (eg rapid catch-up regimes for hepatitis B to ensure that immunity is attained prior to travel). An understanding of allergies, prior vaccination history and pre-existing conditions that may impact ability to be vaccinated are also important.
  • Identification of individuals who may be particularly at risk, such as infants and young children, pregnant women and individuals with pre-existing conditions who may be immune-compromised, and individuals who are travelling for extended periods, particularly in rural and remote areas with poor resources. This group includes people who are visiting friends or relatives and who are thought to be particularly at risk because they are more ikely to have close contact with the local population, consume high-risk foods and beverages, less likely to perceive health risks associated with travelling, and less likely to seek out pre-travel advice.5
  • Avoiding vector-borne diseases (particularly those carried by mosquitoes in areas where there is the risk of transmission of diseases such as malaria, dengue and Zika virus) through provision of advice about avoiding bites with the use of repellents, and other measures such as use of appropriate malarial chemoprophylaxis.
  • Discussion about minimising impacts of potential environmental risks, such as the need to practice hygiene measures including hand washing, potentially using water filtration/iodine tablets and avoiding high-risk foods to minimise risk of traveller’s diarrhoea (TD). Note that TD is very common, affecting 20–50% of international travellers.6 Provide advice also on avoiding walking barefoot or bathing in fresh water in countries where parasitic infections may be endemic.
  • Advice on avoidance of high-risk activities, such as unprotected sex and road safety  recommendations.
  • Advice on preventing altitude sickness, jet lag and/or motion sickness, with provision of prescriptions for medication if indicated.
  • Provision of medication to assist in self-treatment for conditions that may arise while overseas such as  urinary tract infections, vaginal candida infections and malaria, and strategies for management of TD (including rehydration salts and advice as to which symptoms require antibiotic medication) if travelling to high-risk countries.
  • Avoidance of deep vein thrombosis (DVT), and prophylactic treatment for individuals at risk of thrombosis.
  • Understanding potential impacts on travel plans from pre-existing conditions and medications prescribed, including provision of support with development of health action plans in case of deterioration in condition or other issues arising while an individual is travelling. This includes provision of medication for self-treatment (as outlined above), safe transport of medications requiring refrigeration, and a need to carry medication in hand luggage, possibly with certification that it has been prescribed for a health condition.
  • Provision of advice on potential risks and how to minimise these if purpose of travel is medical tourism.
  • Provision of care when travellers return, particularly for those markedly at risk because they did not seek or accept advice prior to travel. This is to identify and manage communicable diseases, especially awareness of exotic tropical infections that may have been contracted overseas.

References

  1. Australian Bureau of Statistics. Overseas arrivals and departures, Australia, June 2015. ABS cat. no. 3401.0. Canberra: ABS, 2015. [Accessed 7 April 2016].
  2. Morgan S, Henderson KM, Tapley A, et al. Travel medicine encounters of Australian general practice trainees – A cross-sectional study. J Travel Med 2015;22(6):375–82.
  3. Family Medicine Research Centre. University of Sydney. Travel vaccination and prophylaxis in general practice patients – 2013. SAND abstract number 215 from the BEACH program 2013–14. Sydney: FMRC, University of Sydney, 2014. [Accessed 7 April 2016].
  4. Chen LH, Hochberg NS, Magill AJ. The pre-travel consultation. Atlanta, GA: Centers for Disease Control and Prevention, 2015. [Accessed  7  April 2016].
  5. Department of Health. The Australian immunisation handbook. 10th edn. Canberra: DOH, 2015. [Accessed 7 April 2016].
  6. Leder K. Advising travellers about management of travellers’ diarrhoea. Aust Fam Physician 2015;44(1–2):34–37.

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