A PRACTITIONERS PERSPECTIVE.
Given at School of Public Health, Claremont Graduate University, Los Angeles, California.
Derek was invited to present to PhD and MD the view of the practitioners role in affecting Global Health through routine practice considerations. He began by reviewing the classical style of Global Health provision using the definitions of Kaplan and MacFarlane linking these with some of the broader Global Health terms and scenarios produced the image of a top-down cascade of policies and practices placed upon practitioners to deliver.
Derek’s view was that as an experienced practitioner it was possible for a bottom-up approach to be applied to some core principles with a wider and broader understanding of the impact on a global scale. Following the definition of travel heath and travel medicine he elaborated from his own experience of the differing types of traveller groups, all with different priorities who are now travelling. In addition with the increasing access to lower cost air fares there is an annual increase in tourists (UK estimating +5% year on year, of which 30% will be travelling to new destinations.) Activities such as diving are increasing (PADI estimates 900,000 new registrations each year globally). Derek also highlighted the increasing number summiting Everest this year; global sports events such F1 Grand Prix and pilgrimages. Combining these new opportunities increases the number of new travellers, some of which will have medical conditions that require higher levels of maintenance and potential demand on the visited country.
The travel practitioners goal is to reduce health inequalities by considering the patient before travel, protecting the patient during travel and reduces the impact of local health services when in lower income countries.
By considering the policies implemented by global and national authorities the local implementation falls to the travel health practitioner who is required to understand the wants (needs), expectations, requirements the traveller. Some of which the traveller will already be aware. However commonly are other areas where the traveller is unaware and these require a degree of education, increased knowledge (of local standards and customs) and their impact if non-compliant.
Derek reviewed 5 key WHO Global Health targets where travel health practitioners can influence directly. These included communicable diseases and the correct administration and supply of vaccines, antimalarials and supply of preventative products. Education was demonstrated by the scenario of UK traveller refusing rabies vaccinations pre-travel. Following a post-exposure bite required 5 of the 25 rabies vials stocked in the local community clinic in Africa. This clinic covered 400 square miles and he used 20% of the entire stock. If he had received 3 pretravel then only 2 would have been required and the problems to obtain replacement stock could have been reduced in a high risk country.
The cost of medication in some countries was highlighted to be over 46% higher than the generic price due to poor control of the purchases. Situations in some countries were leading to black-market costs of over 100% which were only affordable to high income tourists. To reduce the costs then counterfeits and banned drugs were entering the market.
The healthcare workforce was commented upon by showing the WHO directive highlighting the need of pharmacists to enter into more clinical roles, but this was not always supported by national legislation at country level.
The travellers impact on the environment showed the amount of erosion and pollution that can be obtained from rubbish. Even though products are marked as recyclable in many countries the facilities are lacking to enable this to occur and hence the extensive reuse of discarded plastic bottles to produce counterfeit bottled water.
Finally, Derek raised that the point in many cases the traveller needs to be protected from themselves. He highlighted studies that showed of travellers reported diarrhoea in one study 99% had consumed a banned food or drink and in another there was an expectation of increased risk taking due to the travel occurring.
In conclusion the role of the travel health practitioner in global health can have an impact when delivering education of the conditions to be expected and compliance with these. Through the supply and provision of equipment for personal protection can reduce the demand on health inequalities in visited countries.
Non-pharmacotherapeutic interventions in travellersdiarrhoea (TD)
Derek P. Evans, MRPharmS, MFTM RCPS (Glasgow), FRGS
Submitted 17 November 2017; Revised 2 February 2018; Editorial decision 5 February 2018; Accepted 7 February 2018
Background: This is a review of some of the non-pharmacotherapeutic interventions in travellers diarrhoea (TD) looking particularly at the role of pre and probiotics, the evidence behind water purification and the impact of advice given and its adherence by travellers.
Method: A systematic review of the research completed under section using the listed key words and searched using the databases of Google Scholar, Journal of Travel Medicine, QxMD, ReadCube and The Knowledge Network.
Results and conclusions: Travellers’ diarrhoea and use of pre/probiotics: There is no significant evidence to suggest the benefit of using pre or probiotics to prevent or treat TD. A new second generation of B-GOS prebiotics shows some potential in preventing the incidence and symptoms of TD but lack high levels of graded evidence. Recent reports from the biotics industry suggest that a review of the above issues is being addressed and in the future more robust studies may be completed. The evidence behind water purification and diarrhoeal disease: Evidence suggests there is no direct correlation that water purification has an impact on diarrhoeal disease, although some studies underline the value of water purification. The use of bottled water is questioned as being unreliable due to the inconsistencies of microbio-logical safety. With new water purification products and methods being introduced a benefit could be found for publishing effectiveness against pathogen groups to improve comparison. Are travellers given good sanitary advice and do
they follow it? The advice given to travellers by non-clinical sources is unregulated and not a statutory obligation of a reservation to travel. Within the clinical sector the advice provided and the outcomes of advice provision do not correlate with a reduction in TD as a variance can occur by travellers’ changes and behaviours towards the advice given.Following recommended advice and consuming higher risks foods do not correspond directly with levels of reported TD, suggesting attitudes and practices deviate away from this advice when travelling.
Ref: Journal of Travel Medicine, 2018, Vol 25, Suppl 1, S38–S45
Comparison table of zika, dengue and chikungunya viruses
Comparison table of zika, dengue and chikungunya viruses
Following the recent amount of volume of information currently issued concerning the Zika, dengue and Chikungunya viruses and the similarity of overlap of each of the conditions, below is a simplified table for use by all travel health professionals support the advice give to travellers. The evidence gained is either from the PHE or CDC sites and is current at 5.3.2016.
Comparison table of zika, dengue and chikungunya
| || |
Common Symptoms Mild conjunctivitis
Dengue Haemorragic Fever
Mortality Low mortality,foetal deaths
0 > 1.4 %
Low-more complications in
GBS reported - rare
V low risk
Mosquito spp Aedes aegypti
Aedes albopictus (less than zika)
Highest Geographical South + Central America
location SE Asia
India, SE Asia,Brazil
Vaccine available No
Yes,Chimeric (licensed in 4 countries) for children 2-16 years
Virus family Flavivirus
Incubation period Considered 2-7 days
(range 2-14 days)
4-7 days (range 3-14 days)
3-7 days (range 2-12)
Lifetime immunity Unknown at moment
4 serotypes and cross immunity does not occurbetween the serotypes. Infection from one type is thought to provide lifetime immunity against that specific serotype
Infection is thought to incur
Infectivity rates CDC indicate 73%
(around 3 in 4)
Approximately 1 in 4 people infected will the develop the disease
Approximately 3 in 4 people infected will develop the disease
Tick Borne Encephalitis - does the current vaccination schedule reflect the necessary requirements for all travellers to infected areas? Journal of BGTHA, Volume XXVI, 2015.
Hydration Levels for Travellers and Advice given by Travel Health Providers
(Journal of British Global Travel Health Association volume XXV, 2015; 62-64)
Keeping the traveller hydrated and healthy is an examination of the published information of the required hydration levels for travellers and the advice given by travel,health providers; including a comparison of water filter systems for individual use.
A web based search for details of correct hydration levels and how to achieve non-infected water supplies when travelling indicated that no clear information or references to the required rehydration volumes were suggested in commonly referenced sources but these were available in specialist reference material to which few had direct access.
The WHO guidelines are based on an adapted style of the U.S. Military Fluid Guidelines and provides a suggested fluid intake according to the level of activity and working temperature. These are suggested as a guide for travel health specialists to advise travellers, preventing the risk of dehydration and reduction in cognitive affects that accompanies it after only 2-3%.
The review of travel health providers to give advice of rehydration showed that the advice was inconsistent and a reliance on non-evidenced information to advise on correct hydration levels and alternative water purification systems.
A study and review of water purification systems showed that many systems will provide up to the U.S. EPA standards for water purity but only one system exceeded these standards. The Aquapure system can be classified as a water purification system and not just as water filter.
In conclusion the importance of correct levels of hydration is generally realised but rarely advised in a consultation. A reason for this may be that the information required is only available in specialist references based upon military research.
The ability to obtain supplies of of personal non-infected water for correct hydration should include a reference to water purification systems that exceed the U.S. EPA standards. Further improvement in the information that should be given to travellers will require greater consistency and accuracy of information being provided that will come about from more education on this subject.
Derek Evans BSc(Pharm), MRPharmS, MPSI, Independent Prescriber,
(Extract from BGTHA Journal XXI4, 2014)
RABIES TREATMENT MODEL, SOCIAL
COSTS COMPARISON FOR POST EXPOSURE TREATMENT BETWEEN PRE VACCINATED AND
In a paper by Rossi et al (1) the study concluded that the difference in activities between pre travel history and post travel return indicated that the risks associated with changes to the pre travel history were only significant with regard to rabies prophylaxis.
In a study from Thailand (5) only 14.3% of travellers had received pre exposure vaccination and 75% of these were assessed as WHO category 3 status.
The pre-travel prophylactic treatment ranges from avoidance advice of animals through to a course of rabies vaccinations. This advice is often supported with the explanation of the post exposure treatment regime, but is declined by the patient. This model looks to explore one of the possible reasons for patients to decline and that is the perceived cost to the inconvenience of additional attendance for treatment.
The CDC website (2) indicates a study that suggests the cost of treating a post exposed traveller with Rabies Immunoglobulin and 5 doses of vaccine exceeds $1000 (£645). However as all practitioners are aware the true treatment cost needs to include an element of the social and additional hours required to receive treatment.
Using UK guidelines ( 6) for pre travel prophylaxis and post exposure treatment the courses of vaccination and RIG were reviewed A scenario model was used based on a recently reported case of rabies exposure to an adult including clinic attendance patterns.
Costs defined as
Rabies vaccine per unit £31.90 (3) [Clinic values range between £30-60, depending on route and formulation]
Human rabies immunoglobulin (HRI) £305.28 (4)
Traveller hourly rate £10 (arbitrary value)
Traveller A is on holiday with his family in an at risk country for rabies. He is a male, aged 45, with no other medication or patient history of underlying conditions. On day 5 of a 14-day holiday they visit a local village where he is bitten by a dog that exits the area and is unable to be traced. The wound is characterised by a deep puncture that has broken the skin with traces of saliva around the margin. Traveller telephones his health insurance company for Traveller telephones his health insurance company for advice and is told to immediately wash the wound with water, deeper cleansing with antiseptic or alcohol and to seek local medical advice.
1. Costs if he were vaccinated pre-travel
Pre travel UK guidelines 3 injections at 0,7,21 days cost £95.70
Post exposure treatment costs 2 injections at 0,3 days cost £63.80
Total costs £159.50
2. Costs if he was NOT pre travel vaccinated
Pre travel £0
Post exposure costs 5 injections at 0,3,7,14,28 days cost £159.50
Plus HRI cost 305.28
Total costs £464.78
Considering other revenue streams e.g. operational, social, then the added costs inflate the total treatment costs. Listed below are the breakdown additional steps required by this traveller in seeking treatment.
Cost of telephone call from abroad to insurer
Time to call insurer and receive advice
Time to find local clinic/ hospital
Travel time to local clinic/hospital
Additional time to travel another hospital to gain HRI
Cost of consultation with clinician
Cost of treatment
Return time to family
Repeat trips to clinic for further follow up treatment.
Returning home, trips to GP for follow up treatment and costs (see attached sheet for breakdown) total additional cost £167
Social exclusion, family concern for wellbeing.
The value of this is both emotional and psychological and remains immeasurable in terms of monetary value. However the restrictions to the family plans, occurred on a minimum of 3 occasions where attendance was required at the local clinic.
Total costs for treating a post exposure traveller A for rabies ranged between £326.50 and 2 restricted holiday days for pre vaccinated traveller through to £631.78 with 3 holiday and 2 work restricted days for the non vaccinated traveller.
The CDC figure is accurate to within the variations of the daily exchange rate between UK pound and UD dollar (calculated at 1.55), however it does not make any allowance for the number of restricted days for each of the treatment periods.
The social and psychological value of the restricted days is traveller specific however between extremes this could lead to changes in travel plans or itinerary.
The complexity of rabies is different to other vaccinated travel related diseases and therefore cannot be compared as similar to these, something that is not necessarily understood by travellers when making decisions on vaccination.
Pre vaccination treatment is often not understood by the traveller as necessary, as post exposure treatment is usually required after infection.
Health care professionals understand the high priority to be given to this disease.
The interface between patient and health care professional needs to be utilised to raise the dangers and costs of not completing a pre travel course by using patient focused literature
Costs comparison as above due to the unique nature of this disease treatment, this study uses the UK guidelines, which relate only to the intramuscular use. However discussion abounds regarding the cost effectiveness of the intradermal use with lower volume, costs and also efficacy.
Consideration needs to be given to the timing of payments, as pre travel costs are normally the responsibility of the traveller or support organisation, whereas treatment costs are more likely to be covered by travel insurance or NHS. Further questions need to be asked if this is a significant reason for travellers to risk not having preventative treatment before travelling to a high-risk area?
1 Rossi et al, The Reliability of Pre-travel History to Decide on Appropriate Counseling and Vaccinations, Journal of Travel Medicine 2012; 19:284-288
3 British National Formulary edition 59
4 Bio Products Laboratory.
5 Rabies Immunisation of Travelers in a Canine Rabies Endemic Area, Journal of Travel Medicine 2013; 20: 159-164
6 Immunisations against infectious disease " The Green Book" www.gov.uk
Derek Evans MRPharmS, BGTHA Exec. Council Member
63 Journal of BGTHA, Volume XXIv, 2014
Proposed consultation style for Pre-Travel clinic assessment developed from existing consultation models. (British Global and Travel Health Association Journal, January 2014)
Much work has been written on the importance and need for a pre-travel consultation following a pre-designed format and often described as a risk assessment (RA).1,2 However the use and completion of an RA is only part of the patient/practitioner interaction with the remainder being the style of the consultation with the patient.
Many theoretical styles of consultation are published and documented.3 These consultation styles are based on the traditional medical practice of the practitioner interacting with people who frequently deem themselves to be unwell.
In pre-travel consultation the practitioner deals with dominantly well patients who wish to remain well whilst traveling and this then raises the question should they receive advice and supply in the same consultation style as the former category of patients?
In the thesis by Willcox, it is indicated that a travel health consultation is not linear and the rule- based models of Pendleton and Neighbour do not work with the social rules that govern behaviour and interactions.4 This is currently witnessed and evidenced in current practice where recommended vaccines can be refused or malaria prophylaxis abruptly discontinued.
In a web based search using the key words below there was no close web hit to specific consultation style for pre-travel RA and this was further supported with a review of the Royal College of Nursing (RCN) competencies on travel health nursing which does not mention consultation styles.5
By comparison the Royal College of General Practitioners (RCGP) published in their statement6 the changes that were needed to be made and understood with general practitioners were “illness presenting in general practice requires a normality-orientated approach, as opposed to the disease-orientated approach in secondary care”. The RCGP areas of competence highlight that person centred care relates to relating to patients as individuals and working in partnership with them
Information and Resources
The basis of this article is that in the pre-travel RA model a different consultation style could be considered from an amalgamation of several other models. A brief review of the more popular consultation styles is listed below.
Considers other problems e.g. Risk factors. Shared action with the patient.
Defining reasons assumes the patient has a knowledge of the diseases for prevention or action.
Achieving full shared action is unable to reviewed as compliance to malaria prophylaxis for example has no external patient measurement and the decision making surrounding the proposed vaccinations is subject to other influences e.g. cost.
By summarising all the known points of the traveller and the destination then the safety net activity will only be partially effective as the patient will ultimately determine the final selection often through financial influence.
Establishing the rapport- this expects that the patient knows they need some prophylactic measure and that their itinerary will not be changing. A recent study6 indicates that pre travel history does not adequately reflect what patients do.
COHEN-COLE and BIRD (1989)
This introduced the Three Function Model of gathering data, developing rapport, education and motivation; and describing the functions of the prescriber and the skills necessary to be used in each function.
Launer developed the concept of narrative based medicine where there is no definite answer to why has the patient attended for consultation as this often raises more questions as expected.8 However in the BMJ article the evidence based clinicians held onto the importance of their expertise; however the clinical assessment draws on narrative overlapping ideas and views told by patients, clinicians and patient repre- sentatives. As clinicians we select the most appropriate prevention of treatment on clinical grounds and disassociation is experienced when occurs when we the narrative paradigm is abandoned.9
In other words the skills that help the patient to understand better (e.g. the need to have all selected vaccines rather then just self select) are specific to the timing of appropriate questions and to the spirit of the eventual outcome (e.g. what may occur if these vaccinations or prophylaxis are avoided or not completed) rather than the production of clinical evidence.
Any designed consultation model for use in a travel health assessment where a healthy patient presents themselves for travel abroad and wishes to remain healthy has an element of risk. The clinician can pro- vide the technical advice but the views of the patient (often subjective) can lead to some or all of the advice being disregarded and increasing the public health risk. These are more likely to occur in a private pre- travel clinic than a traditional GP surgery. To reduce the subjectiveness but still maintain the patient right of choice then the proposed consultation model could be adopted for such consultations:
- 1 Connecting to establish rapport (Neighbour)
- 2 Gathering Data (Three Function)
- 3 Define the reason for the patient’s attendance (Pendleton)
- 4 Education and motivation (Three Function)
- 5 Narrative based handover (to raise points of concern and negotiate behaviour change) circularity and co-creation
- 6 Narrative based safety net- curiosity, contexts, caution
There appears to be a requirement for an adapted consultation model with behaviours for specialist private clinical service that has a higher risk element due to the patient financial considerations or their behaviours. Further study of determining how and when the timing of the appropriate questions with respect to the views of the patients during the consultation needs to be completed.
Keyword data search
Medical, consultation, style, travel, clinic, pre travel, risk, assessment, patient, framework.
- 1 Center for Disease Control and Prevention, Yellow Book wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2- the-pre-travel-consultation
- 2 Field, Ford, Hill eds, Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK 2010.
- 3 Simon, Everitt, van Dorp, Oxford University Press, Oxford Handbook of General Practice, third edition, chapter 5.
- 4 Willcox, Nurse- led Pre-travel Health Consultation: Evaluating Current Practice and Developing a New Model, chap 2.4. PhD thesis University of Warwick 2010 Proposed Consultation style for Pre-Travel clinic assessment developed from existing consultation models 63 http://go.warwick.ac.uk/wrap/38543
- Travel Health nursing: career and competence development, RCN guidance, Royal College of Nursing, published September 2012.
- 6 Rossi, The GP Consultation in Practice, Royal College of General Practitioners Curriculum 2010 revised 26 April 2013. www.rcgp.org.uk
- 7 Genton, The reliability of pre travel history to decide on appropriate counseling and vaccinations: a prospective study.J Travel Med 2012; 19:284-288.
- 8 Launer J. (2002) Narrative-based primary Care: a practical guide. Radcliffe Medical Press Abingdon Oxford
- 9 Greenhalgh, Narrative based medicine in an evidence based world. British Medical Journal 1999; 318:323.
Derek Evans BSc (Pharm.), GPhC, RPS, Independent Prescriber in Travel Health
62 Journal of BGTHA, Volume XXII, 2013
How a mid-air emergency launched my travel medicine career and why the launch of the Royal Pharmaceutical Society will improve my prospects. (Pharmaceutical Journal, January 19 2013)
AS A community pharmacist I was involved in the regular supply of over-the-counter medicines for malaria prophylaxis along with the prevention and treatment of bites, motion sickness and travellers’ upset stomachs.
My first real interest and awareness of the role that a pharmacist could play in the ever expanding travel market came from a personal journey when returning on board a flight from Canada.
About an hour after take off from Toronto a message came over the speaker system: “Could anyone with medical training please make themselves known to the cabin crew.” My wife nominated me and I was asked to follow the cabin crew to the forward galley area to be presented with an elderly Canadian woman lying across the floor in partial consciousness.
Attending with me was a medical student and a part-time practice nurse.The airline crew provided a medical bag and the nurse and student attended to the patient while I went to take a medical history from her husband, who was in the main cabin. Upon viewing all the medicines that she was taking it became clear to me that she had cardiovascular conditions, complicated by diabetes.
At the time of her last prescription she had not requested a fit-to-fly declaration from her doctor or had been advised not to travel by the supplying pharmacist.
By the time I had returned we had left Canadian airspace and were refused re-entry, instead being advised to proceed to a medical evacuation centre at Reykjavik, Iceland. Upon approach to Reykjavik the patient’s condition started to improve and her blood pressure was rising, so the decision was made to continue to Birmingham in the UK.
Travel health opportunity
I spent a total of six hours working with colleagues monitoring this patient during the flight and as I started to consider what could have been done to prevent this from happening again it became clear that pharmacists could have an opportunity in the management of travel health.
Later in my career I came back to the role of the specialist pharmacist where, as a PADI- qualified diver, I was asked to assist in the supply of insect repellents and antimalarials that would not affect scuba divers in warmer climates.
This time I reviewed both the medical and pharmacy professions and found that travel health was largely disregarded as not
00 Month 2013 (Vol 290)
important enough under the NHS for preventive treatment and appeared to be unregulated in the private sector.
The research indicated that one of the most important parts before the supply was of the risk assessment. As pharmacists we do this daily, of course, whether it be for an OTC preparation or a medicines use review. A risk assessment is an extension of what we do daily and in an environment where extended hours allowed better access than regular doctor’s surgeries. I could see an opportunity for community pharmacy.
At this time my career had evolved to a point were I was responsible for a number of stores as an area manager.The concept of patient group directions had just arrived and many people saw this form the supply function of an additional method. My belief was that if we were to use prescription-only medicines in a supply function then the level of expertise needed to be raised above the basic levels that had been set at university and during preregistration years.
I am fortunate to be working with a company that had the same futuristic vision and I started working with external specialist colleagues in the field of travel health to design the first internal training document that supported an advanced service of supplying with PGDs, using training matrices and material from other health care professions. By developing this level of training I have been able to support a large number of pharmacists to develop and be accredited to practice at advanced level.
The idea of credentialing finally came to me and I realised that community pharmacists
Soon we are about to change again, with the introduction of revalidation, which will be mandatory and regulatory. Therefore to continue to practise, the challenge will be how do I demonstrate my competence and here is where the RPS Faculty will help, support and develop
will be required to revalidate in the future and also questioned how they are to be recognised for the years of experience without a necessary formal qualification.
Working alongside senior members in the RPS, I realised that the principles of credentialing can be demonstrated in my specialist field by providing an in-house accredited qualification that leads to a recognised advanced level of practice.
I continue to develop my knowledge and understanding of travel health and to progress to a higher specialist level, have realised that I need to move outside my profession and work alongside other healthcare professionals.To this end I am currently a member of the British Global Travel Health Association and of the pharmacist subgroup of the International Society of Travel Medicine.
To further my career I am currently completing an independent prescribing course in travel health and I am undertaking the international examination for the certificate of knowledge of the ISTM. Having these professional qualifications recognised by the profession as part of my development is hugely important for me and the patients I serve.
During my career I have seen a huge change is the way we practise.We now need to rise to meet the challenge of the loss of dispensing revenue. Services are now expected as the norm but to survive we pharmacists, needing to play catch up, have some unique advantages in the way we operate in primary community care.
The prevention of poor health is a primary care imperative and many models exist where regulation is already in place.There is huge scope for the role of a pharmacist as the medicines expert. Moving into travel health I first recognised that we had an unregulated area of medicine that was dominated by doctors as they had the diagnostic skills and advanced level training.
Travel health is largely undefined and we have a wide range of providers who claim to have an established service ranging from those who supply antimalarials via a PGD to others who will provide full specialist advice. I define a pharmacist-led travel health service to include the supply via PGD of antimalarials and vaccinations following a detailed risk assessment and including the public health message of advisers on food and water hygiene, sun protection, motion sickness, and suppliers of equipment, for example, insect