Travel health specialist Dr Charlie Easmon on protecting the last-minute traveller
There will always be travellers who leave it late to seek health advice, often perilously so, but there’s still a lot we can do for them.
I would advise for those travelling to risk areas a basic vaccine course of hepatitis A, typhoid, diphtheria, tetanus and polio – all of which can be given as two injections at a single visit. Any others will depend on the patient’s medical history and their destination.
The key is to assess them systematically during the consultation, asking:
• Where are you going?
• For how long?
• What will you be doing when there?
• Have you been there before?
• When did you last have vaccines or travel health advice?
• Do you have any significant past medical history?
• Are you insured?
Anyone answering no to the last question should be told they must get insurance and they can buy it right up until they leave.
Never be afraid to warn them about the sexual health risks of travelling, including HIV, and hepatitis B and C, as well as the more common sexually transmitted infections.
And remind them to come back to complete their vaccine courses and to try to plan a little further ahead next time.
What have they already had?
I find a lot of travellers forget what vaccinations they have had in the past – or even if they’ve had any – but we can still estimate what will be required.
I first ask when they last travelled anywhere exotic – in other words, anywhere other than Europe, the US, Australia and New Zealand.
Then I ask whether they saw a doctor or nurse before they went away and whether they remember getting any vaccines.
The odds are high that they would have been advised to have hepatitis A, typhoid, diphtheria, tetanus and polio. But if there’s any doubt, there is no harm in giving them these basic vaccines again.
The late traveller may not see any point in having a vaccine so soon before travelling, but explain that any disease has an incubation period and, fortunately, most are longer than it takes the vaccine to provide some degree of protection.
Hepatitis A and typhoid
Hepatitis A and typhoid are spread by faecal-oral transmission and can occur anywhere in the world.
Hepatitis A is much more common but typhoid is more serious and can cause death through infective perforation of the Peyer’s patches in the gut.
The hepatitis A component only needs two doses to be given within three to five years of each other for the traveller to have 20 or more years of protection. If the gap between the first and second dose is longer than five years, treat the new dose as the first.
Typhoid should be boosted every three years. The vaccine is only 70% protective and you need to advise about the risk of paratyphoid infections – particularly for people travelling to Nepal – for which there is no vaccine.
Diphtheria, tetanus and polio
The diphtheria, tetanus and polio single vaccine lasts for 10 years. We all know that most people do not need any more than five tetanus vaccines in their lifetime but we have to be pragmatic and have no choice but to give the triple vaccine for anyone needing a polio or diphtheria booster.
Yellow fever vaccination is an unusual case as it has to be provided by a registered National Traveller Health Network and Advice Centre (NATHNAC). Technically it only becomes valid 10 days after administration, so you should warn your late traveller that a zealous border guard could turn them away.
The centre’s excellent free website, www.nathnac.org.uk, is a mine of information – particularly on yellow fever – and I would recommend anyone providing travel advice to consult it about this disease, in preference to charts and proprietary databases.
It will tell you if the destination country requires travellers to arrive with a yellow fever certificate. This information has to be comprehensive and up to date.
Some countries require a certificate even if yellow fever is not a problem there. For example, India has the carrier mosquito but not the disease and, to protect its citizens, requires travellers arriving from certain countries in Africa to have a certificate.
NATHNAC also advises on what to do with those increasingly adventurous over-60s who have never had yellow fever vaccine and have a greater risk of vaccine complications.
It is important to remember that thymus disorders, DiGeorge syndrome and myasthenia gravis are contraindications to the vaccine.
For late travellers needing meningitis vaccination I would ideally use the conjugated vaccine ACWY Vax.
Anyone visiting the ‘meningitis belt’ of sub-Saharan Africa – 25 countries stretching from Senegal in the west to Ethiopia in the east – should have the meningitis vaccine. And you can check for the latest on meningitis outbreaks at www.promedmail.org.
A history of splenic injury or dysfunction (think of your sickle-cell community) should alert you to the need to protect against encapsulated bacteria: meningitis, pneumonia and haemophilus. For the latter I see no option but to give adults the child Menitorix vaccine.
Remember any pilgrims to the Hajj or Umrah in Saudi Arabia will need to be given a certificate of vaccination.
If the traveller is going to an area with tick-borne encephalitis you should at least give the first dose – and the same applies to Japanese encephalitis (JE).
It is good news for the late traveller that the new JE vaccine does not have the same allergy/side-effect profile as the old mouse brain-derived vaccines, so doesn’t need to be given at least 10 days before travel as before.
The rabies vaccine has been described as the only vaccine that’s 100% protective against a disease that’s 100% fatal.
It’s best not to take chances with fatal diseases, so if your late traveller is at risk it’s better to start the course than not.
If only one dose is possible before they leave, warn them they will need more – on top of rabies immunoglobulin – if they get bitten.
Also tell them immunoglobulin is not always readily available in rabies-endemic areas and their insurance company may have to fly them to get it.
Hepatitis B risks are higher in those likely to get tattoos abroad, have unprotected sex or who will require transfusions while away. Give late travellers the choice of starting the course, which would run concurrent with their rabies course.
BCG vaccination is a tricky one for the late traveller. We still give a skin-based vaccine that leaves a scar and can suppurate for several months, plus we need three days to read a prior Mantoux test.
There is also huge debate over how protective the vaccine is. If your risk assessment finds suitable justification then offer the vaccine but remind the patient of this. Also advise them they can still get TB and remind them of the typical symptoms: prolonged cough, coughing blood, unexplained weight loss or night sweats.
People who decide to go travelling at the last minute may well be happy-go-lucky types by nature, but it’s not advisable to take this attitude with malaria prophylaxis. Malarone need only be taken a day or two before leaving so is ideal for the last-minute traveller.
The pregnant traveller
Pregnant late travellers pose many problems. Depending on the destination, your first piece of advice might be not to go. But non-live vaccines can be given safely to pregnant women. Seek NATHNAC advice for live vaccines such as yellow fever.
Dr Charlie Easmon is a specialist travel adviser in travel medicine and medical director of Your Excellent Health in London
Your Excellent Health is a designated yellow fever centre and travel clinic. In addition to travel advice, vaccines, malaria medication and travel products, the clinic also carries out Mantoux/BCG testing and provides some less readily available vaccine such as chickenpox, cholera and rotavirus. For further details go to www.yourexcellenthealth.co.uk
The female Aedis aegypti mosquito bites during the day and transmits yellow fever Insect