Immunisation & Treatment - Travel preparedness and vaccinations

Aida Bakri: 0:00

Welcome to ESWI Airborne. This series on immunization and treatment is made possible thanks to the kind support of AstraZeneca, GSK, Novavax and Roche.

Clare Taylor: 0:27

Welcome listeners to ESWI Airborne. This is your host, Clare Taylor is speaking, and today we're going on a journey through the wonderful world of travel medicine with three distinguished and knowledgeable guests to guide us on our way. First up we have ESWI board member Dr George Kassianos. Good to see you again, George.

George Kassianos: 0:48

Hello, lovely to meet and be with you again, Clare.

Regular listeners to ESWI Airborne will remember George from our episode on vaccinations for pregnant women. George, that was really a comprehensive overview that you gave us then. Now for today, tell me about your interest in travel health.

Well, Clare, I'm alive. Therefore I travel. It comes naturally to any human being to want to travel, to discover. How else do I appreciate what I have and enjoy, but also what I don't have? Travelling allows me to see, discover, enjoy, stay in other places and reach my knowledge about other countries, but also the infections they do battle with. And as I travel, I am becoming a greater and greater advocate of infectious disease prevention, not only for our travelers, but also for the indigenous population. As a family physician, my particular interest is vaccines and prevention of disease. Remember, Clare, what Louis Buster said, which is this: when meditating over a disease, I never think of finding a remedy for it, but instead a means of preventing it.

OK, so our focus is on prevention today, folks, and next I'd like to bring in Dr Dipti Patel, director at the National Travel Health Network and Centre in the UK. Dipti, you're both a consultant in occupational medicine and a travel medicine physician, so how do you see the link between travel health and occupational health?

Dipti Patel: 2:36

Yes, thank you. It's a pleasure to be here. Yes, so I guess the easiest way to explain the link between occupational health and travel is that occupational health is concerned with assessing and managing the risk that workers might be exposed to, and that risk might include international travel and many occupations journalists, aid workers, diplomats, air crew travel is part of their work. And then, I guess, at a more fundamental or practical level, both specialities are associated with assessing risk and managing risk in individuals that aren't presenting with illness generally, but presenting for advice and prevention of illness.

OK, so we're prevention again. Thanks, Dipti. Now I'm really honoured to welcome our third expert on travel medicine, Professor Robert Stephan, I understand that you're regarded as the father of travel medicine and your professional achievements are too many for me to list here because we'd be here for the next half hour and more. But I understand that 20 years ago you authored the Manual of Travel Medicine and Health and this is kind of like a Bible for travel health professionals. So this is a big question. But how have you seen the field of travel medicine evolve since then?

Robert Steffen: 3:56

Since the turn of the millennium, many scientific studies have been conducted and the evidence on which recommendations are based is much improved, If I say improved, but not superb. Yet we are lacking much of the needed information. For instance, to a large extent we lack of data on what is happening to travelers while they are abroad. But there are new studies which are going to clear these questions as well.

Okay, that's an interesting start and I suppose, to come in from really a layperson's perspective. I mean, Dipti referenced that people have to travel for their work often, but why is it important to get vaccinated before you travel?

I guess there's two main reasons. First of all, it's to protect you as an individual when you are traveling to infectious disease risks that you might be exposed to, and I guess the bit that people forget about is that vaccination has a wider public health role to either prevent introduction of disease into a country that you might be traveling to or bringing that disease back to the country that you live in, and to protect people that might not be vaccinated against disease or can't be vaccinated against certain diseases, measles being a good example of that?

Yes, George. Do you have any comment there? Because I think you noted also that prevention to the indigenous populations was an important aspect.

Yes, indeed, we are interested in the health of our travelers when they travel abroad, but also we're interested in the health of the indigenous population as regards to the infectious diseases they have to battle with.

Now I suppose for most of us that maybe we travel a little for work or not a lot, but the recent COVID-19 pandemic was really the first time that everyone became very aware of this necessity to vaccinate in order to travel, and of course, it was a public health emergency. And, Robert, how did that impact on the field? How did you see travel medicine change?

Well, actually, when I started to do travel medicine, I had to vaccinate against smallpox just to enter the United States, and so vaccinations that have been required, that has existed for ages, and still there is yellow fever vaccination, which is a requirement for mainly destinations in Africa and South America but also to participate at Umrah you need to be protected against meningococcus disease. So, required vaccinations were on the menu list, if I may say so, for travellers even before we had these requirements with respect to Covid-19 vaccine, which actually no longer exist right now.

And Dipti, did you see any changes from your perspective?

Yeah, I mean, I think obviously early on in the pandemic there wasn't much travel and then when it started being reintroduced or travel started again, I think there were things that you sort of noticed in terms of health professionals. Certainly some of them had less confidence in advising because there were sort of rapidly changing sort of guidance and policy changes that countries were introducing. But we also had to practice travel medicine differently. So you know things like PPE that we probably wouldn't have used previously when we were vaccinating individuals. And then I think one of the things that came out of it is there was a lot of focus on COVID and people perhaps were forgetting other disease risks that might exist. And then now, sort of now that travel has restarted, I guess the key thing that we're seeing we have a website that's available to the general public and we can analyse sort of usage of that website and what we are seeing is a different pattern of usage. Our website has information on countries and what we're seeing now is that historically we would have seen the most popular countries visited on our website would have been the long haul tropical destinations India, Thailand, South Africa and now what we're seeing is the most popular countries being visited on our website are the European destinations, sort of France, Spain, Italy and I think that, hopefully, is reflecting that people are researching their health needs more than they perhaps would have previously and are seeing that travel might impose certain risks or restrictions, so hopefully there's a better awareness in travellers as well. So I would say that those are probably the key changes that we're noticing. It's a different pattern of sort of research that's occurring.

This would be fabulous, because we all know that so far, or pre-COVID, only a minority of the travellers, even to high risk destinations consulted either with a travel clinic or the family physician, and so possibly the immediate future looks much better.

That's interesting. How small is the minority?

Well, that depended on the continents. But, for instance, we know from a survey conducted in Boston that only some 20% got immunised against hepatitis A, despite the fact that this is certainly recommended for travellers going to high or intermediate risk countries, that vaccination.

And Dipti, have you seen a bigger volume of visits to your website?

Yeah, so that's the other thing. So at the moment we don't know whether it's travellers or health professionals, that we just have data on whoever visits. But we certainly noticed a huge spike during COVID, particularly obviously countries like China and Italy, which first had the sort of cases that people were interested in initially, and then now we're still seeing an increased volume, certainly ahead of pre-2019 levels of traffic on our website, which again is a good thing. How that might translate into people actually visiting travel clinics, their GPs or pharmacists for advice, I don't know, but certainly it feels like people are researching more than they were pre-COVID.

Okay, great. Well, that is good news, I guess, for this field, which doesn't get the attention it deserves. And so far we've mentioned several different types of vaccines and what are the most widely used ones currently?

So I don't think that the, sort of, in terms of the vaccines that are most widely used things have changed very much. I mean, obviously the ones that are most widely used will be the ones which are most prevalent in the countries that you might be traveling to. So I guess hepatitis A and typhoid will always come up top of the list of travel-related vaccines. But of course, travel appointments are often a time for people to update themselves on their routine vaccines that might need for life in their home country. So you may find that people are getting tetanus, polio, diphtheria vaccines as well when they're attending travel appointments. So I would say that hepatitis A and typhoid probably is travel-related vaccines. But then of course there'll be other diseases, like flu, that you might have in your own country, but you might have it for travel purposes as well, because you might be more likely to expose to influenza during your travels or encounter influenza during your travels. And I guess, while COVID-19 vaccine isn't a travel vaccine, that's something that we might need to think about in the future. Some countries still have a requirement for you to be vaccinated before allowing you to enter or have testing before you enter. Very few now, but they still exist.

Actually, I have just looked at the statistics of the Zurich University Travel Clinic and the number one vaccine which was used there was the one against guess what - rabies. And typhoid actually we rate as rather of little interest, except for the destination of South Asia.

I think in the UK hepatitis A and typhoid, and George will probably correct me if I'm wrong, they're both available on the National Health Service, so I think that it might get more usage in the UK than perhaps in other countries. So it's available to people through their GPs free of charge, whereas other travel vaccines predominantly have to be paid for.

George what's your take here?

It is important really to also look at the way healthcare professionals get their information so they can advise their patients. In the UK we are fortunate enough to have two travel advice centres the National Travel Health Network Centre, which we call short NAFNAC, which is based in London and of course Dipti is leading on that and Travax, which is based in Scotland. Now these centres advise us also on the vaccines that are needed according to the traveler's destination, and this allows, Clare, more uniformity in the advice we all give to our travelers. They come to us, of course, for vaccinations, but we get a chance to give them also advice on how to stay healthy abroad, particularly as regards to mosquito bite avoidance, the clothes they should wear, hand hygiene, water and food safety, sun exposure, sexual health, as well as taking medication when they go abroad. And we SGPs in the UK, when we see our patients in the travel clinic, we have a chance to bring them up to date with other vaccinations they may still need that are routine here in the UK. For example, if you have a young patient going abroad and they haven't had their human papillomavirus vaccine, or if you have an older adult who has not as yet had their pneumococcal or shingles vaccination, we can actually do it.

On the traveller side, there's also a source of really good information, and a lot of people abroad also know this. Is the Fit for Travel website, which is maintained by Travax and which one, in fact, it can be accessed by going on to www. fitfortravel. nhs. uk. And the other travel vaccine is influenza vaccine. During the influenza season it also is very important throughout the year for travelers to tropics and subtropics. And of course, don't forget, as Dipti mentioned, the COVID vaccine, which is changing dramatically, as Robert mentioned, it is now going to be monovalent but no longer will contain the Wuhan strain. It will contain the new Omicron variant XBB, which is basically a recombination of two or more lineages of Omicron that then form the XBB lineage, which now forms the basis for the autumn COVID-19 vaccine. Currently, the XBB lineages actually dominate around the world.

That is interesting to hear how it's changed over time and has to be updated, both the vaccine and the information, public information provision. There were some extremely useful references in that, George. Robert, do you want to comment on that?

I fully agree. It will continuously need to be updated with the latest news on epidemiological situations.

Thank you, that's from the father of travel medicine from the horse's mouth, let's say. Now, honing in on the individual, what are the profiles, say the occupational profiles that we're most concerned with, like I'm thinking immediately of pilots and airline staff, as a very obvious example? Robert, what can you tell us about this?

Well, actually, cockpit and cabin crews are not my major concern. As an aviation medical examiner, I know that major airlines are well aware on what vaccines are essential to keep the crews in good health. Additionally, my staff requests that all consulting me for a checkup, be they pilots or other people, should bring their vaccination certificates. Who am I concerned with? Actually, mainly with the VFRs, those visiting friends and relatives who often believe that they will stay healthy as they are just going home. This is the population at highest risk abroad and, at the same time, the one often not consulting any health care professional, be that in a travel clinic or the family physician.

Wow, ok, so it is not who I would have suspected anyway.

Yeah, I mean I would agree with that. I think, on the whole, big organisations sending individuals out overseas have good systems in place to help support them, so those sorts of organisations I wouldn't be as concerned about. I mean, there are specific issues to occupational groups, particularly groups that might be doing quite dangerous work or sort of high-risk work. So journalists, aid workers, but I think for us as well, those that are visiting friends and relatives, um, are the group that we would be most concerned about for two reasons. Firstly, because they often don't see risk in the same way, but also they and they aren't accessing health care to uh, or accessibility to health care is different, or their sort of health care behavior is different. So they're not getting the advice that perhaps the leisure traveller might get, because for them it might be just I'm visiting family back home.

Isn't it interesting the way we think about it. Yes, I'm going home, I'll be safe. So, when we're talking about occasional travellers, I think we've referenced some good addresses for where they should seek advice. This is something you can go online for, or you should go to your GP, or what do people do in this instance?

Yeah, I think so. Obviously there are websites. So George has mentioned Fit for Travel from Scotland and NaTHNaC's Travel Health Pro website, which is another comprehensive resource. Obviously, different countries will have different resources, so the US will have the US CDC Traveller Health, Canada will have something similar, I think Switzerland I'm not sure what exists in Switzerland, but certainly there are other national resources that can be addressed. The other thing is a lot of people still want to go to their family doctors for advice and I guess, I mean George might have some views on this, but I think it's our duty as healthcare professionals particularly if we're seeing that VFR group, if you're seeing them for other reasons really to ask them about whether they have plans to travel, because they generally will, and then that's an opportunity to sort of highlight that they might want to get advice before they go or seek advice.

This is a problem with the occasional traveller and generally travellers actually that we think they're going to actually come and see us before they travel. Not always actually, they do that. But on the other hand, they may be prompted by their travel agent or they may see something on social media and go to a travel clinic to get advice. The problem is that they don't allow usually enough time before the date of travel when they come to see us. We would like them to come and see us if possible three months before, that doesn't usually happen, but at least six to eight weeks before they travel. But in reality they actually come just before they are due to travel or a week or two before that. And of course they can go to the travel clinic. They can go to a number of pharmacists who also give advice on travel, but they can go in the UK also to the IGP, because most of the GP practices actually have a travel clinic. And what drives that? What drives that is the fact that there are four vaccines that are given entirely free on the NHS as long as Nothlac indicates that the patient is going to be at risk, namely they are typhoid, cholera, hepatitis A and polio. But at least we have a chance to actually see them and talk to them about prevention of disease when they're actually abroad. And of course the next problem is how quickly they can get an appointment, so valuable time before travel is not lost.

Okay, so prevention, preparedness, really being emphasised here, and that's about the outbound journey. What about the inbound journey? Say when people return ill after a trip? George, you're a GP. Do doctors ask about recent travel say, when a patient presents with a fever?

Well,GPs and nurses do see patients with fever every day. Sometimes it is obvious what the problem is. For example, it could be acute tonsillitis. In a situation like this, I doubted whether a GP or a nurse will take a travel clinic, a travel history. On the other hand, there are cases where the fever the patient has is unexplained. The patient may present with a skin rash or flu-like illness or generally feeling unwell. In a situation like this, I think many of my colleagues will inquire about recent travel abroad. Not to do so may delay the diagnosis or cause deterioration of the patient's condition because the diagnosis has not been made, because you haven't actually asked about travel. And that's actually very important that we do remember to ask if they have been recently abroad and where they have been, and built on that to actually really get to the final diagnosis.

Actually, if I may briefly underline what George just said, particularly during the seasonal flu epidemic, when we as GPs see many patients with fever and possibly complications of influenza, there might be an odd case of malaria in midst of that crowd and that would result in a very dangerous situation if we do not realise, okay, traveller X returned from abroad and he may have malaria, so let's check for that.

Actually, something else may be happening and at the last ESWI meeting in Riga there was a presentation where there were 15 travelers in Finland traveling to meet West Africa. There they all fell ill and they were all treated very well for malaria. They came back and they were checked again and what they found the problem was influenza.

The other way around.

The other way around, but it brings in this, I mean, a lot of this depends on where you travel, right? So what are the hotspots or the high risk routes, Robert, that you would look out for?

Overall, my number one as a hotspot is South Asia. In clear text that would be India, Pakistan, Nepal, but with respect to malaria, clearly tropical Africa.

I mean, I think, yeah, I would agree. If you're talking about serious disease, then for UK travellers, West Africa, in terms of malaria, is the biggest risk. As you said earlier, it does depend on travelling patterns, and how UK travellers travel might be slightly different to how Swiss travellers travel. But yes, I think we have a lot of traffic between the UK and South Asia. We have a lot of traffic between the UK and West Africa as well, and certainly, if you look at our malaria data, West Africa is the hotspot for malaria. And then I think it's being aware of what is happening at the time of travel. So things change very rapidly and Robert mentioned how dynamic things are and I guess at the moment, while it's not vaccine preventable, we've got to think about extremes of temperature. We've got the situation in Europe where we've got sort of risks of wildfires, but also heat exhaustion and other things. So I think you have to stay up to date with what's happening, and and be aware of sort of what might be occurring, because things can change quite quickly.

Actually Dipti, just a little comment - not all Swiss travellers are rich bankers. We also have people travelling who are on a low budget, and that very often puts us in a difficult situation, because in Switzerland travelers often have to pay for all their vaccinations. So those who are at highest risk because they travel on a low budget have the least amount of money to spend for their vaccines, while those going to five-star resorts they wouldn't need too many vaccinations because the risk as compared to the backpackers is certainly less.

I think that's a really important point because, again, in the UK, while some vaccines are available on the NHS, most travel medicine is privatised. And again it can cost an awful lot of money to, perhaps if you had a family going to somewhere on safari to East Africa, that could add quite a lot to your budget. But people, the middle classes might be able to afford that. But someone who is on a budget may choose, may pick and choose what they'll have based on their resources.

This opens up so much I feel we could probably do another episode on it. Actually, this is a really interesting point to cover. Um, I will say um, when we kind of look at this, there's different places we've touched upon and the need to stay up to date in a very dynamic and fast changing world. What do you see on the horizon for travel medicine? I mean, is it equitable access perhaps, as we touched upon as a public health issue or what do you see as the next major change or evolution in this field? And I'd like to hear that from each of you. Dipti, I'm going to start on you with an impossible question.

I mean, I think I was thinking about this as a couple of things. I think sort of how, how travellers I hope that the pandemic has sort of changed how travellers behave and how they do their research, some of the sort of good practices we had like respiratory and hand hygiene. I hope that would continue. I don't know if that's the case, but I was sort of thinking sort of in the short term, there are some new vaccines that are going to become available or are available in some countries that didn't exist. So a traveller vaccine for dengue is on the horizon but in some countries is already being used. And then I was thinking more sort of generally things like artificial intelligence in healthcare. I think there's a whole area around information that may be available and more accessible, but of course we have to balance that with misinformation. And then the other area that I was thinking about is that extreme tourism. We've now had we've had commercial space flights, so while it's not an area of travel medicine, I do wonder if, sort of like, there's going to be a push towards doing things that haven't been done before, and of course that then brings additional risks to it.

What an extraordinary notion, extreme tourism. I shudder rather. George, what do you see on the horizon for travel medicine?

I think COVID-19 has enabled new technologies to enter the contest of formulating new vaccines. I see the malaria vaccine effectiveness improving with the new technologies and more vaccines against mosquito-borne disease being made available Already Dipti mentioned that we do have now a vaccine in some countries against dengue, but also Zika and chikungunya vaccines are not really far. As part of global health I see great improvement in combating disease locally, where infectious disease is thriving. Formulating more effective vaccines, we all agree, is very important, but so is the elimination of infectious diseases where they exist.

Very good. Robert, what do you see happening in this field?

Well, adding on to what Dipti and George said, I have a further area, and that concerns that research conducted during travel abroad. We do have first indications from people who collaborated in pilot studies and who reported about their problems while they were, for instance, in Thailand. And to somewhat our surprise actually, dermatological problems are very important, not only following insect bites, but also trivial things like sunburn. And also the psychological stress during travel seems to play a much larger role than we ever thought of. And so travel medicine might need to be redirected to some extent also to prepare travellers for these challenges they face while they are abroad, because that's of concern.

So we might be seeing a more holistic approach to travel medicine.

How interesting. That is the last word. Thanks to all of you for taking the time to be here with us today. And thanks to you folks for tuning in today to ESWI Airborne. I hope you learned a lot about travel preparedness and vaccination recommendations today. I know I sure did. A reminder that this episode is one of a three-part series on immunisation and treatment, so we've got more coming up, stay tuned. For example, on how lessons from the pandemic can change how we deal with flu prevention and treatment. Don't miss it. Happy travels to all of you VFRs visiting friends and relatives and until next time, dear listeners, stay safe.

Aida Bakri: 32:51

ESWI Airborne is brought to you by ESWI, the European Scientific Working Group on Influenza and other acute respiratory viruses. These episodes would not be possible without the team's efforts and we would like to extend special thanks to our ESWI Secretariat, our technical and IT teams, our arts team and our host, Clare Taylor. The podcasts are recorded virtually and we thank our guests for their participation in this inspiring series. Talks are adapted to a global audience and are intended to be educational. For any specific medical questions you may have, these should be addressed to your local general practitioner. Many thanks to our sponsoring partners and thank you for listening.

Immunisation & Treatment - Travel preparedness and vaccinations

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