10th Annual Scientific Conference
The British Travel Health Association
10th Annual Scientific Conference
Birmingham 14th June 2008
Chaired by Prof. Larry Goodyer
Conference presentations were made by a range of national and international experts.
Dr Nick Beeching (Senior Lecturer, Liverpool School of Tropical Medicine) presented an overview and update on a range of insect borne diseases that could be encountered by travellers overseas. Increases in travel to areas of high endemicity for these diseases have been seen worldwide. He described his experience in 2005 with eight British travellers who went on a two week fishing trip to the increasingly popular Gambia; 5 were subsequently admitted to intensive care with malaria. As imported malaria often results in a hospitalisation and may be life-threatening, it represents 80% of ITU admissions due to imported tropical disease in adults, with 10-15 deaths per year in the UK. Other diseases have spread in distribution and in South America there has been a recent increase in the number of regions where yellow fever is a problem and vaccination is now recommended. Dengue continues to cause epidemics in parts of Asia, the Pacific and Central and South America and is increasingly common in travelers. A new tetravalent vaccine against dengue has now entered expanded clinical trials. Chikungunya, spread by the same species of Aedes mosquitoes, is similar to dengue, but often has more prolonged sequelae. The current epidemic began in the Indian ocean islands and spread across to India and Sri Lanka, resulting in 133 cases imported to the UK in 2006. Also worrying was a local outbreak in north Italy in September 2007, and this and the spread of West Nile virus in the USA over the past decade demonstrate how imported vector borne diseases might become established in the UK. The conference was reminded of the danger from other insects apart from mosquitoes and Dr Beeching described a number of cases of tick borne typhus acquired by British travelers after visiting the very popular African game parks.
Dr Nigel Hill (Head of the Disease Control and Vector Biology Unit London School of Hygiene and Tropical Medicine) argued that personal protection measures should be tailored to the circumstances of travel and vector behavior. For instance the species of anopheles mosquito causing malaria in many countries in South America tend to bite out of doors and in the earlier part of the evening, resulting in a limited effectiveness in the use of bed nets to reduce malaria. A recent study by Dr Hill published in the BMJ using a lemon eucalyptus based skin repellent on the local population in Bolivia, demonstrated for the first time that repellents can reduce the incidence of malaria. On the other hand in Sub Saharan Africa the mosquito species tend to bite indoors and later in the evening so the use of insecticide treated bed nets are a key strategy in the prevention of malaria. In the discussion concerning the potential of malaria being imported to the UK he concluded that climate changes could well see the introduction and spread of different mosquito species but doubted this would ever result in the establishment of endemic malaria. Dr Hill confirmed that DEET was still the most effective of repellents, particularly in terms of dose for dose longevity. 50% DEET is now recommended for all higher risk malaria endemic areas. He emphasized the use of insecticide treated bed nets, which were now available as longer lasting nets not requiring retreatment for many years. Another use for insecticides such as permethrin was in treating clothing, a strategy recommended for avoiding tick bites.
Dr Lisa Ford (Lecturer in Travel Medicine Liverpool School of Tropical Medicine) covered travel to environmental extremes and described her own personal experiences of Polar travel with some of the inherent health risks. In her presentation she described the attractions of visiting the Antarctic and the inherent risks that might be encountered. Awareness by travellers of the dangers of exposure to the extreme cold and UV light were viewed as important, particularly in view of the more elderly population attending increasingly popular cruises. She also pointed out that there had been cases of poorly equipped cruises and even some liners not having hulls strengthened against the ice that could potentially have extremely serious consequences. The impact of tourism on the unique environment of the Antarctica was also a cause of growing concern.
Dr Geoff Tothill (Chief Medical Officer, First Assist) gave an overview of dealing with medical emergencies as they arose in remote and environmentally dangerous locations. He summarised the problems of a rise in the mass marketing of trips to remote locations; people often undertook little additional planning, had a false sense of security, lacked an understanding of the environment, had inappropriate expectations of local medical capability and often misunderstood the role of the Assistance Company He explained the key elements of personal and contingency planning and the importance of checking exactly what was being offered in terms of emergency assistance under the terms of any insurance cover. An important part of contingency planning was adequate communication in an emergency and the use of satellite systems, which he illustrated with a multimedia presentation of a real life case in which he had been involved.
Dr Ron Behrens (Consultant in Travel Medicine, Hospital for Tropical Diseases, London) described a controversial view of the lack of consideration to research incorporated in travel medicine practice and policy and even expert opinion can be divided. In a study of 33 European experts given 4 case scenarios describing travel to low to moderate areas of malaria risk there was dived opinion as to whether prophylaxis was required and in the type of medication recommended. He believes that while prophylaxis is justified in high risk areas such as SS Africa current policies may be encouraging over prescribing to destinations in India and South America It is common practice to try and spend time advising on food and water hygiene to avoid traveller's diarrhoea but a Swiss study indicated that despite detailed advice being given it was accurately adhered to by only 2% resulting in 20% of the cohort developing TD. This is compared to 84% being cured of symptoms by the use of a quinolone antibiotic within 72 hours (most within 24 hours) and yet very few travelers in the UK being provided with this treatment. Japanese encephalitis vaccine is currently available on a named patient basis although a new licensed vaccine should soon be available. Current policy is to recommend vaccination for those staying more than one month in certain rural areas of Asia, yet there have only been 33 reports of JE in travelers worldwide 1978-2006 despite very few being vaccinated and even these do not correlate to travel in high risk rural areas. Some interesting observations were made regarding pre travel consultations and how little is known about traveller's health beliefs and attitude to risk, whether health professionals change these attitudes and whether the highest risk travelers actually seek advice. There is some evidence that those who have pre travel advice are more likely to be adherent to malaria chemoprophylaxis, but a study he has recently conducted in his own clinic indicates that those who spend the longest in discussion regarding prophylaxis the less adherent they tend to be. He hypothesized that these individuals were often seeking some confirmation that prophylaxis would not be required.
Mrs Claire Wong (specialist nurse in Travel Health), described recent developments in her organisation, The National Travel Health Network and Centre (NaTHNaC). Since 2002 they have provided a travel health advice line, administered and supported the yellow fever vaccination centers and maintained a website of travel medicine resources. Last year NaTHNaC introduced its own country information pages and outbreak surveillance database, covering vaccine requirements, malaria prophylaxis and a range of other advice relevant to travellers. This is supported by a fully searchable database of disease outbreaks and informs regular clinical updates posted on the site, which is open access.
Dr Kitty Smith (Medical Lead Health Protection, Travel Team, Health Protection Scotland) described the malaria mapping activities of the well established TRAVAX information service that produces country specific information used by health professionals, as well as the 'FitForTravel' site designed specifically for the general public. Their malaria maps, which summarise the levels of risk and chemoprophylaxis recommendations, are among the most frequently used pages on their websites. Dr Smith described how recent detailed mapping had shown a change in risk for the Indian Sub-Continent since 2002. There had been no overall change in risk in Bangledesh 2001- 2004, a reduced risk in India 2003-2006 but experiencing periodic outbreaks, and a low risk in Sri Lanka with unreliable information for the northeast of that country.
Dr Eric Walker (Dean of the Faculty of Travel Medicine, Royal College of Surgeons and Physicians of Glasgow and President of the BTHA) discussed the activities of the Faculty and how it was a truly multi-professional body. He reported that from 2009 entry to the Faculty will be possible by an examination for those eligible to apply. The current activities of the Faculty include basic practical 'nets and bolts' training courses held in various parts of the UK and an annual Travel Medicine Symposium. Work under way include the development of defined professional competences in anticipation of Specialty Recognition and an 'E' Journal from Jan. 2009 which aims to encourage consistent, rational and effective decision making in practice.
Dr Iain Mcintosh Deputy Chair of BTHA chaired a very lively debate concerning the provision of travel medicine education to health professionals, also including the question of competence to deliver and funding for travel medicine services. The general conclusion was that more 'apprentice style' training provision was needed rather than formal education, but the capacity to achieve this widely was debatable. The conference was divided over the question of whether clinics should be available only through certain general practices or private clinics with sufficient expertise, or whether it should be only available privately rather than part NHS supported as at present.
(Part of this article was published in the Pharmaceutical Journal 12th July 2008. www.pjonline.com)
Sarah Buckley Travel health clinic director and former Executive Committee member of BTHA.