Travel medicine

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Prior to 2020, international travel to and from Australia had become increasingly accessible and was occurring at higher rates than ever before.1 While international travel decreased because of the global COVID-19 pandemic, it demonstrated the interconnectedness of the world in terms of the spread of infectious disease as well as highlighting international differences in healthcare access and quality. The general practice consultation is the primary environment to discuss prevention strategies for risks associated with travel, either as part of a specific pre-travel consultation or opportunistically, recognising that many individuals will not seek specific health advice prior to travel.2 General practice is also where many individuals will present with symptoms that have developed during or soon after travel and a careful assessment of these presentations is essential from an individual and public health perspective.

Travel-related risks are not limited to infectious diseases nor to international travel, and it is important that the general practitioner (GP) be able to discuss other potential risks such as altitude and climate extremes, accidents and personal safety, as well as individual risks related to age, pregnancy or underlying health conditions. Many of these risks exist for travel within Australia and there are numerous infectious diseases where epidemiology and risk differ between states and regions. Access to healthcare including screening, treatment and vaccination services may also be more challenging for those residing or travelling through regional, rural and remote Australia.3 Aboriginal and Torres Strait Islander peoples face additional challenges travelling both within Australia and internationally where they may be required to navigate unfamiliar health systems as well as language and cultural differences at their destination.4 Some types of international travel provide increased risks such as medical tourism where travel is undertaken for the purpose of undergoing a medical procedure.5 Another risk is travel to visit friends and relatives where individuals are less likely to seek pre-travel advice and often undertake more high-risk behaviours related to food and water safety or insect bite prevention.6 It is a key skill to be able to discuss travel-related behaviours in a culturally sensitive manner as health beliefs and travel risk prevention behaviours are strongly influenced by past experiences and cultural practice.

Prevention or modification of risk for travellers involves the GP being able to discuss individual risk and costs associated with risk management strategies including routine and targeted vaccinations, insect bite prevention, malaria prophylaxis, and other treatment strategies for common illnesses. It is also important to be aware of any potential challenges that may prevent rapid access to healthcare services and the limitations of travel insurance cover. The management of chronic conditions may be more challenging in the context of travel, and discussion of ways to modify this risk is an important part of the pre-travel consultation.

Over recent years the emergence of the Zika virus and the COVID-19 pandemic has shown the need for GPs to be aware of new and emerging challenges facing travellers. While new diseases and antimicrobial resistance have become challenges, this has occurred simultaneous to the development of new vaccinations, treatments and evidence-based prevention strategies for other travel-related conditions. Travellers will continue to face issues including dilemmas regarding health equity and ethical tourism, alongside their own individual risk. Travel and travel medicine continues to be a complex and evolving topic in general practice.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • discuss prevention and treatment strategies for common travel-related illnesses including vaccination and chemoprophylaxis
1.2.2
  • discuss in a respectful manner how the patient’s personal sociocultural context and beliefs may impact their access to treatment in some destinations
1.3.1
  • develop a healthcare plan with patients, their family or carers for the management of chronic conditions or disability during travel and assist patients in maintaining a shared healthcare summary
1.4.1, 1.4.3, RH1.4.1, AH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • conduct a comprehensive pre-travel history and assessment of common travel-related risks and provide tailored pre-travel health advice based on this risk assessment
2.1.1
  • manage post-travel presentations such as gastrointestinal and febrile illness, rashes and respiratory presentations
2.1.3, 2.1.4, 2.1.6
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • assess risk of post-travel illness through screening for conditions including malaria, tuberculosis and other endemic, epidemic and pandemic infections and consider potential isolation or quarantine requirements
3.1.1, 3.1.3
  • advocate for access to appropriate medicine and healthcare in rural, regional and remote communities
3.2.4, RH3.2.1
  • identify issues regarding access to, or supply of, medicines in rural and remote areas and discuss with patients the means of overcoming these
3.2.4, AH3.2.1, AH3.2.2, RH3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • discuss ethical and social challenges related to international healthcare access and travel-related illness
4.1.1
 
  • establish strategies to remain up to date with epidemiological knowledge of travel destinations and emerging travel health challenges
4.2.1, 4.4.1
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • consider international and legal requirements for vaccination and documentation of health conditions
5.2.3
  • identify eligibility to free vaccines, for example, hepatitis A catch-up and influenza, as appropriate for Aboriginal and Torres Strait Islander patients
AH5.2.1

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Travel advice shouldn't be approached as a checklist. You should tailor it to the individual and their risks. Building rapport at the start of the consultation and showing an interest in the planned travel will give you a better idea about the potential risks and help you provide advice tailored to the individual traveller.
  2. Never make assumptions about the type of travel or activities that may be undertaken based on what people do in their usual environment.
  3. Always talk about travel insurance and what it does and doesn't cover. Pregnancy and pre-existing conditions are essential to declare.
  4. Travel-related risks exist even in domestic travel. It is still important to discuss travel and travel-related risks to destinations in Australia, particularly for trips of longer duration, those to more remote destinations, or for individuals with pre-existing medical conditions.
  5. Lots of people won't make a specific appointment for a travel consultation. Encourage them to book a long appointment, where possible, and use practice systems to help patients indicate that they are attending for a travel health consultation. However, you might only learn about their travel incidentally at a consultation for another reason, and they may be leaving too soon to book in again. Be prepared to rapidly prioritise travel health strategies in the available consultation time and give patients resources that they can look at afterwards.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Travel medicine

Harry is a single 24-year-old male who is travelling to India to volunteer for three months. He is leaving in one month and presents to discuss vaccinations and malaria advice. He thinks he had all his scheduled childhood vaccinations but doesn't have any documentation. On his way to India, he's planning on spending a week in Bali.

Questions for you to consider Clinical exam assessment area Domains

How could you sensitively ask about and discuss risk-taking behaviours, such as taking drugs and activities that could lead to sexually transmissible infections?

How would you ask about these issues if the patient was visiting Australia from overseas and became unwell? What language and cultural contexts might you need to consider?

Many travel consultations are long. How could you prioritise the discussion if the patient was not able to return for further consultations?

  1. Communication and consultation skills
1,2,5

What do you need to know about Harry’s planned activities, modes of travel and specific itinerary to determine any required prevention strategies?

What past medical history or family history is essential to discuss in a travel consultation?

What different travel health issues might you need to consider if this consultation was with a 24-year-old female?

  1. Clinical information gathering and interpretation
2

What resources or guidelines would you use to determine recommended prevention strategies for the specific destinations?

How would your advice differ if Harry was going to Bali or on a driving and camping holiday to Cape York?

What diagnoses would you need to consider if your patient was febrile or had diarrhoea on return from travel?

  1. Making a diagnosis, decision making and reasoning
2

How would your management change if Harry were leaving in one or two weeks?

How would your advice differ if the patient was taking immunosuppressive medication, had type 1 diabetes or was pregnant?

What extra advice would you give if Harry were returning home to India to stay with family?

  1. Clinical management and therapeutic reasoning
2

How would you prioritise vaccinations if Harry had a limited budget?

What are some challenges for Aboriginal and Torres Strait Islander patients when seeking healthcare whilst travelling internationally? What about when travelling domestically?

What advice could you give to reduce the risk of road traffic-related injuries during travel?

  1. Preventive and population health
1,2,3

Think about situations that may come up during a travel consultation where your values may not align with the patient's; for example, in accepting the risk associated with some behaviours. How would you respond in that situation?

How might a traveller put a community they are visiting at risk; for example, bringing an infection into a remote community?

What barriers to timely vaccination might there be for people living in rural and remote communities? How can you help patients access the care they need?

  1. Professionalism
4

How can you find out what vaccinations a patient has had previously?

How will you record the vaccinations provided in this consultation?

What vaccinations require mandatory documentation or certification for travel?

  1. General practice systems and regulatory requirements
5

How do you plan your set-up for vaccinations to minimise the risk of vaccine errors?

What do you need to consider when getting consent from a patient for a vaccination?

How would you monitor for, manage and report any adverse events following vaccination?

  1. Procedural skills
2

What advice could you give if Harry has not planned his full itinerary or doesn’t know what activities he will do?

  1. Managing uncertainty
2

What advice would you give about how to manage illness during travel and the symptoms that should make the patient get a healthcare assessment?

For how long after travel do you need to consider serious travel-related illnesses in your differential diagnoses (eg malaria, dengue, bacterial diarrhoea)?

What other factors do you need to consider in a patient with significant chronic illness who wants to travel? Who could you consult to determine if a patient is fit to travel?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify resources to help you keep up to date with outbreaks or new travel-related risks.

  • Do these match the ones listed in the learning resources section below? Are they appropriate for Australian travellers?

From your current knowledge, identify travel risks for Southeast Asia, South Pacific/Oceania region, Africa and altitude destinations. Check these risks with the resources you identified above.

  • What did you forget? How could you find this information quickly next time you need it?

Find out about the dose schedules for vaccine-preventable travel-related conditions.

  • Which dose schedules or recommended vaccinations differ for different age groups, in pregnancy and for Aboriginal and Torres Strait Islander peoples?
  • How can you find out what vaccinations people have had previously?

Identify what you find challenging about managing travel health and review webinars or travel textbook chapters on the topic/s.

  • How will this new information change the way you manage travel presentations?
With a supervisor

Review your clinic processes for travel vaccination, including recording data and entering recalls, and discuss with your supervisor any non-rebatable costs for the patient. Are all vaccinations available in the practice? If not, where would you access them?

  • Do you have any questions about this process? Have you used this process with a patient yet? Did you identify any difficult parts?

Do some case reviews of travel consultations. Review the cases against the recommended vaccination guidance for the location.

  • Why might clinical management differ? For example, cost or time before travel.

Present the management of common post-travel illnesses to your supervisor or to medical students in the practice. Discuss how to access required investigations or referrals.

  • What feedback did you get? What did you learn in the process?

Discuss what you might include or prescribe for use in a travel medical kit and how this might differ depending on the specific travel health risks related to the individual, the destination, and the planned activities. How would you discuss with patients the use of any prescribed medications? Check your list against recommended first aid kit lists from the suggested travel medicine resources.

  • What did you learn? What can you incorporate into your next consultation?
In a small group

Role-play how you might sensitively explore travel risks with a patient. Consider scenarios with communication challenges, such as discussion of sexual or drug-related risk behaviours or exploring risks in a cultural context. Give feedback to your colleagues about the strategies they used and any communication challenges.

  • As a group, discuss the approaches used. What are some strategies to talk about travel risks in a sensitive way?

Discuss how the location of a practice can impact access to travel healthcare. Consider rural and remote areas and the difference there may be in getting access to timely vaccination or healthcare for the returned traveller who is unwell. Aboriginal and Torres Strait Islander travellers may face additional barriers to getting healthcare when they are away from their own home and community. Brainstorm ways to improve healthcare equity and access.

  • What did you come up with? Can you put these ideas into practice?

Discuss a case that is challenging because of patient or destination factors. Discuss situations where things were handled differently from what is recommended, and how you could approach these situations. Discuss why patients may refuse preventive treatment or prophylaxis. Discuss the recommended management approach and times where that was different, and why.

  • What advice could you use or what support could you seek if you were faced with a similar situation in practice?
  • What are the legal requirements in this situation?

Discuss any possible legal requirements when taking medicines overseas.

  • What is your role as the prescriber?
  • Set up a travel medication letter template in your medical software that includes information that might be required and check that it includes all the necessary information.
With a friend or family member

With a friend, discuss travel destinations they have visited and what activities they did and any risks that they were aware of. Did they have travel insurance? How did they make that choice? Ask about what healthcare was available, especially if they were unwell or injured while away, and any differences from the Australian healthcare system. Ask about what access they had to health advice and vaccination before they travelled.

  • How does knowing about the type of travel and planned activities influence the way you could give advice to a patient before travel?

Discuss a dream holiday destination and consider how you would plan to make your trip a safe one. Talk about any costs you might expect as part of your preparation for a healthy trip and what the costs are.

  • If the budget was limited, which costs would you prioritise?

Practise discussing food and water safety or insect-bite prevention and explain the risks and relevant illnesses using non-medical language.

  • What prevention strategies did you find the most difficult to explain in non-medical language?
  • Review how these prevention strategies are explained in patient resources. What changes could you make to your explanation?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Provide travel advice tailored to the individual, the destination and the planned activities.
  • Discuss general travel health education and prevention including:
    • prevention ofinfectious diseases: 
      • the need for routine, catch-up and destination-specific vaccinations
      • prevention of blood-borne andsexually transmissible infections 
      • insect bite prevention
      • food and water hygiene
      • personal hygiene
    • management of pre-existing conditions whilst travelling
    • prevention of non-infectious illness and injury:
      • deep vein thrombosis prevention
      • jet lag management advice
      • advice about minimising risk, such as road traffic accidents or avoiding high-risk activities, such as extreme sports
      • advice about personal safety.
  • Provide destination-specific information and advice to reduce the risk of injury, illness or infection including from:
    • current outbreaks
    • risks to personal safety; for example,due to crime, war or political instability 
    • altitude-related illness
    • ingestion of contaminated food or beverages:
      • hepatitis A
      • traveller's diarrhoea
      • typhoid
      • cholera
    • insect-borne (particularly mosquito-borne) infections:
      • malaria (including risk minimisation and prophylactic medication)
      • dengue
      • Japanese encephalitis
      • tick-borne encephalitis
      • yellow fever
      • leptospirosis
      • Zika virus
      • chikungunya virus
    • aerosol and/or droplet transmission:
      • influenza
      • coronavirus infections
      • measles
      • tuberculosis
    • blood-borne, body fluid and sexually transmitted infections
      • hepatitis B
      • hepatitis C
      • human immunodeficiency virus (HIV)
      • syphilis
      • gonorrhoea
      • ebola
    • exposure to other agents:
      • schistosomiasis
      • rabies
      • leptospirosis
  • Provide specific advice for populations at higher risk or with specific circumstances, including:
    • Aboriginal and Torres Strait Islander peoples
    • travellers visiting friends and relatives overseas
    • extended travel
    • working or volunteering overseas
    • travellers with occupational risk
    • travellers attending mass gatherings
    • children and infants
    • pregnant travellers
    • travellers with disability
    • immunocompromised travellers
    • older travellers
    • travellers with pre-existing medical conditions
    • medical tourism
    • sex tourism.
  • Manage conditions and presentations in the returned traveller, such as fever, traveller's diarrhoea and other specific illnesses.
  • Provide routine, catch-up and travel-specific immunisations.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Key considerations for travel vaccination requirements in children. An overview of the issues and impacts of the medical tourism industry. An overview of the clinical impact and management guidance for high-altitude related illness. Implications of immunosuppressant medications for travel, including pre-travel vaccinations, minimising risks during travel and travelling with medicines.
Textbooks
Clinical advice on the safest and most effective use of standard and travel vaccines. US-based travel health textbook that provides internationally relevant advice on a variety of travel health topics. International guidance covering prevention and management of a wide range of travel-related conditions.
Online resources
Provides dose guidance for antimalarial prophylaxis, including for children and in pregnancy. Fact sheets, planning tools and information for clinicians and travellers. Australian Government destination advice including destination-specific travel warnings and how to access consular support. UK website with destination-specific information, guidance and news. Resources for developing further knowledge and skills in travel medicine.
Learning activities
eLearning activities on travel health.
  •  The Royal Australian College of General Practitioners. gplearning:
    • Travel health MCQs
Recorded webinars on a variety of primary care travel topics.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/travel-medicine 27/09/2022