How to make the most of travel health consultations

Pharmacists are increasingly becoming the first port of call for individuals seeking travel advice and services. Pharmacists can perform pre-travel risk assessments, routine and travel-related vaccination, advise on malaria prophylaxis, and offer travel-related counselling and advice. Some pharmacists may be independent prescribers and capable of prescribing medicines related to travel. Additionally, patient group directions (PGDs) are often used for vaccinations, as well as other travel health related medicines (e.g. antimalarials). 

The following case provides an overview of the different components that need to be considered during a travel consultation. This includes the important questions to be asked during the consultation, risk assessment and advice on disease prevention, to ensure that travellers have all the information they need to stay safe on their trip. Each consultation will be different and the advice needed influenced by the traveller’s destination and medical history. Depending on the complexity of the case an initial consultation could last 15-30 minutes and be recorded on an appropriate proforma.

If offering a formal travel health consultation service, consider the essential training and competences that are recommended to be demonstrated, these can be seen below.

The consultation

We can talk about vaccinations, but would you like a consultation to identify any other health related issues for your trip too?

That would be great, thank you.

Where are you travelling to?

How long will you be away?

I will be spending six weeks in India.

Where do you plan to visit?

What modes of transport will you use?

What activities do you have planned?

Destinations, reasons for travel and excursions planned on the trip can influence disease risk and ensuing advice

Itinerary

• Flying into Mumbai —
  five days sightseeing;
• Travel by bus to Goa —
  three weeks yoga retreat, beach days and day trips to nature reserves, waterfalls etc.;
• Travel by train to Kochi —
  one week, backwaters boat tour and visiting historical sights;
• Travel by train to Chennai —
  three days sightseeing;
• Fly to Assam —
  one week trekking;
• Fly home.

When is your departure date?

Three months from now.

It is important to consider departure date when initiating vaccination regimens as some may require multiple injections over several weeks/ months

What is your budget for this trip?

What types of accommodations will you be staying at?

I will be doing this trip on a budget and I will be staying in hostels and low-budget local guest houses.

Budget and accommodation type can influence advice on disease prevention. For example, accommodations like hostels are unlikely to have appropriate netting on windows/doors meaning additional precautions will need be taken

Travelling alone can increase personal safety risks, but all travellers should be advised on precautions they can take whilst away. Click ‘Staying safe while travelling’ to find out more

Staying safe while travelling

There are several safety risks that travellers should be aware of before embarking on their trip, travellers should be advised:

• Consult the Foreign, Commonwealth and Development Office advice on safety and security for their chosen destination(s) before leaving for their trip;
• Be aware of local laws, customs and sensitivities. It is important to dress appropriately and avoid acts that are illegal in some countries (for example, drinking alcohol in a country with abstinence laws);
• Road travel accidents may be more common in some countries. Wear seat belts in cars, helmets on bikes and avoid night-time driving and driving under the influence of alcohol;
• Take a first aid and medical kit with them, stock it with usual medications and ones that may be relevant to the trip (e.g. antidiarrheals), including antiseptic and dressings to minimise infection risk if injured;
• Make sure their travel insurance covers their planned activities, existing medical conditions, treatment costs and repatriation.

This is not an exhaustive list of safety advice, those wishing to find out more can consult the safety advice compiled by the NaTHNaC.

Are you likely to be able to access healthcare if required while you are away?

I will be staying in cities/small towns for most of my trip, it is only when trekking in Assam that access to healthcare may be an issue.

Do you have travel health insurance?
What level of cover do you have?

Travellers should be advised on the importance of travel insurace to cover any unexpected scenarios that may occur during their trip, such as paying for medical treatment or medical repatriation (return to home country)

Yes, I have cover for emergency medical treatment and repatriation of up to £5m.

Medical history

Enquiring about a patient’s past and present medical history allows pharmacists to judge whether travellers have any additional needs that they may need help managing when travelling. Click ‘Patient medical and family history’ below to find out more

What is your age and gender identity?

I am a 26-year-old woman.

Are you currently in good health?

Do you have any known or prior health conditions?

I have asthma, but it is well controlled.

I have also experienced insomnia in the past. I am in good health otherwise.

Patient medical and family history

Enquiring about a patient’s past and present medical history allows pharmacists to judge whether travellers have any additional needs that they may need help managing when travelling.

Travelling with a medical condition does not need to be limiting, but there are additional measures that may need to be considered to ensure patient safety. Patients that are immuno-compromised or that have complex medical conditions (e.g. diabetes or autoimmune conditions) may be at increased risk of complications if they become ill or injure themselves when abroad. These patients are also more likely to need to access healthcare when abroad, which may be a concern if they are in areas where there is limited healthcare or healthcare settings are of a different standard.

Patients with complex health needs should be encouraged to speak to their specialist healthcare provider prior to their departure. The National Travel Health Network and Centre (NaTHNaC) provides a telephone advice line for healthcare professionals advising travellers with complex itineraries or specialist health needs.

Maya has asthma, in this scenario it would be appropriate to enquire about the following:

• Is her asthma well controlled?
• Maya should be reminded of the importance of adhering to her treatment regimen while away.
• Has she previously been hospitalised for her asthma?
• Maya should make herself aware of local healthcare services and how to access them in the locations she is visiting.
• What are her triggers? Is she likely to be engaging in any activities that may trigger her asthma?

If Maya has any concerns about managing her condition while abroad, she should be advised to make an appointment with her GP/ asthma nurse prior to her departure.

Do you currently take any medications?

I am prescribed two puffs of beclometasone dipropionate per day and take two puffs of salbutamol as needed.

I also take the combined contraceptive pill.

Patients may need advice on managing their medications while abroad. Click ‘Patient medication’ to find out more

Patient medication

Patients should be asked whether they are taking any regular medications so that pharmacists can best advise patients on how to manage their medications while they are away. It is also important to understand a patient’s medications when making recommendations for vaccination and malaria prophylaxis in case there is the potential for any interactions.

Travellers should be advised:

• The NHS will provide a sufficient supply of medication for patients spending up to three months abroad.
• It is advisable to travel with a supply of medication in both the hand and hold luggage, in case either is lost, and to take medication in its original pharmacy packaging or have a note from the GP to confirm personal prescription.
• To check local airport regulations for restrictions on what can be taken in luggage, for example there may be limits on liquids.
• If for any reason a traveller needs to obtain medicines while abroad, they should be advised to contact a reputable healthcare provider as there may be differences in strengths/ concentrations of some medications and concerns over falsified medical products, which may contain toxic or inactive products.
• Travellers with complex needs and medicine requirements should be aware that there could be additional considerations when travelling with controlled drugs, drugs that have storage requirements and travelling with needles and that they may need to contact the airline in advance and check country requirements depending on their medications before travel.

Maya is currently prescribed two puffs of beclometasone dipropionate per day and two puffs of salbutamol as needed, she also takes the combined contraceptive pill; she is adherent to her medication.

It is unlikely that there are any restrictions on her medications, and she is not travelling with controlled substances, but Maya should be advised to check local airline regulations to be certain.

Because Maya will be gone for two months, she should be advised to contact her GP to ensure she is prescribed an adequate supply of her medication to take with her on her trip.

Do you have any relevant family history of illnesses?

One of my grandparents died of a stroke and my father lives with type 2 diabetes.

Relevant family history may influence disease prevention recommendations.

For example, history of epilepsy in a first- degree relative may influence the recommendations for choice of malarial chemoprophylactic medication.

Is there a chance you could be pregnant or are you planning on becoming pregnant within two months of your return?

No, and I have no current plans.

Pregnant women or those that are planning to conceive in the near future may be at additional risk when travelling. Click ‘Travelling when pregnant’ to find out more

Travelling while pregnant

There are several additional considerations for pregnant travellers, some examples include:

• The BCG, oral typhoid, oral cholera and Japanese encephalitis vaccinations are contraindicated in pregnant women;
• Pregnant women and their babies are at increased risk of developing serious infection if they contract malaria;
• Not all malaria prophylaxis is safe in pregnancy, use of doxycycline is usually avoided in pregnant women;
• There is an increased risk of deep vein thrombosis in pregnancy;
• Women visiting Zika virus risk area should be advised there is risk to their developing baby. Women planning a pregnancy should avoid conceiving until more than 8 weeks after they have returned;
• Most commercial airlines allow travellers who are up to 36 weeks pregnant (up to 32 weeks for multiple pregnancies). Some airlines require documentation from a doctor or midwife to confirm that the patient is in good health, and the due date.

Additional considerations for pregnant travellers can be found via the patient.info website.

Choose from the options below:

Malaria Vaccination Traveller’s diarrhoea

All individuals travelling to areas where there is malaria risk should be advised to follow an ‘ABCD’ guide to preventing malaria:

Awareness of risk

Risk depends on the location of travel, season, length of stay, planned activities and the type of accommodation the traveller will be staying. Risk of malaria at a destination can be checked using the TravelHealthPro website.

The following groups are at increased risk of developing severe malaria if infected:

• Pregnant women; Children and babies;
• Older individuals;
• Individuals who are immune compromised;
• Individuals without a spleen;
• Certain medical conditions.

Bite prevention

Travellers should be advised to use an appropriate insect repellent. Patterns of bite activity vary between mosquito species, however, travellers should assume that there is a risk of being bitten during the day and night, both indoors and outdoors.

The Advisory Committee on Malaria Prevention (ACMP) recommends a 50% N,N-diethyl-m-toluamide (DEET)-based insect repellent as first line. DEET may be contraindicated or not preferred by some patients. Some travellers may wish to use a plant-based repellent, they should be advised to use eucalyptus citriodora oil, hydrated, cyclized (PMD), which occurs naturally in the lemon eucalyptus plant and is the only plant-based active ingredient recommended by ACMP. PMD must be applied more regularly than DEET.

Some other plant products, such as citronella, are utilised by patients as natural insect repellents, it should be communicated to patients that there is not enough evidence to support their use for this indication.

Budget/low-end accommodations are unlikely to have appropriate netting on windows and doors. Travellers staying in such accommodations should be advised to sleep under an insecticide treated mosquito net. Nets should be checked for tears and when in use should be tucked under the mattress and kept taut.

Bite prevention advice is relevant for the prevention of all diseases spread by mosquitos.

Chemoprophylaxis

When advising patients on antimalarial prophylaxis regimens, it is important to ask about the places they will be visiting, the activities they plan to do, their allergies, current medications, medical conditions and family history.

Travellers going to areas where there is a high risk of malaria should be advised to consider malaria chemoprophylaxis.

Detail on common antimalarials can be seen in the table below:

The dosing schedule and possible side effects can affect patient choice when selecting an antimalarial medication. These should be clearly explained to the patient to assist them in selecting the most appropriate antimalarial for their trip.

It should be communicated to patients that no antimalarials are 100% effective but using them in combination with mosquito bite avoidance measures will significantly decrease their risk of contracting malaria.

Guidance from the UK Malaria Expert Advisory Group (UKMEAG) should be followed when prescribing antimalarials and providing advice on the prevention of malaria.

Diagnosis

Travellers should be advised to seek immediate medical attention if they develop a fever more than one week after being in a high-risk area, or if they develops any symptoms suggestive of malaria (e.g. fever, headache, fatigue) within a year of their return.

Maya will be spending most of her time in areas that have a low risk of malaria, but this risk will be increased when she travels to Assam.

She should therefore be advised to take appropriate antimalarial prophylaxis before, during and after her time in Assam.

Maya has previously experienced insomnia so does not want to risk the side effects of mefloquine, and also does not want to deal with the increased tablet burden of doxycycline – she therefore decides that atovaquone/ proguanil is the most appropriate prophylaxis regimen for her.

Additional information can be found in ‘Advising patients about malaria risks and prevention’.

When discussing vaccination, it is important to ask the patient about their departure date, the places they will be visiting, the activities they plan to do, their allergies, current medications, medical conditions and vaccination history. This will helps in evaluating their risk factors and advising on the vaccinations that are most relevant to them.

Vaccination recommendations are dependent on the destinations and activities that a traveller is planning to undertake, as the risk of exposure of different pathogens varies in different regions. Certain activities and reasons for traveling — for example health volunteering — will also increase exposure risk. Resources like the National Travel Health Network and Centre (NaTHNaC) should be consulted to find out which vaccinations are recommended for particular destinations.

A list of common travel vaccines, considerations for their use, doses and protection length can be seen in the table below.

Not included are vaccinations on the routine immunisation schedule in the UK, a list of these vaccines can be found on the NHS website. If during the consultation a patient discloses that they are not up to date with any of these routine vaccinations, it should be recommended to them that they receive the missing vaccination(s).

Maya is up to date with all of the routine vaccinations that are recommended in the UK, including a tetanus booster which she received in 2019. As diphtheria, tetanus and polio are given as a single vaccine in the UK, this means she is vaccinated against diphtheria.

• Typhoid and hepatitis A vaccinations are recommended for all travellers going to India;
• Cholera, hepatitis B, Japanese encephalitis, rabies and tuberculosis vaccinations are recommended for some travellers based on their health history and planned activities.

Maya is provided with the information above, considering her age, health and travel plans (travelling for leisure, not volunteering/ working in healthcare settings), she is low risk for most of the additional vaccinations that could be considered. Maya is concerned at the risk of rabies if she was to be exposed in a rural area with limited healthcare access, so does decide to get vaccinated for rabies, as well as the recommended typhoid and hepatitis A vaccines.

There is no risk of yellow fever in India;, however, there is a certificate requirement. A yellow fever vaccination certificate is required from travellers aged nine months and over arriving within six days of departure from an area with risk of yellow fever transmission. Additional information about yellow fever vaccination and certificates can be found via the NHS fitfortravel website.

Maya is flying from the UK to India, so will not require a yellow fever certificate. She should be made aware of the requirements in case her itinerary changes.

Prevention

The National Institute for Health and Care Excellence defines traveller’s diarrhoea as passing three or more unformed stools in a 24-hour period with at least one additional symptom (e.g. abdominal pain or cramps, nausea etc.)

While not normally life threatening, traveller’s diarrhoea can be uncomfortable, inconvenient, and can negatively impact a trip; travellers should be given appropriate prevention advice.

The risk of traveller’s diarrhoea is dependent on the destination, travellers visiting high- risk areas and those that are at an increased risk of infection should be provided with the following advice, which is relevant to the prevention of all food and water-borne diseases:

• Emphasise the importance of handwashing with soap and water before eating. If soap is not available an alcohol-based hand sanitiser can be used as an alternative;, however, it should be noted this method has limited effectiveness against certain pathogens (e.g. norovirus);.
• Caution should be taken when eating out. Food should be thoroughly cooked and served steaming. Food should be avoided that hasn’t been kept hot or refrigerated. Fish, seafood, meat and poultry that hasn’t been thoroughly cooked should be avoided. If hygiene standards are in doubt, salads and uncooked vegetable should be avoided. Unpasteurised dairy products should be avoided;
• Travellers should be advised to drink bottled water and to check the seal before drinking. Travellers should avoid tap water when brushing their teeth. Travellers should avoid ice and food that has been prepared using tap water. If there is doubt, water can be boiled for at least one minute to ensure its safety for drinking. If a traveller is going to an area with a limited water supply, chemical water treatments and filters can be considered but should be used with caution;
• Prophylactic treatment with bismuth subsalicylate, probiotics and antidiarrheal drugs (e.g. loperamide) is not recommended. Antibiotic prophylaxis is not recommended for most travellers but should be considered in high-risk patients who are at increased risk of complications (e.g. individuals with Crohn’s disease, individuals with type 1 diabetes mellitus).

Maya takes the combined contraceptive pill, if she experiences sickness or diarrhoea there is a chance that the effectiveness of her contraception will be compromised. Maya should be advised to use an alternative form of contraception (e.g. condoms) for seven days if she becomes unwell.

Management

During episodes of diarrhoea, it is important that travellers stay hydrated. Most healthy travellers can achieve this by eating and drinking as normal.

For severe symptoms or in travellers at increased risk of complications from diarrhoea, the use of oral rehydration sachets, diluted into bottled water, can be considered to correct electrolyte imbalances. Travellers may want to consider purchasing a supply of these sachets prior to travel to guarantee access.

The use of antidiarrheal drugs can be considered in adults to relieve mild-to-moderate diarrhoea for a maximum of two days.

Travellers should be advised that neither loperamide or bismuth subsalicylate should be used if they have blood or mucous in their stool and/or high fever or severe abdominal pain.

‘Stand by’ antibiotics, to be used if travellers do experience diarrhoea, should not be routinely prescribed. Antibiotics for this indication should be considered in individuals travelling to high-risk locations with limited access to appropriate healthcare and for those at risk of becoming seriously ill. Specialist advice should be sought if ‘stand by’ antibiotics are being considered. The National Travel Health Network and Centre (NaTHNaC) provides a telephone advice line for health professionals advising travellers with complex itineraries or specialist health needs.

Sexual health Altitude sickness

Individuals may be more likely to have sex with a new or casual partner while travelling and research suggests that they may be up to three times as likely to contract a sexually transmitted infection (STI) while abroad than during a sexual encounter in their home country. Providing prevention advice is therefore important in preventing the global spread of STIs.

It is important to not make assumptions when providing information around sexual health, the information is relevant to people of all gender identities, sexualities and ages.

While travellers may be unlikely to disclose that they are planning to engage in sex tourism, it is a reason for travel, and it is important that these travellers receive relevant information about reducing the risk of contracting an STI, as sex tourism often involves sex workers in countries that have high rates of STIs.

All travellers should be advised on the following:

• STIs can be transmitted during vaginal, anal or oral sex, the only way to protect against STIs is to use a condom (or a dental dam during oral sex);
• To take a supply of condoms with them, reliability of manufacture may differ in other countries;
• To take condoms with them even if they are not planning on having sex, being in a new environment and the increased likelihood of drinking alcohol means their intentions may change;
• Latex condoms are easily damaged by oil-based lubricants (e.g. Vaseline, baby oil and sun lotion);
• Condoms perish with age, and heat,, and should be discarded if they are out of date or show any signs of damage.

Altitude sickness happens when the air pressure is lower meaning there is less oxygen available to breath, it can start to occur at heights over 2,500m.

While Maya will be trekking at increased elevations while in Assam, she will not be at risk of altitude sickness as the highest possible elevation of a treck is 1,960m.

Travellers who are at risk of altitude sickness on their trip should be advised of the following:

• There are three types of altitude sickness: acute mountain sickness (AMS); high altitude pulmonary oedema (HAPE); high altitude cerebral oedema (HACE). HAPE and HACE are life- threatening medical emergencies;
• Symptoms of AMS include headache, fatigue and nausea. Over-the-counter treatment options can be used to manage these symptoms (e.g. taking ibuprofen or paracetamol to relieve a headache);
• To prevent altitude sickness travellers should avoid quickly reaching heights above 2,500m. If possible, they should avoid flying directly to places above 2,500m, they should spend two to three days at a location below 2,500m to acclimatise and when trekking a slow, gradual ascent is advised;
• When trekking to higher altitudes travellers should stay well hydrated (drinking four to five litres of water per day), abstain from alcohol and eat a light but high calorie diet;
• Acetazolamide can be taken to prevent AMS. It is recommended for travellers who have previously experienced AMS or if a gradual ascent is not possible. The recommended dose is 125mg twice daily to be commenced one day prior to starting the ascent and then continued for at least two days after reaching the highest altitude.

This is not an exhaustive list of considerations for the prevention and management of altitude sickness, additional information on this topic have been produced by the NaTHNaC.

Are you up to date with your routine vaccinations?

Have you had any additional vaccinations?

I am up to date with all of the routine vaccinations that are recommended in the UK, including a tetanus booster, which I had in 2019.

I have not had any additional vaccinations.

Do you have any allergies?

None that I am aware of.

Have you travelled much previously?
Are you aware of the potential health risks?

I have travelled to several European countries, but this will be my first time outside Europe.

I understand there is an increased risk of contracting diseases while travelling, which is why I wanted to have this consultation to discuss vaccination options.

Other relevant articles from The Pharmaceutical Journal

Pharmacists can provide advice on a number of other considerations for travel, readers may want to consult the following resources that have been produced by The Pharmaceutical Journal:

• Motion sickness: causes, prevention and management;
• Melanoma: risk factors and advice on sunscreen use;
• Case-based learning: insect bites and stings;
• Heat-related illnesses: physiology, symptoms and management.

MAT-XU-2404694 (v1.0) Date of preparation: January 2025