RCN Travel Health Nursing: career and competence development

CLINICAL PROFESSIONAL RESOURCE

RCN Travel Health Nursing:

career and competence development

The RCN would like to thank all those who have supported the development of this document,

especially the nurse specialists who have ensured it remains at the forefront of travel

medicine practice across the UK. Three of the current authors were involved in the original

and revised RCN documents in 2007, 2012 and 2018. They are all members of the RCN

Public Health Forum and Fellows of the Faculty of Travel Medicine of the Royal College of

Physicians and Surgeons of Glasgow.

We would also like to acknowledge the contribution of Lorna Boyne who was involved in

the publications prior to 2023. The current authors are all involved in national and

international bodies and committees within the field of travel medicine.

Authors

Jane Chiodini MBE, Travel Health Specialist Nurse, Immediate Past Dean, Faculty of

Travel Medicine, Royal College of Physicians and Surgeons of Glasgow

Sandra Grieve, Travel Health Specialist Nurse, Lead Nurse Travel Health for the RCN

Alexandra Stillwell, Travel Health Specialist Nurse, National Travel Health Network and

Centre (NaTHNaC)

Clare Walker, Senior Nurse Specialist (Travel Health), Travel and International Health

Team, Public Health Scotland

Statement of interest: Jane Chiodini is Founder and Director of Travel Health Training Ltd.

Acknowledgements

This publication is due for review in May 2026. To provide feedback on its contents or on your

experience of using the publication, please email publications.feedbac[email protected]

RCN TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT

Foreword and introduction 6

1. How to use the competency framework 9

Producing evidence – revalidation 9

2. Travel health services in the UK 10

Introduction 10

Education and professional support – a historic overview to current day practice 11

Historical information 11

Current education in travel medicine 11

Nurse specific contribution to UK travel health 12

Travel health service factors 12

Service delivery 12

Governance within travel health settings 14

Financial provision 16

Prescribing, supplying and administering travel vaccines 16

Administration of travel vaccines 18

Indemnity cover 18

3. Pre-travel risk assessment and management 19

Introduction 19

What is a pre-travel risk assessment? 19

Information about the traveller 20

Information about the traveller’s itinerary 20

Reasons for asking questions 20

Age and gender identity 21

Medical history 23

Medication 25

Allergies to drugs or food/reaction to vaccination 25

Previous travelling experience 26

Current knowledge and interest in health risks 26

Travellers visiting friends and relatives (VFRs) 26

Female genital mutilation (FGM) and forced marriage 27

Contents

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Previous vaccination history 27

Additional needs 28

Destinations 28

Departure date 28

Length of stay 29

Transport mode 29

Purpose of trip and planned activities 29

Medical tourism 30

Quality of accommodation 31

Financial budget 31

Health care standards at destination 31

Performing risk assessments 32

Appointment guidance 32

How to conduct a risk assessment 33

Steps to follow after a risk assessment 34

Documentation to accompany the travel consultation 35

Conclusion 37

Important information to note 37

4. The competency framework for travel health nurses 38

Core competency 1: General standards expected of all nurses working in travel health 38

Core competency 2: Travel health consultations 40

Core competency 3: Professional responsibilities for nurses working in travel health 42

5. References 45

6. Appendices 56

Appendix 1:

Sample travel risk assessment form 57

Sample travel risk management form 59

Appendix 2:

Summary of travel health-related information sources 61

Essential guidance documents for travel health practitioners 61

RCN TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT

Essential resources for day-to-day-practice 61

Other related useful resources 62

Professional development in travel health 63

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Foreword and introduction

Before the arrival of the SARS-CoV-2 pandemic, travel health was an expanding and

challenging specialist field of practice. In a post-pandemic era, travel, health, and

climate change issues globally, are likely to increase these challenges for travellers and

practitioners. In the UK, travel health services are mainly delivered by nurses, mostly,

but not exclusively, in primary care settings. Pharmacists are increasingly providing

advice and flexible services for travellers. Travellers include people of all ages and ethnic

backgrounds going abroad for a variety of reasons. Their needs vary, are increasingly

complex and may be compounded by ongoing pressures on general practice and differing

requirements of host countries. One of the greatest challenges in travel health medicine is

that the world order can change in an instant and without warning.

Despite natural disasters, disease outbreaks and terrorism threats, pre-pandemic the

number of travellers from the UK was rising year-on-year. Mass migration, often by

people displaced from war-torn countries, also affects tourism in destinations frequented

by British travellers. As the pandemic affected all countries, the situation changed

dramatically with borders closed and international travel and tourism ground to a halt. Few

people required travel health services and practitioners were redeployed to support the

pandemic effort.

As travel began to resume, another global catastrophe emerged in Ukraine. Travellers are

becoming adept at researching options and choosing destinations deemed to be “safer”.

With added factors now to consider, planning a trip overseas has become a logistical, and

often expensive, exercise. Cruising in international waters was suspended from the UK

and elsewhere for a considerable time. Solo and adventure travel companies also ceased

offering bespoke holidays in exotic and remote destinations. The UK is a multicultural

society with many settled migrants returning to their country of origin to visit friends and

relatives (VFRs). They may not present for pre-travel advice but as the rate of imported

disease can be higher in this group, it’s important to reach out to them (NHS, HEE). The

VFR group continued to travel “home” during the pandemic (ONS, 2021).

Directional guidance and resources are continually improved and available to both

practitioners and the public. Health professionals are reminded to refer to national

websites such as NaTHNaC, TRAVAX and fitfortravel for updates and current evidence-

based information. Expanding technology and social media outlets also provide access

to advice. For example, nurses can access education and training through in-person or

virtual conferences, or through e-learning portals. With internet connections and instant

communication increasingly available in remote locations, travellers can stay informed

when abroad. This publication reflects these changes.

The RCN Public Health Forum resources are available through the travel health pages

on the website at: rcn.org.uk/Get-Involved/Forums/Public-Health-Forum. These pages

are regularly updated, related to all four UK countries and linked to further resources

through the RCN Library. Please note, the terms travel medicine and travel health

are often used interchangeably. In general, within this document, when referring to a

service, the term ‘travel health’ is used, and when referring to practitioners, the term

‘travel medicine’ is used.

This is the fourth edition of published guidelines and standards in the field of travel health

medicine. Previous documents have inspired nurses in Australia, Japan, the Netherlands,

New Zealand and the USA to develop their own guidance. In 2020, travel health nursing

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gained speciality recognition in the USA through the American Nursing Association

(ANA) (Richards and Rosselot, 2021). Following an audit and evaluation (Currie, et al.,

2017), revised editions of this document continue to respond to the survey by retaining

and updating elements that nurses find most useful, for example, the pre-travel risk

assessment and risk management which underpin the pre-travel consultation and form

the keystone of travel medicine practice. Following a Nursing and Midwifery Council

(NMC) Fitness to Practice case related to travel health advice, these forms were carefully

developed to help the nurse document in a simple but efficient way in order to offer

as much protection as possible. These forms have again been updated to reflect the

changing nature of the discipline and to travel health service provision.

Undertaking the delivery of travel health services requires competence, as defined in ‘The

competency framework for travel health nurses’ on pages 38-44. The NHS Knowledge

and Skills Framework (RCN, 2005) has core and specific dimensions, descriptors and

indicators, describing novice to expert level. This enables nurses to identify their current

level and see how they can progress to a higher level of competence. Competencies

are the essential building blocks that shape nursing work in all clinical and practice

settings. As practitioners acquire skills, knowledge, understanding and confidence

in their field, they are able to demonstrate how they meet increasingly challenging

levels of competence (RCN, 2018, Chiodini et al., 2020). Therefore, an expert nurse

is able to function across the entire range of descriptors of practice. Information on

current guidelines and standards for the care of travellers by appropriately registered

practitioners has been revised and updated. The focus remains on the work of a registered

nurse, defining standards expected for:

• competent nurse (level 5)

• experienced/proficient nurse (level 6)

• senior practitioner/expert nurse (level 7).

The information is equally applicable to other qualified practitioners providing travel

health services, including doctors and pharmacists.

Several political and professional issues and initiatives continue to be addressed, including:

• a need for leadership in specialist nursing

• a need for development of standards relevant to all four UK countries

• increased focus on work-based and lifelong learning and supervision

• changing focus towards professional rather than academic accreditation.

NMC specialist practitioner’s accreditation for public health nursing:

nmc.org.uk/standards/standards-for-post-registration/pre-2022-post-registration-

standards/standards-of-proficiency-for-specialist-community-public-health-nurses

Nurses continue to contribute to the travel health agenda through several national and

international bodies. Formal training and qualifications in travel medicine have been

available in the UK since 1995. The Faculty of Travel Medicine (FTM) at the Royal College

of Physicians and Surgeons of Glasgow (RCPSG), was established in 2006. The FTM

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publications (Chiodini, et al., 2012 and Chiodini et al., 2020) are complementary and can

be used in conjunction with this document to support nurses, doctors and pharmacists

delivering travel health services to achieve optimum safe practice for practitioners and

travellers. For doctors and nurses working in general practice and the private travel sector

in England, the recently published guidance from the Care Quality Commission (CQC)

should also be observed (CQC, 2022).

It is anticipated that expert nurses, as described in this document, should have sufficient

qualifications and experience to be awarded FTM membership.

With the process of revalidation now in place, this updated integrated career and

competency framework remains important for travel medicine practitioners. We hope this

document continues to meet the needs of those delivering travel health services in this

dynamic area of practice.

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1. How to use the competency

framework

Nurses working in the field of travel health practice work in a variety of settings, including

primary care, occupational health, NHS clinics in secondary care, private travel clinics, armed

services, universities and schools. The scope of practice depends on a variety of factors,

which vary between settings and the different requirements for the NHS or the private

sector, for example. Therefore, while the broadest spectrum of practice has been included in

the descriptors and levels of practice, some elements may not be covered. The descriptors

and levels do however provide an indication of the expected ability to function at that level.

Producing evidence – revalidation

Health care professionals are responsible for producing their own portfolios of evidence

of competence. Revalidation came into effect in April 2016 and is a process that nurses

and midwives in the UK need to follow in order to maintain their professional registration

with the NMC.

Every three years, in order to renew NMC registration, nurses must produce or maintain a

revalidation portfolio that demonstrates:

• 450 practice hours, or 900 if renewing as both a nurse and midwife

• 35 hours of CPD including 20 hours of participatory learning

• five pieces of practice-related feedback

• five written reflective accounts

• reflective discussion

• health and character declaration

• professional indemnity arrangement.

On completion, a confirmation declaration is signed and submitted online to the NMC.

For more information on revalidation visit: nmc.org.uk/revalidation

While this framework provides comprehensive guidance for nurses working in travel

health, it should be used flexibly and within the context of meeting revalidation

requirements. It can help individuals to determine the scope of their current level of

practice, determine current and future development needs, and can help prepare

individuals to progress into roles in line with changing needs in the field of travel health.

Please note, the title ‘nurse consultant’ is referred to in this publication. This is defined as

a clinical expert in travel health/medicine with responsibility for travel health/medicine

leadership, including strategic development of policy and practice, research, education

and advanced clinical practice. Also, advanced knowledge of national and international

innovations that contribute to travel health/medicine service provision. For further

information, visit the clinical pages on the RCN website at: rcn.org.uk/professional-

development/your-career/nurse/career-crossroads/career-ideas-and-inspiration/clinical

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2. Travel health services in the UK

Introduction

Historically, travel health advice was mostly, but not exclusively, delivered in primary care

settings. Other providers offering travel health services include private travel clinics,

occupational health sectors (NHS and industry), military facilities, universities and

schools. Pharmacists are becoming more involved, offering appointment flexibility, which

is more acceptable to the travelling public.

Understanding travel patterns and destination preferences for travellers from the UK is

valuable for those advising travellers. Travel and tourism data is collated through the Office

for National Statistics (ONS, 2021), previously through the International Passenger Survey.

The survey was suspended during the pandemic, so accurate data for that period is scarce

and should be viewed with caution. ONS conducted a review of travel and tourism statistics,

and recommended a new hybrid method of collecting data (ONS, May, 2022).

Undoubtedly, international travel and tourism was severely affected by the pandemic. As

countries continue to attempt recovery, the United Nations World Tourism Organization’s

(UNWTO) dashboard on COVID-19 and tourism, shows data on the impact of COVID-19

on the tourism sector globally, regionally and by destination. This is a comprehensive

resource providing current information and statistics (UNWTO, 2022).

In 2021, there were 1 billion fewer international tourist arrivals globally. Figures dropped

everywhere, including by 93% in Asia Pacific, which was previously predicted to see

increased growth. Most international borders were closed leading to a loss of revenue

from tourism and trade. Many jobs related directly to tourism were lost or put at risk.

International tourism began to recover in 2022, but the pace of recovery was impacted

by further COVID-19 variants and the re-introduction of travel restrictions in several

destinations.

People travel abroad for a variety of reasons, including business trips, holidays, study and

visits to friends and relatives (VFRs). In 2021, the number of visits abroad by UK residents

was 80% down on 2019 figures, when visits reached 93.1 million.

As travel restrictions eased, holidays, followed by visits to VFRs remained the most

popular reasons for travel from the UK, with Spain and France the top destinations. The

UNWTO provides the most current global data (UNWTO, 2022).

Whilst some travellers seek travel health advice before they leave the UK, surveys indicate

that a significant number still do not see a health care professional before departure

(LaRocque et al., 2010; Schlagenhauf et al., 2015, NaTHNaC 2021a).

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Education and professional support – a historic

overview to current day practice

Historical information

Formal education in travel medicine commenced in 1995 at the University of Glasgow

in collaboration with the Scottish Centre for Infection and Environmental Health (now

Public Health Scotland). In those early days, courses at Foundation, Diploma and Masters

level were developed. In 2003, full management and administration of the Diploma and

Foundation courses transferred to Health Protection Scotland with the Royal College of

Physicians and Surgeons of Glasgow (RCPSG) conducting assessments and awarding

the Diploma qualification and course certificates. The Masters element of the course was

taken into a new format (Global and International Health) at the University of Sheffield,

but this has been discontinued.

In 2006, the Faculty of Travel Medicine (FTM) was formed within the RCPSG – the only

faculty of travel medicine to exist in the Northern Hemisphere. The aim of the faculty is to

lead the way in raising standards of practice and achieving uniformity in provision of travel

medicine services to protect the health of travellers. This was the first time that nurses

and pharmacists were eligible to become Associates, Members and Fellows of the FTM

in this medical Royal College, using aligned post nominal qualifications to denote their

seniority and experience. The FTM acquired responsibility for the Diploma and Foundation

courses in 2011. They also developed the Membership of the Faculty of Travel Medicine

examination (MFTM), so that practitioners could take a membership examination (with or

without undertaking the Diploma course). Successful candidates were eligible to join the

faculty and use these post nominal qualifications. The MFTM examinations were paused

prior to the COVID-19 pandemic and news of their return is still awaited.

Current education in travel medicine

A number of private companies provide an entry level introductory two-day training course

in travel health. The suggested curriculum and trainer qualifications were described

in Good Practice Guidance for Providing a Travel Health Service from the Faculty of

Travel Medicine (Chiodini et al., 2020). For further information, see pages 15 to 17 in

this publication, which can be found at: rcpsg.ac.uk/travel-medicine/good-practice-

guidance-for-providing-a-travel-health-service

In 2019, a Professional Diploma in Travel Health run by the Liverpool School of Tropical

Medicine developed together with NaTHNaC, was launched. The online course can be

studied over six to 24 months. NaTHNaC also provides other short courses which can

be viewed on their website. In addition, TRAVAX provides details of courses – see the

‘Education and training in travel health’ section on page 64.

The Faculty of Travel Medicine provides a pathway of education in travel medicine,

including a Professional Development Certificate which launched in 2021. The online

course takes six months to complete.

In January 2022, a new RCPSG Postgraduate Diploma in Travel Medicine, credit rated by

Glasgow Caledonian University (GCU) was launched, providing students with 120 credits

at Masters level, and allowing admission to membership of the FTM if successfully

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passed. Those who successfully complete the RCPSG Postgraduate Diploma in Travel

Medicine may then progress to a higher qualification, a Masters in Advanced Practice

(Travel Medicine), studying at GCU. The RCPSG also provides a Postgraduate Diploma in

Expedition and Wilderness Medicine, which enables successful students to progress to a

Masters in Advanced Practice (Expedition and Wilderness Medicine), also at GCU.

Nurse specific contribution to UK travel health

Nurses have been at the forefront of travel health care in the UK since the early 1990s,

and the RCN was among the first bodies to recognise travel health nursing as a specialist

area of practice. In 1994, the RCN Travel Health Group – which subsequently became a

special interest group and then a forum from 2000, began to produce newsletters and

hold conferences for nurses working in the field. Membership of the group exceeded over

5,000 at its height and was highly active in the support of education and standards for

nurses working in the field. In 2010, the RCN Travel Health Forum was merged into the

RCN’s Public Health Forum.

Nurses continue to work in leadership roles within the RCN Public Health Forum, the

Faculty of Travel Medicine (RCPSG), the National Travel Health Network and Centre within

the United Kingdom Health Security Agency (UKHSA), and the Travel and International

Health Team of Public Health Scotland (PHS). Nurses qualified in travel medicine also

provide the majority of the entry level training to this field of practice.

Travel health service factors

Who can deliver travel health care?

Travel health care can be delivered by registered health care practitioners who are

appropriately trained and demonstrate competence in this field of practice. Nursing

associates became registrants under the NMC in January 2019 (NMC, 2018b), so since

the last review of this publication, they became a new group of nurses who could

deliver travel health services. Currently, there are certain prescribing obstacles for the

administration of travel vaccines for this particular group that need to be taken into

consideration as explained under the ‘Prescribing, supplying and administering travel

vaccines’ section on pages 16-17.

Service delivery

Service delivery does vary between the four countries of the UK as described below.

England

In 2019, NHS England and NHS improvement published a document: Interim findings

of the Vaccinations and Immunisations (NHS England, 2019), which looked at a review

of this subject in preparation for the forthcoming five-year framework for GP contract

reform, being undertaken at the time. From April 2020, the GP contract included the NHS

travel vaccines to be given in general practice as an essential service (as opposed to an

additional service in the previous contract) (BMA and NHS England, 2020a). The outcome

of this decision meant that for travel, a GP surgery in England must provide travel health

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services including all the NHS travel vaccines as this service is paid for within their global

sum. Therefore, whereas previously it was feasible to opt out of a travel service, from

April 2020 and thereafter for the five years of the contract, the service of travel health

must be provided within an NHS GP surgery. This includes undertaking a pre travel risk

assessment, travel health advice, administration of the NHS travel vaccines and malaria

prevention advice. In addition, other identified risks, including those where a private travel

vaccine may be appropriate, need to be highlighted. This would include directing the

traveller to a private travel clinic if necessary. A GP surgery is also permitted to provide

this private aspect of the service if they wish, and therefore charge for these private

vaccines (BMA, 2020b), but they are not obliged to do so.

In May 2022, the CQC published a new GP mythbuster 107: Pre-travel health services

(cqc.org.uk/node/8422). This explained the settings where travel health was delivered

and stated that NHS primary care settings provide a large proportion of travel health care

to their registered eligible patients with the care being mainly delivered by nurses. It

stated that providing travel health services is part of the core GP contract and as an

essential service, must be provided to patients (CQC, 2022).

For those working in an NHS general practice setting, this guidance document is essential

reading and should be brought to the attention of GPs and management within the practice.

Recent reporting indicates that NHS England has begun work on a national vaccination

service (Pulse, 2022). A board meeting was held in May 2022 between NHS England and

NHS Improvement, which indicated in the minutes that: “Opportunities for alignment and

co-administration including catch up across all our vaccination programmes continues and

the development of a long-term NHS vaccination service has commenced,” (see item 44,

NHS England, 2022), but no further information has been made available at the time of

publication of this document.

Scotland

On 1 April 2022, the process to access NHS travel health services in Scotland changed and

fitfortravel (fitfortravel.nhs.uk) became the national entry point for travellers seeking free

travel advice and vaccines provided by NHS Scotland. If a traveller cannot access fitfortravel,

they are advised to call the NHS inform helpline on 0800 22 44 88 for information on local

travel health service provision. The NHS inform call handler will not provide the traveller with

a travel health risk assessment, but can guide them through fitfortravel content and advise

on how to access travel health services in their local health board.

The changes to travel health service provision in Scotland are rooted in the Scottish

governments Vaccination Transformation Programme (VTP). In April 2018, Scotland began

its national VTP aiming to move the established immunisation delivery models based in

general practice to new delivery models led by NHS Health Boards. Scottish Government

led the VTP, driving the redesign of all national routine immunisation programmes and

the delivery of travel health advice and vaccines. The Scottish Chief Medical Officer

Directorate published detailed information on the changes to travel health service

provision in Scotland (Scottish Government, 2022).

Scottish Health Boards are now responsible for local travel health service provision and

must adhere to the minimum standards set out in the Good Practice for Guidance for

Providing a Travel Health Service document published by the Faculty of Travel Medicine of

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the Royal College of Physicians and Surgeons of Glasgow. The national specification set

out by the Scottish Government is a two-part operational model as follows:

• part 1: The prescription and administration of vaccines that are currently available free

of charge in the NHS

• part 2: Facilitated access to non-NHS provided travel health services, including

prescription or signposting of anti-malarial prophylaxis and vaccines which are not

available free of charge in the NHS.

Wales

GP surgeries in Wales are expected to provide the travel vaccinations that are available on

the NHS, and these are covered under additional services within the GP contract. The

private travel vaccines that attract a fee do not have to be given by practices (NHS 111

Wales, 2017, BMA, 2022a).

Northern Ireland

GP surgeries in Northern Ireland are expected to provide the travel vaccinations that are

available on the NHS, and these are covered under additional services within the GP

contract. The private travel vaccines that attract a fee do not have to be given by practices

(BMA, 2022b).

Governance within travel health settings

• In England, GP surgeries and private travel clinics must be registered under the Care

Quality Commission (CQC). Pharmacy-led private travel clinics are currently registered

under the General Pharmaceutical Council, although in these settings, if the service is

delivered by a nurse or a doctor, then the CQC regulations still apply. Travel health

services provided in an occupational or military setting will work under their own

standards of practice and are exempt from CQC registration (CQC, 2022).

• The situation is similar in Scotland where private clinics are registered with Healthcare

Improvement Scotland (HIS).

• In Wales, private clinics are registered with the Healthcare Inspectorate Wales (HIW)

as private health care providers.

• The Regulation and Quality Improvement Authority (RQIA) is the regulator for private

clinics in Northern Ireland, although they currently appear to have no private travel

clinics registered.

• Under the World Health Organization (WHO) International Health Regulations (IHRs),

the state party for England, Wales and Northern Ireland is the NaTHNaC, which has

responsibility for administering Yellow Fever Vaccination Centres (YFVCs) (NaTHNaC,

2022a). In Scotland, the state party is Public Health Scotland (PHS, 2021).

Yellow fever training is now mandatory for all individuals administering yellow fever vaccine.

NaTHNaC and PHS provide yellow fever training online (either an eLearning module or tutor

led training) and all health professionals working at the YFVC or multiple YFVCs must

undertake the required training every two years (NaTHNaC, 2022a, PHS, 2021).

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In a position paper of the FTM, published by the RCPSG in 2014, the authors

acknowledged that travel medicine is not currently a recognised medical specialty in the

UK or the Republic of Ireland, and that within the UK and Ireland, there is a lack of

structure and delivery of travel medicine services, absence of a formal training pathway to

a recognised professional standard, and lack of assurance of practice against defined

standards. Whilst travel medicine as a specialty continues to remain unrecognised, in

October 2020, the FTM published an important document entitled: Good Practice Guidance

for Providing a Travel Health Service, (Chiodini et al., 2020). This publication was developed

for all health care professionals involved in, or considering embarking on, travel health

practice. The following facts were presented in key statements:

• the most important aspect of delivering travel health care is not which professional

group delivers the care, but that each person doing so exceeds the minimum standard

of practice and meets the health needs of the individual traveller

• travel health care is delivered in a variety of settings, but the standard of care should

be equally high no matter where it is practiced

• a minimally acceptable standard travel health service should include a consultation

room which is in a confidential area, set aside from the general public, accessible to

disabled individuals and large enough in which to place a desk, computer, seating for

the health care provider and traveller, as well as a fully reclining clinical chair/clinical

bed for use when vaccinating travellers who are prone to fainting

• included assurance and governance regarding topics such as the standard of the

consultation; record keeping and documentation; legal framework for prescribing of

medicines in the UK; governance of travel medicine practitioners; regulatory

differences in the UK

• required training and a further supervised period of consolidation to achieve

competence before seeing travelers was detailed

• further training and how continuous professional development should be maintained in

this field of practice was included

• the recommendations for the qualifications of trainers were described

• the Competency Assessment Tool for travel health practitioners from the FTM RCPSG,

provides evidence of measurable standards of practice. This tool, which was

developed in line with this RCN publication, is provided both in PDF and as an editable

Word document. This online assessment tool allows the practitioner to be signed off

as competent prior to providing pre travel consultations unsupervised.

• the guidance stipulated that each workplace or organisation needs to ensure a

practitioner new to travel health practice has this supervision. It was recommended

that this supervising practitioner needs to have good, up-to-date knowledge of travel

medicine with evidence of clinical practice in this specialist area.

Readers of this RCN publication are strongly recommended to use its contents now in

conjunction with the Good Practice Guidance for Delivering a Travel Health Service

document, each of which help to protect practitioners in this complex field of practice and

ultimately maximise the potential for protecting the health of the traveller. The

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Competency Assessment Tool for Travel Health Practitioners can be found at: rcpsg.

ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service

Financial provision

Funding of travel vaccinations both on the NHS and as a private provision has been a

complex issue for many years and description of such has been included in the previous

version of this document. Basic information for England, Wales and Northern Ireland is

available from the NHS (BMA, 2012, NHS 2018, NHS, 2019) or can be reviewed at:

janechiodini.co.uk/help/faqs/faq-2-charging-vaccines. In Scotland, the GMS Statement

of Financial Entitlements 2020-21 (table 15) contains information about which vaccinations

for the purposes of foreign travel the Scottish NHS can provide (Scottish Government

Health and Social Care Directorates, 2020/2021).

In summary, across the UK, travel vaccines are available to travellers within an NHS

provision as a public health measure to protect against cholera, hepatitis A, typhoid and

polio (only available in a combined tetanus, polio and diphtheria vaccine). In addition,

anyone who has not received two doses of measles, mumps and rubella vaccine (MMR) in

the national immunisation programme, remains eligible for this vaccine as an NHS

provision. A small group of individuals, for example, those under the age of 16 years may

warrant vaccination against tuberculosis for certain travel as an NHS provision, but the

guidance within the Green Book must be followed (UKHSA, 2018).

Vaccines which are private to provide disease protection for travellers are hepatitis B;

Japanese encephalitis; meningococcal ACWY; rabies; tick borne encephalitis and yellow

fever. Other new vaccines are anticipated to become available in the future including

disease protection against dengue and chikungunya, but these would also be a private

provision. Malaria chemoprophylactic drugs are a private provision since the risk of the

disease does not pose a public health risk in the UK.

Prescribing, supplying and administering travel vaccines

The prescribing of travel vaccines is complex. The following information provides a basic

outline, but further reading is recommended (see the resources section).

Doctors are by far the largest group of prescribers, who along with dentists, prescribe on

registration. They have been joined by non-medical independent and supplementary

prescribers from a range of other health care professions, who are able to prescribe within

their scope of practice once they have completed an approved education programme. This

extension of prescribing responsibilities to other professional groups is likely to continue

where it is safe to do so and there is a clear patient benefit (Jenkins J, 2021). All travel

vaccines could be prescribed by a doctor, nurse or pharmacist independent/

supplementary prescriber, as long as travel medicine care is within their scope of practice.

The setting where administration of these vaccines occurs, often determines what happens.

• In an NHS setting, travel vaccines are most often supplied under a Patient Group

Direction (PGD). Some national PGD templates have been developed in England and

Scotland for a number of these products. However, PGDs do not remove inherent

professional obligations or accountability. It is the responsibility of each professional

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to practise only within the bounds of their own competence and professional code of

conduct. Such or similar wording is found on the signatory section of national PGD

templates and individuals signing the document, then agree to abide by the legal

framework of the document (UKHSA, 2022b, PHS, 2022). Note, nursing associates

(and physician associates) cannot operate under a PGD currently, as they are not

included in the legislation to do so (SPS, 2021).

• As an alternative, Patient Specific Directions (PSDs) can be used, or vaccines can also

be prescribed. This method would be useful in the situation of a nursing associate who

cannot work within a PGD or in the situation described in section 3, How to Conduct a

Risk Assessment, point 5. The prescriber of the PSD is responsible for assessment of

the patient and the decision to authorise the supply/administration of the medicine(s)

in question. The prescriber has a duty of care and is professionally and legally

accountable for the care they provide. The prescriber must also be satisfied that the

person to whom the administration is delegated has the qualifications, experience,

knowledge, and skills to provide the care or treatment involved. A person who supplies

or administers a medicine is accountable for their own practice and must be trained

and competent to undertake such tasks. They must act according to their level of

competence and in accordance with the directions of the prescriber (Jenkins J, 2020a).

Travel vaccines must not be administered without the PSD or prescription being signed

prior to administration if this method is to be used.

• In the Human Medicines Regulations 2012, an exemption was made for the provision of

prescribing within private practice. An NHS GP practice can now, in law, develop their

own PGDs for use in their private practice (non NHS work), for example, for the

administration of travel vaccines (such as yellow fever, rabies, tick borne encephalitis and

Japanese encephalitis) (Chiodini J, 2015). If they choose not to do so, then these vaccines

can be administered under a PSD or prescribed by a medical or non-medical prescriber.

• Private travel clinics can operate under PGDs for all vaccines. Alternatively, if the

health care professional is a prescriber as previously described, then they can operate

independently.

• Travel vaccines given within Occupational Health Schemes (OHS) are exempt from this

regulation but must operate under their own written instruction (BMA, 2019). This area

is complex and requires further research. The NHS Specialist Pharmacy Services

provides a page of resources on PGDs and Occupational Health Service, which

includes a helpful FAQ document (Jenkins J, 2020b, SPS, 2022a).

• In military settings, the Defence Primary Healthcare (DPHC) service provides travel

vaccines and malaria chemoprophylaxis through PGDs (and PSDs if required), which is

covered by relevant leaflets in the Joint Service Publication (JSP) 950 Medical Policy

(GOV.UK, 2014). There are also guidance notes in DPHC. All service personnel access

such services through DPHC for service-related travel. Most UK-based dependents

are registered with a civilian GP and their travel medicine service requirements are

accessed in the usual way if a posting abroad requires such protection.

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Administration of travel vaccines

Registered nurses who are fully trained and competent can administer travel vaccines.

In England, Wales and Northern Ireland, all practitioners should be familiar with the Public

Health England National Minimum Standards and Core Curriculum for Immunisation

Training for Registered Healthcare Practitioners (UKHSA, 2018). The aim of these

standards is to describe the training that should be given to all practitioners engaging in

any aspect of immunisation, so that they are able to promote and administer vaccinations

confidently, competently, and effectively. Therefore, those undertaking travel health

practice should already have undertaken this specific training. In addition, the publication

states “those who give travel immunisations will require specific training on travel health – a

generic immunisation course alone would not be sufficient”.

National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare

Support Workers (HCSWs) was published by the PHE for the administration of influenza

and pneumococcal vaccines. It is not current practice for HCSWs to administer childhood,

travel, or other vaccines in the UK (PHE, 2015, RCN, 2019a).

In Scotland, NHS Education for Scotland (NES) and Public Health Scotland (PHS) have

developed immunisation learning programmes for registered health care practitioners and

health care support workers. The Promoting Effective Immunisation Practice (PEIP)

programme aligns with the above National Minimum Standards and Core Curricula for

Immunisation Training and is available free through the NES TURAS Learn digital platform

(NES, 2022).

Indemnity cover

If administering travel vaccines, it is important to ensure you have adequate and

appropriate indemnity cover. In 2019, the Clinical Negligence Scheme for General Practice

(CNSGP) operated by NHS Resolution provided indemnity cover to all staff working in

NHS General Practice services in England, which included all practice nurses, locums,

self-employed workers and trainees (NHS Resolution, 2021). The General Medical Practice

Indemnity (GMPI) provided a similar scheme in Wales at the same time. Nursing staff do

not need to pay or apply to register for the scheme.

This indemnity provides cover for all NHS vaccines administered in a general practice.

If the GP surgery provides private travel vaccines as well, then that aspect of practice is

not covered by the CNSGP, and alternative arrangements need to be secured from

another medical defence organisation. RCN membership provides indemnity, and their

scheme includes the private travel vaccines (RCN, 2022). The CNSGP scheme alone is not

sufficient cover for you as a registered nurse, so you will also need professional indemnity

to cover for issues like employment advice, NMC referrals, inquests, and other potential

legal issues. Indemnity cover is also now a requirement of registration with the NMC and

proof of such has to be declared on revalidation (NMC, 2022).

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3. Pre-travel risk assessment and

risk management

Introduction

The concept of the pre-travel risk assessment is important in evaluating and managing

the advice required to minimise the traveller’s risks. The structure, reasons for performing

assessments, and the practical aspects of essential documentation are considered

necessary for best practice in the travel health consultation.

National online websites should always be consulted for the latest information on the

country specific risks – to help inform the traveller on vaccine and any malaria

recommendations, entry requirements and destination disease outbreaks. The main

resources in the UK are: TRAVAX and fitfortravel, which is continually maintained by the

Travel and International Health Team at Public Health Scotland (travax.nhs.uk),

(fitfortravel.nhs.uk/home) and TravelHealthPro from NaTHNaC, which is commissioned by

the UKHSA (travelhealthpro.org.uk).

Produced by the UK National Centres of excellence, these resources are reliable and

current. Practitioners should also have access to the latest online versions of Immunisation

against infectious disease, also known as The Green Book (UKHSA, 2021) and Guidelines

for malaria prevention in travellers from the UK (Chiodini et al., 2022).

The learning objectives of this section are to:

• understand what pre-travel risk assessment is and its importance for best practice in

protecting the health of travellers

• understand the contents and reasons for conducting a pre-travel risk assessment

• be aware of the appropriate use of data collected during the assessment to determine

the risk management advice required, including relevant immunisations and malaria

prevention advice

• have greater insight into the practical aspects of pre-travel risk assessment, including

documentation of the process

• understand the importance of using current national guidance, online websites, the

Green Book and the UK Malaria Guidelines (see resources in Appendix 2)

• have the ability to evaluate relevant current travel information and resources during

the travel health consultation.

What is a pre-travel risk assessment?

A pre-travel risk assessment entails the collection of information regarding the traveller

and the nature of the trip (see below). You will find the pre-travel risk assessment and risk

travel management forms in Appendix 1. The form can be downloaded and adapted as

necessary (see the resources section).

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Information about the traveller

• age and gender identity

• medical history – past and present

• relevant family history

• current health status

• for females only, pregnancy status, actual or planned, menstruation issues, has FGM

been performed?

• disability – visible or invisible

• mental health status

• any other additional needs

• medication

• any known allergies

• vaccination history

• previous experience travelling

• current knowledge and interest in health risks of travel.

Information about the traveller’s itinerary

• destination(s)

• departure date

• length of stay

• mode(s) of transport

• purpose of trip and planned activities

• quality of accommodation

• financial budget

• healthcare standards at destination

• relevant comprehensive insurance provision.

Reasons for asking questions

It is essential to question a traveller on the topics detailed previously. Responses can

influence many things, some of which are detailed below. This knowledge will help the

practitioner to assess potential risk factors before managing that risk by selecting

appropriate health advice, vaccinations, malaria advice and other prevention measures.

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The following section looks at some examples of what should be considered in a

pre-travel risk assessment.

Please note, resources are found in Appendix 2, but for convenience, additional links are

included within some of the sections below. These are mainly linked to advice pages on

the NaTHNaC, TRAVAX and fitfortravel websites, for those practising in the UK. It is useful

to refer to the resources links and references provided within the variety of these sites for

additional interest and learning. Other international resources are also occasionally

provided. It is important to be aware that vaccine and malaria prevention

recommendations may vary depending on which country you are practising.

Age and gender identity

Young travellers

This relates particularly to children under five years old but includes other age groups.

• vehicle-related injuries are the leading cause of death in children who travel (Weinberg

et al., 2020). If travelling with children, a child safety seat or booster seat will be

required (Long and Flaherty, 2018)

• drowning is the second leading cause of death in young travellers (Weinberg et al., 2020)

• risk of illness such as malaria can be more severe. Children visiting friends and

relatives (VFR) tend to be brought for consultations closer to the departure date

(Hagmann et al., 2013)

• small, mobile and inquisitive toddlers, who have limited hygiene awareness and

immature immune systems – put fingers in mouths, touch everything – which leads

to increased risk of faecal oral transmitted illnesses and dehydration. Travellers’

diarrhoea can be more severe

• children are more vulnerable than adults to the exposure of rabies (WHO, 2021)

• increased risk of other hazards like sunburn and heat exposure; careful supervision

is needed

• restrictions on some choices for travel vaccines and malaria chemoprophylaxis

• risk of being subjected to female genital mutilation (FGM) for young female travellers

• risk of being taken abroad for the purpose of forced marriage

• in the UK, it is illegal to take a child abroad without permission from everyone with

parental responsibility (all mothers and most fathers). This should be granted ahead

of travel as failure to do so may be considered child abduction (GOV.UK, undated ‘a’).

Quick links to resources for practitioners on this topic can be found at: NaTHNaC,

TRAVAX, fitfortravel, CDC and ROSPA

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Older travellers

• immune systems reduced, at greater risk of infection and serious sequelae

• immune response to immunisation may diminish with advancing age

• senses reduced, therefore at greater risk of accidents

• pre-existing medical conditions such as diabetes and coronary heart disease can lead

to complications

• primary immunisation may not have been administered if born prior to implementation

of national programmes

• evidence of increasing risk of sexually transmitted diseases in the over 50-year-old

age group (Age UK, 2019)

• increased risk of serious adverse events following a first dose of yellow fever vaccine

in those over 60 years (Lindsey et al., 2016, MHRA et al., 2019)

• in travellers from the UK, mortality from malaria increases with age. Elderly travellers

need to be targeted for pre-travel advice (Checkley, et al., 2012, Allen et al., 2016)

• awareness of cognitive decline in older travellers (Bauer, 2019)

• communication skills and awareness of barriers impacted by a lack of technology

skills (NIH, 2017).

Quick links to resources for practitioners on this topic can be found here: NaTHNaC

and CDC.

Female travellers

• security risk possibly increased if travelling alone (Kennedy and Flaherty, 2015)

• need to be culturally sensitive in personal dress sense and conduct

• sexual health issues should be considered (NaTHNaC, 2019a, TRAVAX, 2022a)

• if of childbearing age, need to determine that there is no possibility of being pregnant

at time of travel and establish if currently trying to conceive (TRAVAX, 2021a)

• consideration of issues when administering travel vaccines in pregnancy

• appropriate Zika prevention advice if travelling when pregnant or planning to conceive

(UKHSA, 2019)

• problems associated with contraception, travelling while managing menstruation

(Borwein, 2019), (TRAVAX, 2022b)

• risk of being subjected to female genital mutilation (FGM) (RCN, 2020)

• risk of being taken abroad for the purpose of forced marriage.

Quick links to resources for practitioners on this topic can be found here: NaTHNaC,

TRAVAX, fitfortravel, and CDC.

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Male travellers

• risk of road traffic injuries is higher in five to 29-year-old age groups. From a young

age, males are more likely to be involved in road traffic crashes than females. About

three quarters (73%) of all road traffic deaths occur among young males under the

age of 25 years who are almost three times as likely to be killed in a road traffic crash

as young females (WHO, 2022). The 10 Facts about road safety from the WHO is useful

to share with travellers and can be found at: who.int/news-room/facts-in-pictures/

detail/road-safety

• sexual health issues should be considered (NaTHNaC, 2019a), (TRAVAX, 2022a)

• appropriate Zika prevention advice if travelling when partner is pregnant, or the couple

has plans to conceive (UKHSA, 2019).

Lesbian, gay, bisexual, transgender and queer (LGBTQ+) travellers:

• attitudes towards LGBTQ+ travellers vary greatly around the world. In some countries

homosexuality and/or homosexual relations are illegal and people can be subject to

severe penalties for their sexual orientation. Punishment can include imprisonment or

death (FCDO, 2022)

• application to change gender on a passport needs to be researched. British transexual

or transgender citizens need to supply a Gender Recognition Certificate (GOV.UK,

undated ‘b’)

• LGBTQ+ travellers are advised to carefully research acceptance of LGBTQ+ in the

culture/ country to be visited (Asher and Lyric, 2022)

• men who have sex with men (MSM) may require vaccinations against hepatitis A, hepatitis

B, human papilloma virus (HPV) and/or monkeypox (TRAVAX, 2022a, UKHSA, 2022a).

Quick links to resources for practitioners on this topic can be found here: TRAVAX,

fitfortravel, FCDO, ILGA, RCN Travel Health resources and CDC.

Medical history

Past and present medical history and current health status:

• previous medical history and current health status may impact on the choice of

destination; for example, a person who has had their spleen removed would be at

increased risk of severe illness, when visiting a destination where malaria, particularly

P. falciparum, is endemic, or for travellers with sickle cell anaemia or coeliac disease

(NaTHNaC, 2021b, UKHSA, 2022c)

• those with other ongoing medical problems may require specialist advice; for example,

those with severe renal or liver disease would need advice regarding malaria

chemoprophylaxis. Where kidney dialysis is required, guidance on the availability of

service provision at the destination and the wisdom of travelling at all should be

explored, preferably well in advance of departure (NaTHNaC, 2022b).

• consideration should be given to immunocompromised travellers, the level of immune

compromise and reasons for immunosuppressive treatment; some live vaccines may

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be contraindicated and other vaccines may be less effective (UKHSA, 2017, UKHSA,

2020). Fitness to travel may impact on the need to seek medical treatment overseas,

whether or not the condition is stable on departure. Medical facilities and medications

need to be discussed for availability, storage and transport across borders for those

with, for example, rheumatic disease or history of solid organ or stem cell transplants

(NaTHNaC 2022c, TRAVAX 2022, Kotton et al., 2019)

• people with pre-existing conditions such as diabetes or coronary heart disease may be

at higher risk if illness occurs overseas, increasing their need for medical attention

that may be of variable quality (NaTHNaC, 2021c, TRAVAX, 2020a)

• people with a family history of relevant illness; for example, the condition of epilepsy

in a first degree relative may influence the choice of the malarial chemoprophylactic

drug options (Chiodini et al., 2022). A formal letter may be required for immigration

purposes. See the section on medication below

• recent surgery or a long-term medical problem such as respiratory disease may impact

on travel, and a fitness to fly examination may be required (UKCAA 2022a). Where

treatment abroad (medical tourism) is given as the reason for travel, advanced planning is

essential (TRAVAX, 2022c, NHS, 2021, NaTHNaC, 2021d, Benowitz and Gaines, 2020)

• visible or invisible disabilities/additional needs may impact on type of trip, limit

activities, and create increased need for medical care, which may be of variable quality

(TRAVAX, 2020b, NaTHNaC, 2021e)

• HIV-infected people may be denied entry into some countries (The Global Database at

hivtravel.org); if entry is permitted, their immune status will need to be known prior to

administration of some vaccines, and for tailoring individual advice. Practitioners

should be aware of the British HIV Association (BHIVA) guidelines on the use of

vaccines in HIV positive adults (BHIVA, 2015, NaTHNaC, 2022d, TRAVAX, 2022d)

• psychiatric history and mental health status may impact on long-term travel or

expatriate lifestyle (TRAVAX, 2021b). For example, mefloquine for malaria

chemoprophylaxis is contraindicated for certain psychiatric or mental health conditions

(Chiodini et al., 2022) and caution is required when carrying prescribed medication.

Careful planning and comprehensive insurance are essential (FCDO, 2020)

• pregnancy increases risk from malaria and other insect-borne diseases like Zika,

chikungunya and dengue, and infectious diseases such as COVID-19, hepatitis A and

hepatitis E. If complications occur in the pregnancy, medical intervention may be

required but reliable medical care may not be available at the destination (NaTHNaC,

2021f, TRAVAX, 2021a, RCOG, 2022)

• venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) following

a long-haul flight is a greater risk in pregnancy. An early scan should be performed ideally

before travel and antenatal records should always be taken on the trip. Tour operators and

airlines will set individual restrictions on a pregnant woman flying in the third trimester

(UKCAA, 2022b, NaTHNaC, 2018, TRAVAX, 2021c). Specialist advice should be sought for

travel insurance which covers premature delivery and the new-born. Full disclosure on the

pregnancy is required (NaTHNaC, 2021f, TRAVAX, 2021d)

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• breastfeeding presents some restrictions on choice of malaria chemoprophylaxis and

precautions regarding administration of live vaccines need to be assessed (NaTHNaC,

2022e, TRAVAX, 2020d)

• determine wellbeing at the time of vaccination, afebrile, feeling well and fit to receive

vaccinations, no possibility of pregnancy as mentioned above. Check the Green Book

for specific vaccine information before vaccinating a pregnant woman and those with

other medical conditions (UKHSA, 2017).

Medication

• some prescribed medication could contraindicate malaria chemoprophylaxis or live

vaccines

• a woman on the oral contraceptive pill could lose contraceptive efficacy if she suffers

travellers’ diarrhoea

• specialist advice is required for those on medication such as insulin or antiviral treatment

• safe storage of drugs in transit, particularly for drugs that need refrigeration

• elderly people on regular medication should be aware of the importance of continuing

regular administration despite crossing time zones, inconvenience of diuretics and

resulting diuresis

• generally taking sufficient supplies of medication for an entire trip is recommended

due to problems of counterfeit medicines found abroad, however the quantity may be

dictated by the destination. It is advisable to take medication in its original pharmacy

packaging or have a doctor’s letter to confirm personal prescription. Problems can

occur when taking drugs into other countries where the legal status may be different

to the UK and restrictions are in place regarding controlled drugs. Correct paperwork

can be helpful at the point of entry to a country (NaTHNaC, 2019b, TRAVAX, 2021e,

NHS, 2021)

• be aware of restrictions for carrying medication and medical equipment through

airport security, on the aircraft and at immigration (check the latest information on

restricted items) (GOV.UK, undated ‘c’).

Allergies to drugs or food/reaction to vaccination

• establish if there was a true anaphylactic reaction to vaccines previously administered

to avoid similar event. It should be noted that anaphylactic reaction to vaccines is

extremely rare (UKHSA, 2017, UKHSA, 2013b, TRAVAX, 2021f) and should be reported

on the MHRA Yellow Card system (GOV.UK, undated ‘d’)

• establish if there was a true anaphylactic reaction to vaccines previously administered

to avoid a similar event

• establish allergy to, for example foods, specific drugs or latex; establish if there is a

true anaphylactic reaction to eggs, which are used in the manufacture of some

vaccines (OVG, 2022), provide specific advice to minimise problems to severe reactions

to insect bites

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• establish previous severe adverse reactions/events to malaria chemoprophylaxis

• consider arrangements for the traveller to carry with them a supply of epinephrine

(adrenaline) for emergency use where there is a history of severe allergic reaction to

an agent (Resuscitation Council UK, 2021)

• establish a history of, or the possibility of fainting by enquiring before administering

vaccines. Fainting is more common than anaphylaxis and practitioners need to know

the difference between the two (Australian Immunisation Handbook 2018).

Previous travelling experience

• establish previous travel experience to identify any problems in the past, for example,

difficulty in compliance with any malaria chemoprophylaxis, whether more prone to

travellers’ diarrhoea, insect bites

• deliver advice in an appropriate way so that it is more likely to be accepted by

travellers (BMJ, 2012, Chiodini et al., 2020).

Current knowledge and interest in health risks

• establish the level of knowledge and concept of health risks of the traveller so that

appropriate travel health advice can be given

• consider traveller’s attitude – for example, a risk taker or risk averse

• establish general interest and response to advice that may be given to encourage

self-learning; for example, suggest well regarded internet sites to increase

knowledge further.

Travellers visiting friends and relatives (VFRs)

• VFR travellers have a different risk profile to other types of travellers – tending to

travel for longer, live as part of the local community, may not seek pre-travel advice,

and underestimate their health risks (NaTHNaC, 2021a, TRAVAX, 2022e)

• data suggests that VFR travellers are less likely than other travellers visiting Africa to

take anti-malarial prophylaxis; this is possibly because they underestimate the risk of

acquiring malaria, and do not appreciate that natural immunity wanes after migrating

to the UK; second generation family members will have no clinically relevant immunity

to malaria (Chiodini et al., 2022)

• those VFRs in countries with endemic malaria make up the majority of cases of falciparum

malaria in the UK, but the risks of this group dying from malaria are much smaller than

for other travellers, with most deaths occurring in tourists (Checkley et al., 2012)

• consultation with VFRs should explore their values and beliefs, and the practitioner

should deliver advice accordingly; the importance of health risks should be stressed

such as how essential it is to take appropriate chemoprophylaxis when travelling to

areas where malaria is endemic (UKHSA, 2022e)

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• cultural awareness and communication skills can impact a successful consultation.

Use of a professional translation service needs to be considered if there is a language

barrier (Chiodini et al., 2020).

Quick links to resources for practitioners on this topic can be found here: NaTHNaC,

TRAVAX, fitfortravel, UKHSA and CDC.

Female genital mutilation (FGM) and forced marriage

• migrants from countries with high rates of FGM may return to visit friends and

relatives intending their children to undergo FGM. It is illegal to take girls who are

British nationals or permanent residents of the UK abroad for FGM, whether or not it is

lawful in that country (TRAVAX, 2021g). Travel health practitioners should be aware of

the potential for a girl to be taken to another country for this purpose, be prepared to

ask the question directly, and where appropriate, initiate safeguarding procedures or

refer for further care

• to protect children and young people from harm, and help improve their wellbeing, all

health care staff must have the competencies to recognise child maltreatment,

opportunities to improve childhood wellbeing, and to take effective action as

appropriate to their role. The importance of prevention must not be overlooked as this

is integral to safeguarding (RCN, 2019b). The RCN has published specific guidance for

travel health services (RCN, 2020). The Faculty of Travel Medicine has an e-learning

course in relation to FGM and the pre-travel health consultation (RCPSG, 2021)

• forced marriage is an abuse of human rights and a form of violence against women

and men. Where it affects children, it is classed as child abuse and for those with

disabilities, abuse of vulnerable people (GOV.UK, 2022, mygov.scot, 2022). The

Guidance Forced marriage: a survivor’s handbook published by the Foreign,

Commonwealth and Development Office (FCDO) is an invaluable resource to be aware

of. Such activities need to be considered within a pre-travel consultation

• appropriate communication skills and access to a professional translation service may

be beneficial (RCN, 2020).

Quick links to resources for practitioners on this topic can be found here: TRAVAX,

fitfortravel, RCN, RCPSG and FORWARD UK.

Previous vaccination history

• having accurate information of previous vaccination history status will ensure previous

vaccinations are not duplicated unnecessarily and allow time within the departure time

limit to plan for appropriate catch-up and new travel-related vaccine schedules.

Vaccine and other costs should be discussed and prioritised as necessary

• gather information on primary immunisation status and establish which country’s

schedule was followed ensuring courses were completed. Advise travellers to keep

personal vaccination records and documents safe, particularly if vaccines were

administered in different centres, such as a GP surgery, private travel clinics or

occupational settings. Apps are now available to record data on a mobile device. See

documentation to accompany the travel consulation later in this publication.

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Additional needs

• identify any specific needs so that plans can be made to ensure travel arrangements

and medical needs are in place; shared care may be necessary

• travellers should research the destination in advance. In case of serious health decline

while abroad, comprehensive travel insurance which includes repatriation should be in

place (NaTHNaC, 2021h)

• identify groups and associations that will inform and protect travellers with additional

needs, such as travellers with a disability or a psychiatric disorder (NaTHNaC, 2021e,

TRAVAX, 2020b)

Destinations

• using a recognised online tool, identify country-specific risks to help make

recommendations. Country-specific risks include vaccine-preventable and mosquito-

borne diseases, (CQC, 2022) for example, yellow fever virus is endemic in tropical

areas of Africa, Central and South America, and currently in Trinidad in the Caribbean

• record stopovers in case the destination impacts on the risk assessment regarding

immigration and entry requirements, such as yellow fever and COVID-19

• rural areas may pose a greater risk than urban areas, particularly for diseases such as

malaria and Japanese encephalitis. In an emergency, in more remote areas, it may be

difficult to reach medical help, for instance, in the event of an accident or potentially

rabid wound

• location may also impact on other risks such as drowning or road traffic accidents.

Some countries may have poorly constructed roads, limited road safety rules and

poorly maintained vehicles (WHO, 2020, NaTHNaC, 2022f, TRAVAX, 2020c)

• accidents may be a greater risk and poor healthcare standards and facilities may also

pose a greater risk from inadequate care and the inability to cope with or treat injuries

• consider the political and cultural issues at the destination and observe any UK

Foreign, Commonwealth and Development Office advice

• areas at high altitude may have unknown, unpredictable effects on travellers, for

example, acute mountain sickness.

Departure date

• departure date will affect the time available for giving advice and the timing of vaccine

schedules

• seasonality of certain diseases will affect advice for travellers to some destinations.

Diseases with a seasonal risk include Japanese encephalitis, influenza and malaria

• travellers who attend a travel advice consultation at short notice may not have time to

receive optimum pre-travel advice or protection; however, it is never too late to commence

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some vaccine protection or provide malaria chemoprophylaxis and give appropriate advice

on essential precautions – for example, food, water, and personal hygiene advice.

Length of stay

• generally, the longer the duration of stay, the greater the likelihood of exposure to

travel related health hazards

• longer stays may cross with seasons where risks can be higher or lower for certain

diseases

• travellers are sometimes less cautious on a long stay, which may increase personal

health risks, for example, relaxing adherence to malaria chemoprophylaxis or

indulging in risky behaviour

• advice on the use of malaria chemoprophylaxis is different for long-stay travellers and

the practitioner may need specialist knowledge.

Transport mode

• long haul travel is most commonly by air, but travel by sea and overland journeys

should also be considered when assessing individual risk. Explore transport plans

within the destination(s)

• risk of travel-associated complications due to prolonged periods of immobility while

travelling, such as Venous Thromboembolism (VTE), should be considered for

travellers with pre-disposing factors (NaTHNaC, 2018)

• any pre-existing medical condition or situation may raise concerns about fitness to

travel, and an examination prior to the trip may be necessary; for example, respiratory

or cardiovascular disorders, psychiatric illness, pregnancy and gastro-intestinal

surgery (IATA, 2020, UKCAA, 2022a). Individual airlines may vary on required intervals

• cruise ship travel is popular with all age groups, issues for consideration during shore

trips could include risk of yellow fever and/or the requirement for a certificate under

IHR for entry into some countries; risk of disease outbreaks such as influenza,

norovirus or COVID-19; and physical problems such as a disability or sea sickness

(NaTHNaC, 2022g, TRAVAX, 2022f).

Purpose of trip and planned activities

• people travel for many reasons, and it is important to establish the reason because

this impacts on potential risks and how tailored pre-travel health advice is given

• holidaymakers may take risks they would not take at home because they are relaxed,

want to enjoy the experience, and may fail to consider potential risks. Package tours

generally provide some security, but that too can lead to complacency or

overindulgence; this is particularly true for inclusive holidays aimed at younger age

groups where limitless alcohol is made available (Drinkaware, 2017, IAMAT, 2020)

• backpackers and those undertaking more adventurous travel or expeditions may travel

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for longer periods, visit multi-destinations and venture to less well-developed tourist

areas. They may undertake risky activities, for example, camping in high-risk areas

where malaria and other mosquito-borne diseases like yellow fever and dengue are

transmitted. They often take part in more hazardous activities such as water sports

like scuba diving and white-water rafting, bungee jumping, trekking, climbing or skiing.

Facilities, equipment and supervision may be inadequate and not subject to the same

health and safety scrutiny as the UK

• those travelling for a pilgrimage, for example – Umrah and Hajj, are at greater risk of

diseases through close association such as meningococcal meningitis, influenza,

COVID-19, and other respiratory diseases. Pilgrims are required to obtain an entry visa,

which proves vaccination status for meningitis ACW135Y. Travellers should be made

aware of annual advice from the Kingdom of Saudi Arabia Ministry of Health provided

for travellers including those in vulnerable groups (NaTHNaC, 2022h, TRAVAX, 2022g)

• people working abroad face special risks depending on their type of work; for

example, medical personnel working in disaster areas, or security workers going to

war zones will be at greater risk of diseases of close association and water and blood

borne infections (NaTHNaC, 2021f, TRAVAX, 2022h)

• business travellers if under greater pressure, making frequent short term and/or

long-haul trips can experience loneliness, isolation, and a cultural divide; this group of

travellers can be at risk from excessive alcohol use and casual sex (Patel, 2015, Chen

et al., 2020)

• expatriate travellers can have similar experiences; they miss family, may experience

language barriers and suffer psychological stress (Chen et al., 2020)

• people travelling to visit friends and relatives are at greatest risk from diseases such

as malaria and may not fully understand the risks; they could have incorrect,

pre-conceived ideas that they have natural protection against the disease, and may

stay longer at hazardous locations such as rural areas

• travellers are more adventurous today so advice must emphasise and focus on, for

example, the wider risks of accidents and environmental hazards

• the risk of sexually transmitted infections and sexual health in general should be

considered for all travellers and age groups, while recognising that some travellers’

risks are increased if travelling for the purpose of sexual encounters (TRAVAX, 2022a)

• social media has significant impact on traveller activity. Individuals should be aware of

the increased risk and danger when meeting people through dating apps which could

potentially make travellers more vulnerable when using them in a country where

surroundings, cultures, customs, and communication issues add to the risk.

Medical tourism

• a growth area has seen people travelling for medical treatment including surgery,

dentistry, cosmetic surgery, elective surgery and infertility treatment; the most

common problems travellers experience result mainly from limited research, booking

treatment without a proper consultation, aftercare arrangements, travel transport

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risks (for example, VTE), lack of insurance, poor communication and language barriers

(TRAVAX, 2022c, NHS, 2021, NaTHNaC, 2021d, Benowitz and Gaines, 2020).

Quality of accommodation:

• good quality air-conditioned hotels can reduce some health risks, but travellers should

be advised not to be complacent about hygiene standards, especially for food

preparation (NaTHNaC, 2019c, TRAVAX, 2021h)

• screened accommodation gives better protection in an area with malaria, but travellers

should be advised about other personal protection and bite prevention measures for

night-time and daytime (UKHSA, 2022d)

• camping and living rough will increase travel health risks.

Financial budget

• budget often dictates the quality of eating places, but food hygiene is not always

guaranteed in an expensive venue

• generally, travellers should be advised not to eat food from street vendors because of

potentially poor (or risky) hygiene standards and the quality and storage of the food

used; however, sometimes the reverse is true if it is possible to observe the thorough

cooking of fresh food at high temperatures

• backpackers often have to manage their trip within a tight budget and need to be

aware of the increased risk of using cheaper forms of transport, living in poorer

accommodation, and having less money for medical help.

• all travellers should make it a priority to buy comprehensive travel insurance which

includes medical repatriation before travelling, and always carry details of policy

documents or be able to access these electronically. Special attention should be given

to the pregnant traveller’s insurance including cover of the foetus for situations like

premature delivery and subsequent care of the baby

• practitioners need to be flexible and provide sufficient information to help the traveller

to prioritise in situations where limited time or finances mean that the optimum

recommendations cannot be followed.

Health care standards at destination

• where destination health care standards are in doubt, it is essential to take out

comprehensive travel health insurance, including cover for medical repatriation

before departure

• people with a pre-existing medical condition, particularly if it is serious, should

consider the suitability of destinations where health care standards are poor and

sparse; check that travel insurance covers such situations, and, if possible, check

medical facilities in advance

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• people travelling to an area where facilities may be inadequate should consider

travelling with a first aid kit and sterile needle pack

• The Foreign, Commonwealth and Development Office provides the following: details of

local medical care standards under the ‘health’ section of their country pages (gov.uk/

foreign-travel-advice), details of the nearest British Embassy or Consulate (gov.uk/

world/embassies) that may be able to provide assistance in an emergency, and a list of

doctors and medical facilities worldwide (gov.uk/government/collections/doctors-

and-medical-facilities-worldwide-list).

Performing risk assessments

Travel risk assessment is an essential process for the health care professional advising

their traveller. A main consideration is to allocate sufficient time to perform the risk

assessment and deliver appropriate travel risk management advice.

Communication skills are also key to an effective consultation. Good skills would include

putting the traveller at ease to establish rapport; utilising a range of communication

methods and tools; allowing time for the traveller to process the information; and allowing

time for questions (Chiodini et al., 2020). Reasonable steps must be taken to meet

people’s language and communication needs (NMC, 2018a). Use of an accredited

interpreter is also very important in some situations, as previously discussed (RCN, 2020).

Appointment guidance

• it would be unsafe to allow only 10 or 15 minutes for a new travel appointment. A

minimum of a 20-minute consultation appointment per person should be allowed to

exercise best practice

• travellers with more complex health needs such as individuals who are

immunocompromised, longer-term travellers such as backpackers, or individuals

requiring malaria prevention advice relevant to their destination – will certainly need an

extended consultation time of 30 minutes or longer. A yellow fever assessment

(travelhealthpro.org.uk/factsheet/87/yellow-fever-pre-vaccination-checklist) is also

complex and requires sufficient time to establish a required pre travel risk assessment

and for comprehensive advice to be given. This one aspect could take 30 minutes or

longer by itself, particularly for YFVCs who see travellers who are not registered, and

whose medical records are not known or available

• when groups of travellers attend e.g., a family, then sensible timing needs to be

applied and consideration given as to how large a group is acceptable within the travel

health setting

• when young children attend, it would be easier if they were not taken into the initial

consultation so that the parent(s) can focus on the information provided. This scenario

presents an example where an online consultation prior to attending for vaccinations

may be very suitable

• small children are easier to vaccinate if taken into the clinical area one by one

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• those needing to return for subsequent vaccines in a course could be accommodated

in a shorter appointment time if all travel health management issues were covered in

the initial appointment.

The NMC’s The Code is about being professional, being accountable and being able to

justify your decisions; employers need to respect the complexity of a travel consultation

and appreciate that sufficient time must be allowed for a nurse to abide by The Code.

Face-to-face contact with the traveller has always been the preferable way to undertake a

travel risk assessment and provide advice. However, the COVID-19 pandemic changed the

way that many consultations are conducted. The pre-travel risk assessment and informed

decision making, supported by many online resources and screen sharing technology,

lends itself to a virtual consultation via a secure clinical system. Regardless of the format

of delivery, the quality and standard of the pre travel risk assessment and confidentiality

need to be maintained. Optimal time will still be required, and if vaccinations are

recommended, the traveller should be asked to attend an appropriate clinical setting to

receive them (Chiodini et al., 2020).

How to conduct a risk assessment

It is better to carry out a risk assessment using one of the methods below rather than

trying to recall the necessary questions from memory. With practise, collecting risk

assessment information can be carried out effectively and without taking excessive time.

Interpretation of the information and applying advice and recommendations appropriate

to the individual risk assessment is the time-consuming part of the consultation.

If working in England, the CQC has stipulated that within their inspections, they would

expect systems or processes to be in place to assess, monitor and mitigate the risks

relating to the health, safety and welfare of patients. Their guidance included the example

of a comprehensive travel health risk assessment completed for each person using the

service (CQC, 2022).

Some suggestions for completing this task are provided below.

1. Ask the traveller to complete a form prior to the consultation which can then be

reviewed by the travel health adviser before the appointment and used to identify

potential problems. However, within the consultation, the nurse still needs to review

the completed form to ensure the traveller understood the questions asked and

confirm that information provided by the traveller is accurate, including reviewing

the medical records if available. This may not be as time saving as originally thought,

but it gives the traveller some idea of the depth of information required about the trip

and helps the nurse feel more prepared. Information can be collected on paper for

scanning into the computer system, or within an online form on a website accessible to

the patient, for example, a general practice surgery website.

2. Complete the risk assessment form with the traveller at the consultation (whether in

person or online), identifying any foreseeable problems and issues which may require

further questioning. The travel health adviser will be assessing the risk with no prior

knowledge of the trip details, which can be more time consuming. It is therefore

helpful to collect information about the traveller’s destination, date of departure and

duration of stay when the appointment is initially booked to support this method.

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Again, the risk assessment can be done on paper and subsequently scanned into the

computer system, although designing a computer template for the process may be

more helpful and ultimately time efficient.

3. A risk assessment could be performed by following a checklist to ensure all

information is collected and the detail is fully documented on the traveller record.

However, this method is less reliable or efficient, is very time consuming, and great

care needs to be taken to ensure all the information is documented correctly. An

exception may be the yellow fever pre-vaccination checklist (screening tool) for

YFVC’s. If advising yellow fever vaccines, in addition to the pre-travel risk assessment,

the pre-vaccination checklist from NaTHNaC and Public Health Scotland must be

completed and recorded in the medical records (NaTHNaC, 2021i, PHS, 2021).

4. Concerns have previously been raised of a trend that some travel health providers were

not performing a risk assessment, but instead sending the traveller to a private service

or instructing them to independently identify their vaccine needs online. Following this,

the original provider then administered vaccines identified as being “recommended”.

This practice is considered unsafe. Those who ‘just give vaccines’ according to

information the traveller has obtained or identified, puts the individual health care

practitioner at significant risk. Knowledge to understand the pre travel risk assessment

and provide appropriate advice remains essential. In Scotland, the health boards are now

responsible for local travel health service provision and the new delivery models must

adhere to the minimum standards set out in the Good Practice Guidance for Providing a

Travel Health Service document published by the Faculty of Travel Medicine of the Royal

College of Physicians and Surgeons of Glasgow (Scottish Government, 2022).

5. More recently, enquiries have been made about the practice of one person within a GP

surgery performing the risk assessment on a traveller and deciding which vaccines

are considered necessary, then passing the task of their administration on to another

practitioner, doing so under a PGD. The nurse administering vaccines in this way,

needs to have been adequately trained and to have personally undertaken the pre-

travel risk assessment. If such a method is used, then a PSD should be utilised, where

the prescriber who has undertaken the pre travel risk is responsible for authorising

the administration of such vaccines. The health care professional who performs

the pre travel risk assessment should also give tailored pre travel advice to the

individual traveller. Refer back to section 2, page 16 for the legal responsibilities under

‘Prescribing, supplying and administering travel vaccines’. Nurses practising in the

UK are reminded of their personal accountability and compliance with The Code when

advising travellers (NMC, 2018).

Steps to follow after a risk assessment

Once a risk assessment has been undertaken and in conjunction with reference to an

online national travel health website (plus other resources outlined in Appendix 2), travel

health advice including malaria prevention must be given (CQC, 2022). This process

enables knowledge to ascertain:

• the disease risks that may be a potential threat to the traveller

• the non-disease related risks the traveller may be exposed to, such as accidents

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• which vaccine-preventable diseases the traveller may need protection against

• identification of any contraindications to vaccination and the relevant information to

be given to the traveller about the vaccines available, including efficacy, length of

protection, schedule, side-effects and cost implications. Details of clinical information

can be obtained from the Summary of Product Characteristics (SmPC) in the

electronic Medicines Compendium (eMC)

• which vaccines could be offered and which schedules are most appropriate

• if any vaccines are recommended after a pre-travel risk assessment but are not

provided at the specific centre (for example, a GP surgery), advice about the vaccines

and information regarding options of where to obtain them should be given

• when malaria prevention advice is appropriate it should include general advice on

awareness of malaria risk, mosquito bite avoidance and information about awareness

and action on symptoms of malaria to facilitate rapid diagnosis and treatment. These

aspects are essential and should always be provided within the risk assessment

consultation. Offer information to enable the traveller to make as informed a choice as

possible for chemoprophylaxis. This would include details about different tablet

options, efficacy, side-effects and cost. Details of clinical information can be obtained

from the SmPC in the electronic Medicines Compendium. Information about obtaining

chemoprophylaxis should also be offered

• any necessary additional travel health advice should be given, tailored to the

traveller’s individual needs; for example, if the traveller has diabetes; or certain

travellers might be advised against travelling to a destination because of extreme

health risks – for example, pregnant women, infants, and young children travelling to a

destination with a high risk of malaria and where there is drug resistant Plasmodium

falciparum malaria

• additional information sources should be given to the traveller to aid self-directed

learning; travellers need to take on a degree of responsibility for self-education,

ideally reviewing potential health risks prior to the travel health consultation (see

‘Useful travel health sites for the general public’ in Appendix 2).

Documentation to accompany the travel consultation

• nurses should work within the boundaries of The Code (NMC, 2018) and Professional

Guidance on the Administration of Medicines in Healthcare Settings (RPS, 2019)

• the nurse is responsible for undertaking and evaluating the risk assessment, and

thoroughly documenting it in a professional manner and keeping records secure

• a checklist is provided in Appendix 1 to highlight the information that could be

documented during the travel health consultation; while it may be considered

necessary to adapt this content to suit your individual workplace, please note items

included are indicative of best practice

• administration of a vaccine must be recorded accurately and thoroughly (UKHSA,

2013a). If the vaccine is administered using a PGD, the method of recording must be

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followed, and this represents best practice in all situations (UKHSA, 2022, PHS, 2022).

For more specific information, visit the Public Health Forum travel pages rcn.org.uk/

clinical-topics/Public-health/Travel-health

• it is best practice to provide the patient information leaflet to the patient prior to the

administration. Please study the information on the checklist carefully. The following

link medicines.org.uk/emc could be given as a resource to the traveller

• provide a written record of vaccinations administered, advise the traveller to keep the

documentation safe and take to any future travel health consultations; these records

will help travel health advisers and aid future decisions on vaccine requirements. Apps

are now available to help document records including the provision of the NHS app

which stores COVID-19 vaccines and other routine immunisations. Adhere to your UK

country of practice recommendations

• in England, information about vaccine administration should be documented in full and

records held for 10 years for an adult and 25 years for a child or eight years following a

child’s death (NHS, 2021, BMA, 2022c)

• in Scotland, records should be maintained, archived and/or disposed of in accordance

with The Scottish Government Records Management Code of Practice for Health and

Social Care (Scottish Government, 2020). This includes observing the defined core

recommended retention periods for child and adult health records. Scottish Yellow

Fever Vaccination Centres (YFVCs) are also subject to this code of practice. Public

Health Scotland recognises that local policy may require observation increased

retention periods; such instances should be clearly justified and evidenced locally

• if vaccines are administered under a PGD, the final authorised copy of the PGD should

be kept for eight years after the expiry date of the PGD if the PGD relates to adults

only (10 years if it relates to an implant), and for 25 years after the expiry date of the

PGD if the PGD relates to children. PGD documentation of staff authorisation also

needs to be kept – it is recommended that the full details of this guidance should be

referred to (SPS, 2022b)

• in accordance with IHR (2005), both NaTHNaC and Public Health Scotland require

YFVCs to ensure that an International Certificate of Vaccination or Prophylaxis (ICVP)

are signed by the YFVCs responsible supervising clinician (RSC) or a health

professional authorised by the RSC. Additionally, all YFVCs should be aware that, due

to lifelong validity, a duplicate ICVP might be requested many years after vaccination

but can only be issued where a satisfactory record exists. When replacing a genuinely

lost, mislaid or badly damaged ICVP, it is acceptable to write the term of validity as

valid for the ‘life of the person vaccinated’ whatever the date of original issue. Where

the person to be vaccinated at the YFVC is a registered patient of that centre, a record

of YF risk assessment and vaccine administration should be made in the patient’s

medical record. Persons attending the centre who are not registered patients at that

centre should have a personal record constructed that should be retained by the

centre (NaTHNaC, 2022i)

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• it may be useful to write a protocol documenting the process of a travel consultation

setting out items such as aims and objectives, key resources to be used, roles of staff

involved, description of the process of booking appointments, the travel consultation,

planned audit, and so forth.

Conclusion

Registered nurses delivering travel health services should be trained and competent in the

discipline and aware of current national guidelines, support, and resources in their country

of practice. No travel health consultation should take place without conducting a travel

risk assessment and documenting the information. This is a two-way process between the

health care professional and the traveller and needs to be discussed in depth at the

outset. Good communication skills are key. The assessment forms the basis of all

subsequent decisions, advice given, vaccines administered and the malaria prevention and

other health advice that is offered. This takes time to perform correctly, and for best

practice, practitioners should leave sufficient time as described.

Important information to note

Risk assessment and risk management forms are found in Appendix 1, but they are

also available as standalone downloadable forms - items 1 and 2 on Jane Chiodini’s

‘Tools’ web page at: janechiodini.co.uk/tools. An alternative travel risk assessment

form is also available from NaTHNaC at: travelhealthpro.org.uk/factsheet/61/risk-

assessment--risk-management-checklist.

The GPG Risk Assessment tool should be used after initial training in travel health to

ensure the practitioner is clinically competent before consulting with travellers.

It may also be used as a document for those more experienced in travel health

practice and support ongoing needs for CPD. This document can be found within the

Good Practice Guidance for Providing a Travel Health Service publication at: rcpsg.

ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service.

However, it is also available as an editable Word version, which can be downloaded

from the same web page. This document complements the following section 4 in this

publication: The competency framework for travel health nurses.

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Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/nurse

consultant (level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5 and 6

as well

1. Upholds the professional

standards required of registered

nurses in accordance with the

NMC Code.

2. Keeps knowledge and skills

up to date through appropriate

learning and professional

development activities.

3. Ensures all information,

advice and/or intervention

given is based on best

available evidence.

4. Communicates clearly and

effectively with travellers

and colleagues, including

taking reasonable steps to

meet individual language

and communication needs,

using a range of verbal and

non-verbal communication

methods, being considerate of

cultural sensitivities to better

understand and respond to

individual needs.

5. Works to established

protocols.

6. Works within scope of

practice to make clinical

judgements for routine

travel health scenarios and

seeks clinical supervision as

required.

7. Works effectively as a

team member.

8. Maintains accurate records

of all information, advice

and interventions given in a

timely manner.

3. Contributes to service

provision planning ensuring it

is suitable to meet the travel

service population needs.

5. Reviews and updates

established protocols.

6. Makes clinical decisions in

more complex circumstances.

For example, a patient over

60 years-of-age travelling to

a country endemic for yellow

fever.

3. In collaboration with other

senior members of staff, drives

service provision planning,

ensuring it is suitable to meet

the travel service population.

5. Oversees effective

implementation of protocols

and makes recommendations.

6. Able to work independently

to make challenging clinical

judgements and decisions.

4. The competency framework for

travel health nurses

Core competency 1:

General standards expected of all nurses working in travel health

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Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/nurse

consultant (level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5 and 6

as well

9. Provides accurate and

consistent advice to travellers

that supports them to make

informed decisions.

10. Knows where and how

to access current pertinent

travel health information and

advice and knows where to

seek further guidance when

required.

11. Recognises and works

within limits of competence.

12. Understands and works

within legal framework for

the prescribing, supply and

administration of medicines.

Demonstrates appropriate use

of Patient Group Directions

(PGDs), Patient Specific

Directions (PSDs), Standing

Orders (in occupational health

setting) and prescriptions

from medical or non-medical

prescribers.

13 Understands and works

within legal framework for

use of unlicensed and off-label

drugs.

12. Oversees effective

implementation of PGDs, PSDs

and/or standing orders.

11. Recognises complex

circumstances that require

referral to more specialist

services.

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Core competency 2:

Travel health consultations

Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/nurse

consultant (level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5 and 6

as well

1. Demonstrates good

geographical knowledge

and knows how to access

further information regarding

global destinations including

use of up-to-date maps and

accessing the internet for

relevant resources.

2. Performs comprehensive

risk assessments and

understands the principles of

effective risk assessment.

3. Interprets the risk

assessment and accesses

the latest recommendations

for travel health information,

advice, immunisations and

malaria chemoprophylaxis

appropriate for the itinerary.

4. Recognises complex cases

beyond personal scope and

knows who to contact for

further information, support

and advice.

5. Checks if UK immunisation

schedules are up to date and

acts appropriately if not. This

includes those who received

their routine vaccinations

abroad.

6. Demonstrates knowledge

and awareness of common

travel related illnesses, their

cause and prevention. For

example, travellers’ diarrhoea.

7. Demonstrate knowledge

and awareness of all vaccine

preventable diseases,

including MMR, flu and

pneumococcal disease in

relation to travel.

2. Supports, mentors and

educates wider team in travel

medicine service delivery.

3. Reviews and updates

existing risk assessment tools.

4a. Provides support and

advice to inexperienced

colleagues in complex cases.

4b. Manages more complex

cases independently but

refers when necessary. For

example, travellers with

serious underlying medical

conditions.

4c. Identifies and advises

travellers with complex

travel or additional needs.

For example, individuals

who are pregnant, diabetic,

immunosuppressed etc.

2. Develops protocols

encompassing risk

assessment. For example,

malaria prevention advice,

vaccine storage.

3. Accepts and interprets risk

assessment in complex cases.

4. Advises travellers with

more complex health needs.

For example, emergency

standby malaria medication,

post-exposure prophylaxis in

relation to blood-borne virus

exposure, management of

altitude sickness etc.

7. Provides advice on more

complex circumstances at a

local/national/board/ strategic

level.

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Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/

nurse consultant (level

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5

and 6 as well

8. Demonstrates knowledge and

awareness of vector borne diseases,

including the ABCD of malaria

prevention advice.

9. Provides tailored advice to the

individual traveller regarding:

• accident prevention

• appropriate travel insurance

• safe food, water and personal

hygiene

• prevention of blood-borne and

sexually transmitted infections

• insect bite prevention

• Prevention of life-threatening

animal bites and stings

• Rabies prevention, management,

and treatment

• Management of extremes of

temperature, for example sun

safety, heat exhaustion, frostbite

• personal safety and security

• Malaria awareness, mosquito bite

prevention, chemoprophylaxis,

and the importance of

compliance, recognising

symptoms to enable prompt

diagnosis and treatment of

malaria.

10. Communicates information

effectively to explain the diseases

and other travel-related risks,

including prevention strategies

appropriate to the risk assessment.

11. Prioritises appropriately, when a

traveller’s time or financial situation

does not permit the uptake of

optimum recommendations.

12. Assesses anxieties, especially to

vaccination, and acts appropriately.

13. Demonstrates an excellent

vaccine administration technique.

7a. Provides specialist advice

to travellers with more

complex itineraries that may

also require the prescription,

provision and administration

of specialist travel vaccines

such as Japanese encephalitis,

rabies, tick-borne encephalitis,

yellow fever and BCG.

7b. Meets the standards

required for administration

of yellow fever vaccine

and complies with national

regulations as a Yellow Fever

Vaccination Centre, which

is under the administration

of the National Travel

Health Network and Centre

(NaTHNaC) in England, Wales

and Northern Ireland and

Public Health Scotland (PHS)

in Scotland.

9. Demonstrates involvement

in the financial governance

of travel health services,

for example, private versus

NHS vaccines. This would

also include the provision of

malaria chemoprophylaxis,

medication in anticipation

of illness abroad and travel

health products such as insect

repellents, sterile medical

kits etc.

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Core competency 3:

Professional responsibilities for nurses working in travel health

Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/nurse

consultant (level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5 and 6

as well

1. Is educated in immunisation

in accordance with UKHSA

National Minimum Standards

and Core Curriculum for

Immunisation Training for

Registered Healthcare

Practitioners or NHS

Education for Scotland

Promoting Effective

Immunisation Practice (PEIP)

programme for Registered

Healthcare Practitioners.

2. Attends annual update on

anaphylaxis and CPR training.

3. Understands professional

responsibility in relation to

informed consent and acts

accordingly.

4. Ensures safeguarding

training is up to date (including

level 3 if caring for children).

5. Ensures that travel health

knowledge is evidence-based

and remains current.

6. Reflects on own

professional competence

and ensures clinical practice

is evaluated against good

practice standards and

guidelines. For example,

The Good Practice Guidance

for Providing a Travel Health

Service

5. Supports and mentors other

nurses to ensure their clinical

practice is evaluated against

good practice standards and

guidelines.

6. Appraises individuals on

professional development as

required.

5a. Uses expert knowledge to

inform protocol development

and guide others in this

process.

5b. Audits documentation

to ensure good practice

standards are upheld.

6a. Speaks/presents research

at travel health educational

events at a national or

international level.

RCN TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT

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Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/

nurse consultant

(level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5

and 6 as well

7. Attends an annual travel health

update study session/conference

at a local, national or international

event, either in person or online.

If such is not available, undertake

self-directed learning by means

of following online news alerts,

vaccine updates, reading

published travel health medicine

articles/information. Undertake a

reflective narrative of the learning

to provide evidence of keeping

up to date in line with current

revalidation requirements.

8. Uses recognised national

travel health websites to

ensure adherence to the latest

recommendations and awareness

of issues, such as disease

outbreaks is maintained.

9. Demonstrates awareness of and

uses a variety of other recognised

travel health resources online (see

Appendix 2).

10. Signs up to pertinent

travel health alerts from key

authoritative sources, for

example, RCN Public Health

Forum, NaTHNaC and/or TRAVAX.

7. Educates nursing, midwifery,

allied health care professionals

(NMAHP) working in the field of

travel health.

8. Awareness of international

websites to inform on global issues

in travel health.

8. Uses international

websites to ensure

awareness and inform

on global issues in

travel health.

10a. Considers

involvement with

national and

international travel

health forums.

10b. Demonstrates

highly developed

knowledge of the

whole range of topics

in travel health.

10c. Acts as a mentor

to competent nurse

Level 5 and

experienced/ proficient

nurse level 6.

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Competent nurse (level 5)

Experienced/proficient nurse

(level 6)

Senior practitioner/

nurse consultant

(level 7)

Fulfil points at this level Fulfil points at level 5 as well

Fulfil points at level 5

and 6 as well

11. Demonstrates evidence of

learning to apply skills and

knowledge in the field of travel

health. For example, minimum of

15 hours of relevant learning plus

mentorship in clinical skills before

undertaking a travel consultation

alone. Demonstrates evidence

of CPD in line with current

revalidation requirements.

12. Insists on adequate time to

perform the travel consultation

and negotiates sufficient time if

this has not been sanctioned.

13. Demonstrates adherence to

the principles of vaccine storage,

administration and related theory.

14. Ensures adequate vaccine

stock control, ordering or

delegating this process to

ensure sufficient stock is always

available as per local protocols.

15. Is involved in the choice of

vaccine products used in relation

to clinical evidence and best

practice.

16. Works effectively with non-

clinical staff who are involved in

the travel consultation process.

For example, non-clinical staff

involved in booking travel health

consultation appointments.

17. Complies with audit procedures

and policy changes.

11a. Considers joining travel health

specific groups. For example, RCN

Public Health Forum, International

Society of Travel Medicine, the

Faculty of Travel Medicine of the

Royal College of Physicians and

Surgeons of Glasgow and/or the

British Global and Travel Health

Association.

11b. Considers formal travel health

training at postgraduate level.

15. Involved in deciding which

vaccines will be utilised.

16. Manages non-clinical staff in a

clinic setting and sets parameters

for their duties related to travel

health enquiries and appointments.

17. Assists in the collation and

development of audit in travel health

clinical practice.

11a. Contributes to

the evidence base for

travel health nursing

practice to support

and promote travel

health nurses.

11b. Identifies areas

for further research

in travel health

medicine.

16. Undertakes

clinical audit in travel

health services and

acts on findings to

develop and improve

standards of care.

RCN TRAVEL HEALTH NURSING: CAREER AND COMPETENCE DEVELOPMENT

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Schlagenhauf P, Weld L, Goorhuis A et al., (2015) Travel-associated infection presenting in

Europe (2008-12): an analysis of EuroTravNet longitudinal, surveillance data, and

evaluation of the effect of the pre-travel consultation, Lancet Infectious Diseases (15 (1)),

pp.55-64. Available at: www.sciencedirect.com/science/article/pii/S147330991471000X

Scottish Government Health and Social Care Directorates (2020/2021) Statement of

Financial Entitlements 2020/2021; Coronavirus outbreak. Available at: www.sehd.scot.nhs.

uk/publications/GMS_Statement_of_Financial_Entitlements_2020-21.pdf

Scottish Government (2020) Records Management Health and Social Care Code of Practice

(Scotland) 2020. Available at: www.informationgovernance.scot.nhs.uk/rmcop2020

Scottish Government (2022) Vaccination Transformation Programme – Travel Health

Services. Available at: www.sehd.scot.nhs.uk/cmo/CMO(2022)13.pdf

Specialist Pharmacy Service (2022a) (FAQs) Patient Group Directions, Written Instructions

and Occupational Health Services. Available at: www.sps.nhs.uk/wp-content/

uploads/2020/10/Questions-About-PGDs-And-OHS-May-2022.pdf

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Specialist Pharmacy Service (2022b) Retaining PGD documentation. Available at:

www.sps.nhs.uk/articles/retaining-pgd-documentation

The Global Database (undated). Available at: www.hivtravel.org

The National Archives (2012) The Human Medicines Regulations 2012. Available at:

www.legislation.gov.uk/uksi/2012/1916/contents/made

TRAVAX (2020a) Diabetes. Available at:

www.travax.nhs.uk/health-advice/special-groups/diabetes

TRAVAX (2020b) Disabilities. Available at:

www.travax.nhs.uk/health-advice/special-groups/disabilities

TRAVAX (2020c) Accident prevention. Available at: www.travax.nhs.uk/health-advice/

general-health-advice/accident-prevention

TRAVAX (2020d) Breastfeeding and bottle-feeding. Available at: www.travax.nhs.uk/

health-advice/special-groups/breastfeeding-and-bottle-feeding

TRAVAX (2021a) Pregnancy and pre-conception. Available at: www.travax.nhs.uk/health-

advice/special-groups/pregnancy-and-pre-conception

TRAVAX (2021b) Mental health and travel. Available at: www.travax.nhs.uk/health-advice/

general-health-advice/mental-health-and-travel

TRAVAX (2021c) Venous thromboembolism. Available at: www.travax.nhs.uk/health-

advice/general-health-advice/venous-thromboembolism

TRAVAX (2021d) Travel insurance. Available at: www.travax.nhs.uk/health-advice/general-

health-advice/travel-insurance

TRAVAX (2021e) Travelling with medication. Available at: www.travax.nhs.uk/health-

advice/general-health-advice/travelling-with-medication

TRAVAX (2021f) Anaphylaxis and vaccines. Available at: www.travax.nhs.uk/vaccination-

practice/special-situations/anaphylaxis-and-vaccines

TRAVAX (2021g) Female genital mutilation. Available at: www.travax.nhs.uk/health-advice/

general-health-advice/female-genital-mutilation

TRAVAX (2021h) Food and water precautions. Available at: www.travax.nhs.uk/health-

advice/general-health-advice/food-and-water-precautions

TRAVAX (2022a) Sexual health risks. Available at: www.travax.nhs.uk/health-advice/

general-health-advice/sexual-health-risks

TRAVAX (2022b) Contraception. Available at: www.travax.nhs.uk/health-advice/general-

health-advice/contraception

TRAVAX (2022c) Medical Tourism. Available at: www.travax.nhs.uk/health-advice/special-

groups/medical-tourism

TRAVAX (2022d) Immunocompromised travellers. Available at: www.travax.nhs.uk/health-

advice/immunocompromised-section/immunocompromised-travellers

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TRAVAX (2022e) Visiting friends and relatives (VFRs). Available at: www.travax.nhs.uk/

health-advice/type-of-travel/visiting-friends-and-relatives-vfrs

TRAVAX (2022f) Cruise travel. Available at: www.travax.nhs.uk/health-advice/type-of-

travel/cruise-travel

TRAVAX (2022g) Hajj and Umrah pilgrimage. Available at: www.travax.nhs.uk/health-

advice/type-of-travel/hajj-and-umrah-pilgrimage

TRAVAX (2022h) Humanitarian workers. Available at: www.travax.nhs.uk/health-advice/

type-of-travel/humanitarian-workers

UK Civil Aviation Authority (2022a) Pregnancy; Information for Health Professionals on

assessing fitness to fly. Available at: www.caa.co.uk/passengers/before-you-fly/am-i-fit-

to-fly/guidance-for-health-professionals/pregnancy

UK Civil Aviation Authority (2022b) Assessing fitness to fly; Guidance for health

professionals. Available at: www.caa.co.uk/passengers/before-you-fly/am-i-fit-to-fly/

guidance-for-health-professionals/assessing-fitness-to-fly

UK Health Security Agency (2013a) Immunisation procedures: the green book, chapter 4.

Available at: www.gov.uk/government/publications/immunisation-procedures-the-

green-book-chapter-4

UK Health Security Agency (2013b) Vaccine safety and adverse events following

immunisation: the green book, chapter 8. Available at: www.gov.uk/government/

publications/vaccine-safety-and-adverse-events-following-immunisation-the-green-

book-chapter-8

UK Health Security Agency (2017) Contraindications and special considerations: the green

book, chapter 6. Available at: www.gov.uk/government/publications/contraindications-

and-special-considerations-the-green-book-chapter-6

UK Health Security Agency (2018) Tuberculosis: the green book, chapter 32. Available at:

www.gov.uk/government/publications/tuberculosis-the-green-book-chapter-32

UK Health Security Agency (2019) Zika virus (ZIKV): clinical and travel guidance. Available

at: www.gov.uk/government/collections/zika-virus-zikv-clinical-and-travel-

guidance#zika-and-pregnancy

UK Health Security Agency (2020) Immunisation of individuals with underlying medical

conditions: the green book, chapter 7. Available at: www.gov.uk/government/publications/

immunisation-of-individuals-with-underlying-medical-conditions-the-green-book-

chapter-7

UK Health Security Agency (2021) Immunisation against infectious disease: the green book

front cover and contents page. Available from: www.gov.uk/government/publications/

immunisation-against-infectious-disease-the-green-book-front-cover-and-contents-

page

UK Health Security Agency (2022a) Smallpox and monkeypox: the green book, chapter 29.

Available at: www.gov.uk/government/publications/smallpox-and-vaccinia-the-green-

book-chapter-29

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UK Health Security Agency (2022b) Immunisation patient group direction (PGD) templates.

Available at: www.gov.uk/government/collections/immunisation-patient-group-

direction-pgd

UK Health Security Agency (2022c) Information for patients with an absent or dysfunctional

spleen. Available at: assets.publishing.service.gov.uk/government/uploads/system/

uploads/attachment_data/file/1059549/UKHSA-12074-splenectomy-leaflet.pdf

UK Health Security Agency (2022d) Mosquito bite avoidance: advice for travellers. Available

at: www.gov.uk/government/publications/mosquito-bite-avoidance-for-travellers

UK Health Security Agency (2022e) Visiting friends and relatives abroad: health advice.

Available at: www.gov.uk/government/publications/travelling-overseas-to-visit-friends-

and-relatives-health-advice

UN World Tourism Organization (2022) UNWTO World Tourism Barometer and Statistical

Annex, March 2022. Available at: www.e-unwto.org/doi/abs/10.18111/

wtobarometereng.2022.20.1.2

Weinberg MS, Weinberg N and Maloney S (2020) Chapter 7 Traveling safely with infants &

children, Centers for Disease Control and Prevention, Health Information for International

Travel. New York: Oxford University Press (2019). Available at: wwwnc.cdc.gov/travel/

yellowbook/2020/family-travel/traveling-safely-with-infants-and-children

World Health Organization (2020) Health risks when travelling. Available at:

www.who.int/news-room/questions-and-answers/item/health-risks-when-traveling

World Health Organization (2021) Rabies. Available at:

www.who.int/news-room/fact-sheets/detail/rabies

World Health Organization (2022) Road traffic injuries. Available at:

www.who.int/news-room/fact-sheets/detail/road-traffic-injuries

(All URLs were accessed on 30 January 2023).

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Appendices

Appendix 1:

The following pages show a sample travel risk assessment form (pages

57-58) and a travel risk management form (pages 59-60).

Source: The two forms have been devised and created by Jane Chiodini.

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TRAVEL RISK ASSESSMENT FORM – ideally to be completed by traveller prior to appointment.

Name:

Your country of origin:

Date of birth:

Male □ Female □ Non-binary □

E mail:

Telephone number:

Mobile number:

PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW

Date of departure:

Total length of trip:

COUNTRY TO BE VISITED

EXACT LOCATION OR REGION

CITY OR RURAL

LENGTH OF STAY

What modes of transport will you be using?

Have you taken out travel insurance for this trip?

Do you plan to travel abroad again in the future?

TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY

□ Holiday □ Staying in hotel □ Backpacking

Additional information

□ Business trip □ Cruise ship trip □ Camping/hostels

□ Expatriate □ Safari □ Adventure

□ Volunteer work □ Pilgrimage □ Diving

□ Healthcare worker □ Medical tourism □ Visiting friends/family

PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY

YES

DETAILS

Are you fit and well today

Any allergies including food, latex, medication

Have you, or anyone in your family, had a severe

reaction to a vaccine or malaria medication before?

Tendency to faint with injections

Any surgical operations in the past, including e.g. open-

heart surgery, spleen or thymus gland removal?

Recent chemotherapy/radiotherapy/organ transplant

Anaemia

Bleeding /clotting disorders (including history of DVT)

Heart disease (e.g. angina, high blood pressure)

Diabetes

Additional needs and/or disability

Epilepsy/seizures (or in a first degree relative?)

Gastrointestinal (stomach) complaints

Liver and or kidney problems

HIV/AIDS

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YES

DETAILS

Immune system condition e.g. blood cancer

Mental health issues (including anxiety, depression)

Neurological (nervous system) illness

Respiratory (lung) disease

Rheumatology (joint) conditions

Spleen problems

Any other conditions?

Are you or your partner pregnant or planning a

pregnancy?

Are you breast feeding (if applicable)

Have you or anyone in your family undergone FGM /

been cut / circumcised

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

Tetanus/polio/diphtheria

MMR

Influenza

Typhoid

Hepatitis A

Pneumococcal

Cholera

Hepatitis B

Meningitis

Rabies

Japanese

encephalitis

Tick borne

encephalitis

Yellow fever

BCG

Other

COVID-19 (dates, brand etc.)

Malaria Tablets

Any additional information

1. Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel

Health Medicine. RCN, London.

2. Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK.

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FOR HEALTH PROFESSIONAL USE ONLY IN CONJUNCTION with TRAVEL RISK ASSESSMENT FORM

Patient Name: dob:

Childhood immunisation history checked:

Additional information:

National database consulted for travel vaccines recommended for this trip and malaria

chemoprophylaxis (if required): NaTHNaC: TRAVAX: Other:

Disease protection

advised

Yes

Disease protection

advised

Yes

Malaria Chemoprophylaxis Yes

Recommendation

BCG/Mantoux

Influenza

Atovaquone/proguanil

Cholera

Meningitis ACWY

Chloroquine only

COVID-19

MMR

Chloroquine and proguanil

Dip/tetanus/polio

Rabies

Doxycycline

Hepatitis A

TBE

Mefloquine

Hepatitis B

Typhoid

Proguanil only

Hepatitis A+B

Yellow fever

Emergency standby

Japanese encephalitis

Other

Weight of child:

Vaccine and General Travel Advice required/provided

Potential side effects of vaccines discussed

Patient Information Leaflet (PIL) from packaging or from www.medicines.org.uk/emc/ given

Patient consent for vaccination obtained: verbal □ written □

Post vaccination advice given: verbal □ written □

General travel advice leaflet given (all topics below in the surgery/clinic advice leaflet) and patient

asked to read entire leaflet due to insufficient time to advise verbally on every topic: Yes / No

Items ticked below indicate topics discussed specifically within the consultation:

Prevention of accidents Mosquito bite prevention

Personal safety and security Malaria prevention advice

Food and water borne risks Medical preparation

Travellers’ diarrhoea advice Sun and heat advice

Sexual health & blood borne virus risk Journey/transport advice

Rabies specific advice Insurance advice

Other specific specialised advice / information given on:

e.g. COVID-19 supportive advice, smoking advice for a long-haul flight; altitude advice; prevention of

schistosomias

is etc.

Source of advice used for further information : NaTHNaC TRAVAX Other

OR no additional specialised advice given □

TRAVEL RISK MANAGEMENT FORM

PTO

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Additional patient management or advice taken following risk assessment – for example:

• Vaccine(s) patient declined following recommendation, and reason why

• Telephoned NaTHNaC or TRAVAX for advice or used Malaria Reference Laboratory e-mail service

• Contacted hospital consultant for specific information in respect of a complex medical condition

• Given appropriate advice in relation to pregnancy and planned conception if travelling to Zika risk

area

• Discussed traveller responsibility regarding COVID-19 travel requirements if necessary

• Identified specific nature/purpose of VFR travel

Authorisation for a Patient Specific Direction (PSD)

Following the completion of a travel risk assessment, the below named vaccines may be administered

under this PSD to:

Name: dob:

Name, form & strength of medicine

(generic/brand name as appropriate)

Dose, schedule and route of

administration

Start and finish

dates

Signature of Prescriber

Date

Post Vaccination administration

Vaccine details recorded on patient computer record

(vaccine name, batch no., stage, site, etc.)

Y / N

SMS vaccines reminder or post card reminder service set up

Y / N

Travel record card supplied or updated:

Y / N

Travel risk management consultation performed by: (sign name and date)

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Appendix 2:

Summary of travel health-related information sources

1. Essential guidance documents for travel health practitioners

1a. Atlas

All practitioners providing a travel health service should use an up-to-date atlas, either

hard copy or online (for example, google.co.uk/maps)

1b. Governance publications

• Care Quality Commission (CQC) Mythbuster 107: Pre-travel health services

cqc.org.uk/node/8422

• Royal College of Nursing: Travel Health Nursing: Career and Competence Development

rcn.org.uk/Professional-Development/publications/rcn-travel-health-nursing-uk-

pub-010-573 (login or free registration required)

• Royal College of Physicians and Surgeons of Glasgow: Faculty of Travel Medicine

‘Good Practice Guidance for a Travel Health Service’ rcpsg.ac.uk/travel-medicine/

good-practice-guidance-for-providing-a-travel-health-service (see this webpage

for the complete document, but also sections are available as individual downloads

e.g. a booklet of resources, a patient information leaflet, and the Competency

Assessment Tool)

2. Essential resources for day-to day-practice

2a. National Guidance documents

• The ‘Green Book’

Immunisation against infectious disease, UKHSA. Available only online at: gov.uk/

government/collections/immunisation-against-infectious-disease-the-green-book

• The latest UK Malaria prevention guidelines

Guidelines for malaria prevention in travellers from the United Kingdom, UKHSA.

Available only online at: gov.uk/government/publications/malaria-prevention-

guidelines-for-travellers-from-the-uk

2b. National online travel health websites

• TRAVAX (from Public Health Scotland)

travax.nhs.uk

• TravelHealthPro (NaTHNaC from UKHSA)

travelhealthpro.org.uk

2c. National telephone advice lines for health professionals

• National Travel Health Network and Centre (NaTHNaC)

For the current service details visit: travelhealthpro.org.uk/contact

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• TRAVAX

For the current service details visit: travax.nhs.uk/contact-us

• UKHSA Malaria Reference Laboratory Email Service

This is for health care professionals only, who need to download a risk assessment

form at: gov.uk/government/publications/malaria-risk-assessment-form. Complete a

form electronically and email it to: phe.malproph@nhs.net. A reply will be received

within three working days.

2d. Travel Risk Assessment and Travel Risk Management forms

See appendix 1 in this document as well as the information provided on page 37.

3. Other related useful resources

3a. RCN general immunisation information

This webpage provides comprehensive detail and a current list of websites relating to

immunisation, including the following topics:

• Current issues

• Administration of vaccines

• Immunisation training

• Storage and the Cold Chain

• Vaccine Incidence Guidance

• Keeping up to date.

To access visit: www.rcn.org.uk/clinical-topics/Public-health/Immunisation

Please note, your membership login will be required. Non-members may complete a free

registration to access.

3b. RCN travel health information

This webpage provides comprehensive detail and a current list of websites relating to

travel health, including the following topics:

• Malaria including the World Malaria Report and other malaria information links

• Disease information e.g. COVID-19, MMR, Rabies, Yellow fever and Zika virus

• Female Genital Mutilation

• Lesbian, Gay, Bisexual and Transgender travel advice

• The Foreign, Commonwealth and Development Office

• Courses, conferences, and study days.

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To access visit: www.rcn.org.uk/clinical-topics/public-health/travel-health

Please note, your membership login will be required. Non-members may complete a free

registration to access.

3c. Drug information for vaccines and Malaria Chemoprophylaxis

• The electronics medicine compendium at: medicines.org.uk/emc

• The British National Formulary (BNF) at: bnf.nice.org.uk

• The BNF and BNF for Children App at: bnf.org/products/bnfbnfcapp

3d. Prescribing

• RCN information about PGDs and PSDs at: https://www.rcn.org.uk/clinical-topics/

Medicines-management/Patient-specific-directions-and-patient-group-directions

Please note, your RCN membership login will be required.

• NHS Specialist Pharmacy Service information on Patient Group Directions at:

sps.nhs.uk/home/guidance/patient-group-directions

• CQC Mythbuster 19 on PGDs and PSDs at: cqc.org.uk/guidance-providers/gps/gp-

mythbuster-19-patient-group-directions-pgdspatient-specific-directions

• Prescribing for Travel Vaccines FAQs at:

janechiodini.co.uk/help/faqs/faq-1-prescribing-travel

3e. International travel related resources

• Centers for Disease Control and Prevention, USA (CDC) at: nc.cdc.gov/travel

• European Centre for Disease Prevention and Control (ECDC) at: ecdc.europa.eu/en

• World Health Organization at: who.int

• World Health Organization Travel and Health information at:

who.int/health-topics/travel-and-health

3f. Useful travel health sites for the general public

• fit for travel at: fitfortravel.nhs.uk/home

• TravelHealthPro at: travelhealthpro.org.uk

• Foreign Commonwealth and Development Office (FCO) at:

gov.uk/foreign-travel-advice and the FCDO Travel Aware campaign at:

travelaware.campaign.gov.uk

• NHS Overview Travel vaccinations at: nhs.uk/conditions/travel-vaccinations

4.Professional development in travel health

4a. Travel-related organisations

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• British Global and Travel Health Association (BGTHA) at: bgtha.org

• Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of

Glasgow (RCPSG) at: rcpsg.ac.uk and go to the travel medicine section

• International Society of Travel Medicine (ISTM) at: istm.org

• The American Travel Health Nurse Association (ATHNA) at: athna.org

• RCN Public Health Forum at: rcn.org.uk/clinical-topics/Public-health

4b. Education and training in travel health

• The Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of

Glasgow provides a selection of education, including a Professional Certificate in

Travel Medicine, the RCPSG Postgraduate Diploma in Travel Medicine, and the RCPSG

Postgraduate Diploma in Expedition and Wilderness Medicine. Visit:

rcpsg.ac.uk/travel-medicine/qualifications-in-travel-medicine for more information

• The Liverpool School of Tropical Medicine (LSTM) provides a part-time and fully online

Professional Diploma in Travel Health educational programme, jointly developed with

the National Travel Health Network and Centre (NaTHNaC) and with LSTM’s Well

Travelled Clinics. Visit Professional Diploma in Travel Health (ONLINE) at: www.lstmed.

ac.uk/study/courses/professional-diploma-in-travel-health-online and Well travelled

clinics at: www.lstmed.ac.uk/consultancy/case-studies/well-travelled-clinics

• TRAVAX (password required) at: travax.nhs.uk/resources

• TravelHealthPro at: travelhealthpro.org.uk/factsheet/24/educational-events

• The NHS Education for Scotland (NES) Travel Health Education resource supports

those working within NHS Scotland travel health service settings to develop the

knowledge and skills they require to safely and effectively deliver the NHS Scotland

Level 2 travel health components specified within the Vaccine Transformation

Programme. This resource will be of interest to those who are new to travel health

service provision, or wish to refresh their current knowledge around the travel risk

assessment and NHS travel vaccines. It is freely available to health care professionals

through the NES TURAS Learn online platform. To access this resource, you will need

to log into TURAS Learn at: learn.nes.nhs.scot/66632. If you do not have an account,

you can sign up for free by clicking on: Registration for TURAS Learn

• There are numerous other providers of travel health education in the UK. Care should

be taken when booking an independent course to ensure the trainer is trained to a

higher level of travel health, and shows a recognisable qualification in the subject

• International Society of Travel Medicine at: istm.org/educationalactivities

Important information to remember

As travel health is a fast-moving area of practice, nurses are reminded to use the most

current information when advising travellers.

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RCN quality assurance

Publication

This is a RCN competence knowledge and skills framework to support personal development and career progression.

Description

This framework defines the standards of care expected for a competent registered nurse, experienced/proficient nurse,

and a senior practitioner/expert nurse delivering travel health services.

Publication date: May 2023

Review date: May 2026

The Nine Quality Standards

This publication has met the Nine Quality Standards of the quality framework for RCN professional publications. For more

information or to request further details on how the standards have been met in relation to this professional publication,

please email: publicat[email protected]

Evaluation

The authors would value any feedback you have about this publication. Please email: publications.feedback@rcn.org.uk

clearly stating which publication you are commenting on.

RCN Legal Disclaimer

This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK,

but readers are advised that practices may vary in each country and outside the UK. The information in this booklet has been

compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the

RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may

be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or

alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN.

system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without

prior permission of the publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of

trade in any form of binding or cover other than that in which it is published, without the prior consent of the publishers.

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The RCN represents nurses and nursing, promotes

excellence in practice and shapes health policies

Published by the Royal College of Nursing

20 Cavendish Square

London

W1G 0RN

rcn.org.uk

May 2023

Review date: May 2026

Publication code: 010 573