Guidance for providing vaccinations and general travel advice to travellers.

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Introduction

Purpose

Suitably trained pharmacists have been authorised under the NSW Poisons and Therapeutic Goods Regulation 2008 to administer certain National Immunisation Program (NIP), privately funded, and COVID-19 vaccines to selected consumers.

The purpose of this document is to provide guidance to pharmacists who are asked by consumers to administer vaccinations for overseas travel. When administering the vaccine, pharmacists will have the opportunity to provide general travel health advice, and the responsibility to refer people to their general practitioner (GP) or travel medicine specialist for more complex travel advice.

This document does not outline any requirements for the accreditation and training of pharmacist immunisers, which are addressed separately by the Immunisation Unit within Health Protection NSW.

Background

Pharmacists have been identified as accessible providers of vaccination for consumers. From 14 November 2022, pharmacist immunisers will be authorised to provide an expanded scope of vaccines to members of the community. The reason for seeking vaccination for some consumers may be connected to an upcoming overseas trip and whilst providing vaccination, there may be an opportunistic discussion between the pharmacist and traveller to provide general travel advice.

Historically, Australian travellers have been reluctant to seek pre-travel health advice before departing on their trips.[1] A pre-travel health consultation examines the risks involved after considering both the traveller's itinerary and their medical history and proposes mitigations that include vaccination and behaviour modification. Pre-departure travel advice and education becomes more important when the consumer is travelling to a high-risk destination or if they have a high-risk medical condition. This consultation is usually performed by a general practitioner or travel health practitioner. Receiving pre-travel health advice not only has benefits for the individual, but also has broader benefits for the health system through decreased incidence of vaccine-preventable and other diseases.

Scope of pharmacists' role in administering vaccines

Pharmacists in New South Wales are authorised to supply and administer the following vaccines:

  • Influenza
  • Adult diphtheria-tetanus-pertussis (dTpa)
  • Measles-mumps-rubella (MMR)
  • Human papillomavirus
  • Meningococcal ACWY
  • COVID-19

From 14 November 2022, pharmacist immunisers will be authorised to administer the following additional vaccines:

  • Hepatitis A
  • Hepatitis B
  • Japanese Encephalitis – mandatory training module required
  • Poliomyelitis
  • Typhoid – intramuscular injection only
  • Zoster – Shingrix only

The role of pharmacists as providers of travel vaccinations and simple health advice

The following two examples are illustrative of situations in which a pharmacist may find themselves supporting a traveller's pre-travel healthcare needs.

  • A general practitioner (GP) may have advised or prescribed a vaccine for the traveller. The pharmacist may be able to administer the vaccination without sending the traveller back to the GP. This provides more options for the consumer and lowers the risk of a vaccine cold chain breach if the vaccines are not held at the general practice. In this circumstance the GP practice should be advised by telephone that the vaccine has been administered and the usual process for uploading to the Australian Immunisation Register (AIR) followed (refer below).
  • Travellers may visit a pharmacist to ask advice about travel vaccinations or over the counter medications for travel-related illness (such as diarrhoea, constipation, allergies, colds and flu or seasickness). This presents an opportunity for the pharmacist to offer travel vaccinations, within the permitted scope, if indicated by the travel destination of the traveller's itinerary. In this context general travel advice relating to food and water precautions, mosquito bite avoidance, avoiding animal bites, making sure medication supplies are adequate and can be safely transported and referral to appropriate websites such as the Smart Traveller and NSW Health (see Section 5) can be provided. Referral to a GP is required if further travel health vaccination, travel related medication or advice including such issues as altitude sickness, sexual health or chronic illness management is required.

Knowing when to refer to a general practitioner

In any scenario in which a pharmacist supports a traveller's pre-travel healthcare needs, it is important that an appropriate standard of care is provided to the traveller. Importantly, a pharmacist needs to recognise the limit of their capability and refer travellers to a GP or travel medicine practitioner where they identify that a more comprehensive travel health consultation is needed.

Providing vaccinations to consumers

If a consumer requests a vaccination for travel purposes, a framework such as "Three R's" (Required, Routine, Recommended) can be applied to determine the appropriate vaccines for the trip.

  1. Firstly, determine which, if any, vaccines are required to cross international borders under International Health Regulations or as specific country requirements. For example, yellow fever or polio, or meningococcal ACWY for Hajj/Umrah pilgrimages. See the WHO International Travel and Health website for detailed information about requirements for travel.
  2. Next, ensure the patient is up to date with routine Australian immunisations including measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, polio, and annual influenza.
  3. Certain childhood vaccines such as measles can be given earlier than normally scheduled with appropriate catch up. This discussion should take place with a GP. See the Australian Immunisation Handbook for information about this and ensure the consumer is aware of any implications to the childhood immunisation schedule.
  4. Then determine which vaccinations should be recommended based on a detailed consideration of the itinerary. If necessary, use accelerated vaccine regimes to provide the best possible protection during the trip.
  5. Immunise opportunistically and pragmatically. Unless there are significant concerns about side effects developing while away, it is never too late to vaccinate before a trip. Particularly for longer trips, some immunity will develop during travel. Immune priming will also occur that could benefit future travel.
  6. Ensure appropriate spacing between live vaccine doses, including BCG. (NB if two live vaccines are to be given they must be given together OR at least four weeks apart).
  7. Refer patients requiring yellow fever vaccination to an authorised provider in NSW. The patient can choose to speak to their own GP prior to referral.
  8. Refer patients requiring BCG vaccination as per the BCG Vaccination pathway. The patient can choose to speak to their own GP prior to referral.

Immunisation area

In accordance with the NSW Pharmacist Vaccination Standards, the pharmacist immuniser must:

'...conduct the vaccination in an immunisation service room, consulting room or immunisation area; this may be a dedicated space or an existing room for the purpose of providing vaccination services. The immunisation service room, consulting room or immunisation area must be consistent with the following:

  1. The room or area is not to be used as a dispensary, storeroom, staff room or retail area,
  2. Provide adequate privacy
  3. Have adequate lighting
  4. Be maintained at a comfortable ambient temperature
  5. Have a hand sanitisation facility
  6. Have ready access to a hand washing facility
  7. Have sufficient floor area, clear of equipment and furniture, to accommodate the person receiving the vaccination and an accompanying person, and to allow the pharmacist immuniser adequate space to manoeuvre, and
  8. Have sufficient bench space (with an impervious surface), a chair and a first aid couch (or similar).'

Reporting vaccinations to the Australian Immunisation Register

Ensure all vaccinations, including those for travel, are reported to the Australian Immunisation Register (AIR). Episodes of vaccination can be reported using clinical software, via PRODA or manually by submitting one of the following:

Notifying Adverse Events Following Immunisation (AEFI)

Report all uncommon, serious, or unexpected AEFI or any event felt to be significant following immunisation to your local public health unit as soon as possible. To report a suspected AEFI, please download the National Adverse Events Following Immunisation (AEFI) Reporting Form and contact your local Public Health Unit on 1300 066 055. The form should also be sent to the Therapeutic Goods Administration (TGA) as follows.

  • Post to Office of Product Review, Reply Paid 100, Woden, ACT 2606
  • Fax to (02) 6232‑8392
  • Email to adr.reports@tga.gov.au

Providing general guidance to travellers

In the course of providing travel vaccinations, pharmacists may find themselves in a position to have an opportunistic discussion with the traveller on simple ways to reduce their risk while travelling.

Vaccination represents only one component in the provision of comprehensive, high quality pre-travel health care to travellers. It is equally important to educate overseas travellers about risks to health that are not vaccine-preventable, such as: the climate at the destination, specific activities undertaken while overseas, and the style of travel. This is done through the travel health focused primary care consultation. Patients should generally be encouraged to see their GP before travelling, particularly if they are elderly or travelling to regions with significant endemic infectious diseases.

In clinical practice, the travel consultation is used as an important opportunity to discuss a traveller's plans and has the following objectives:

  • Review the itinerary and determine potential health risks in the areas to be visited and how they interact with the travellers past medical history and existing health status.
  • Educate the traveller about anticipated risks and methods for prevention, including safe behaviours.
  • Prescribe travel vaccinations.
  • Recommend medication for prophylaxis, or for self-treatment of travel-related illness. Where relevant medication requires a prescription, refer to the person's GP.
  • Recommend that adequate travel insurance is in place to cover risks to health through travel

A useful framework to apply when assessing an individual's risk from travel to a particular destination is "this person, this trip, this time." A summary of the considerations within this framework is given below. A patient identified as high risk should be referred to their GP for a comprehensive consultation.

Considerations for individual's risk area

This person

  • Age (esp. the very young or the very old)
  • General health and fitness
  • Chronic conditions (ensuring they have adequate medications/equipment for trip)
  • Medications (including storage and supply, including considerations for S8 drugs)
  • Allergies (especially if past history of anaphylaxis)
  • Immune status (e.g. past exposures, past immunisation, immunocompromise (including splenectomy/non-functional spleen))

This trip

  • Urban/rural/remote (can change disease risk)
  • Extremes of climate, altitude
  • Length of trip/exposure
  • Purpose of travel: holiday, business, visiting friends and relatives, expatriate
  • Style of travel: accommodation, transport, dining – affects "quality" of exposure
  • Specific or unusual activities: caving, climbing, diving

This time

  • Wet/dry season
  • Current disease outbreaks
  • Political unrest
  • Weather events

Assessing the risk of a traveller's planned trip

Travellers whose planned overseas trip has an elevated risk should be referred to a GP or travel health practitioner for further assessment.

Factors that can affect the individuals risk profile

  • Travel itinerary
    • The specific countries and sub-regions on the itinerary, including the order of visiting if more than one country
    • Visiting urban or rural environments, depending on the country
    • Travelling to a developing or a least developed country
    • Is the trip land-based or offshore, such as a cruise?
    • Will they experience high-altitude (>2500m above sea level)? (NB many world cities are at higher altitude)
    • Will they experience extremes of climate (cold, heat, humidity etc.)?
  • Timing
    • Trip duration
    • Season at the destination(s)
    • How long before they depart Australia
  • Reason for travel
    • Tourism
    • Business
    • Visiting friends and relatives
    • Volunteer, missionary, or aid work
    • Expatriate assignment
    • Other specific reasons, such as medical tourism
  • Style of travel
    • Independent travel or package tour
    • General hygiene standards in-country and level and accessibility of medical care available at destination
    • Modes of transportation during the trip
    • Accommodation e.g., tourist or luxury hotel, budget hotel, host family, or tent
  • Special activities
    • Cruise ship travel
    • Extreme sports (i.e. bungee or heli-skiing)
    • Cycling
    • Climbing or mountaineering
    • Disaster relief
    • Motorcycle/scooter riding
    • SCUBA diving
    • Rafting
    • Caving
  • Travellers with specific high-risk medical conditions or requiring additional consideration
    • Pregnancy
    • Young children
    • Breastfeeding
    • Age >65 years
    • Disability
    • Immunocompromise or immunosuppression (including splenectomy)
    • Surgery or hospitalisation within last 3 months
    • Other underlying chronic conditions e.g., mental health, cardiac, epilepsy, respiratory, diabetes etc
    • Past history of deep vein thrombosis or pulmonary embolism.

It is important for pharmacists to recognise the limit of their capability to provide an appropriate standard of care to individual travellers and refer those with high-risk medical conditions or high-risk itineraries for a more comprehensive travel health consultation by a general practitioner or travel medicine practitioner.

Travellers who must be referred to a general practitioner

In addition to the risk-factors identified in section 4.1, travellers who are likely to experience the following conditions or itineraries, or because of health conditions placing them at higher risk from travel must be referred to a GP or travel medicine practitioner for higher-level clinical assessment and advice:

  • Medical condition
    • Altitude sickness (including travelling to high altitude cities)
    • Malaria
    • Medical Tourism
  • Travel itinerary
    • Extremes of climate including heat illness e.g. Kokoda Track, winter hiking
    • Other adventure travel including diving, caving, extreme sports, climbing, rafting
    • Travellers visiting friends and relatives in developing countries
    • High risk conditions (outlined in 4.1)
    • Travellers undertaking volunteer, missionary, or aid work including disaster relief
    • Animal exposures (e.g. rabies risk)
    • Exposure to sexually transmitted infections/pregnancy risk, alcohol, other drugs altering perception

Pharmacists are encouraged to refer any traveller to a GP or travel health practitioner when elements of the intended trip or the traveller's past medical history or existing health status are beyond their capability to provide an appropriate standard of travel health advice.

Advice to prevent and manage specific illnesses while travelling

As part of an opportunistic discussion on simple travel health, travellers can be provided with advice on preventing and managing the following conditions (refer table below).

Factor Discussion areas Referral to GP
Diarrhoea
  • Discuss strategies to minimise food and waterborne illness
  • Discuss medications such as oral rehydration solution, loperamide, ondansetron or prochlorperazine which could be used to self-manage diarrhoeal illness
  • Discuss strategies to treat water for drinking, if indicated.

Consider referral to a GP if antibiotics may be also indicated for self-treatment

Refer for assessment for oral typhoid vaccine

Arthropod-borne diseases including dengue, chikungunya, Zika, yellow fever, Japanese Encephalitis and tickborne encephalitis
  • Inform travellers that avoiding mosquito bites is essential
  • Educate travellers that risk exists in urban as well as rural areas
  • Advise travellers on insect-bite avoidance and prevention strategies including repellents, appropriate clothing, insecticide treatments for clothing and mosquito nets

Refer to a GP if the itinerary indicates significant risk or requirement for yellow fever, Japanese Encephalitis or tickborne encephalitis vaccination

Refer all pregnant women to a GP if there is a risk of exposure to Zika virus while travelling

Deep vein thrombosis (DVT) and Pulmonary embolism (PE)
  • Risk is increased for 2 weeks after a long-haul flight
  • Risk is increased for flights of four hours or more
  • All passengers should:
    • Drink plenty of (non-alcoholic) fluids during flights
    • Mobilise the ankles and massage/stretch the calves at least hourly
    • Walk up and down the aisle periodically, choosing an aisle seat will help facilitate this
    • Wear loose, non-restrictive clothing
    • Carefully assess the risks and benefits of using long-acting sedatives on long haul flights
    • Be vigilant and seek medical advice if shortness of breath, chest pain, leg swelling or calf pain develop after a flight.
Refer all travellers at higher risk to a GP for assessment and advice
Environmental hazards

Ensure the patient is properly equipped for the anticipated environmental conditions including:

  • cold and wet weather clothing
  • hat, sunglasses, protective clothing such as long-sleeved shirts and trousers, and sunscreen
  • first aid kit
Parasites
  • Avoid walking barefoot as parasites can enter through skin
  • Avoid wading or swimming in freshwater where there is risk for schistosomiasis or leptospirosis
Safety and security
  • Discuss precautions to minimise risks specific to the trip, such as traffic accidents, excess alcohol consumption, personal assault, robbery, violation of local laws, or drowning
  • Educate the traveller about the need to use seatbelts, helmets, and appropriate car seats for children during road travel
  • Recommend the traveller subscribes to Smartraveller alerts
Sexual health and blood-borne pathogens

Advise travellers to:

  • practise extreme caution when having sex abroad with new partners
  • use condoms to reduce the risk of sexually transmitted infections, unwanted pregnancy, and blood‑borne infections
  • avoid skin penetrating procedures like tattoos, acupuncture, or manicures
  • get medical advice if symptoms of sexually transmitted infections develop overseas or on return
Refer the traveller to a GP if requiring HIV PREP and to a NSW Health clinic for mpox vaccination if eligible
Rabies
  • Avoid all contact with animals, including those in tourist sites and national parks, to reduce the potential for bites and scratches that can transmit rabies.
  • If bitten or scratched by an animal, advise the traveller to wash the wound immediately and thoroughly with soap and water and seek medical assistance as soon as possible.
Refer the traveller to a GP if the risk from travel may warrant pre-exposure rabies vaccination e.g. increased risk of animal bite or poor or delayed access to post-exposure rabies prophylaxis
Jet lag
  • Commonly affects travellers crossing more than 5 time zones, particularly in an easterly direction
  • Advise patient to avoid coffee and alcohol, drink plenty of water
  • Particularly for business travellers, be well rested in the days before travel
Refer to a GP if prescription of melatonin or short acting hypnotics might be appropriate
Motion sickness
  • If prone to motion sickness, advise the patient to avoid activities requiring close concentration such as reading
  • Don't eat large meals prior to or during the journey
  • Medications can be used in children and adults if appropriate.
Refer to a GP if prescription medication may be indicated
Over-the-counter medications and first aid items

Patients may want to consider carrying some over the counter medications and first aid items. This will depend on factors including general health, travel itinerary, and access to items at destination.

Consider dispensing appropriate items, including:

  • alcohol-based hand rub
  • analgesics/antipyretics
  • anti-diarrhoeal medication e.g., Loperamide
  • antifungal cream
  • antiseptic cream and cleanser
  • bite and burns cream
  • condoms
  • decongestant or saline nasal spray
  • dressings and bandages
  • ear plugs for use in-flight
  • insect repellent
  • mild steroid cream
  • motion sickness medication
  • rehydration salts
  • scissors and safety pins
  • sunscreen
  • sports tape
  • thermometer
  • water purification tablets

Remind the person that frequently used medicines available in the supermarket or in pharmacies in Australia may not be as readily available overseas.

Prescription medication will require referral to a GP or travel medicine practitioner

Links for further information

For pharmacists

For travellers

Appendix

Referral checklist for pharmacists

Travellers that meet any of the criteria below must be referred to a GP or travel medicine practitioner for a more comprehensive travel health consultation.

Does the itinerary contain any of the following elements?

  • Travel to altitude >2500m above sea level
  • Exposure to heat illness (e.g. Kokoda Track or similar, ice activities)
  • Risk of malaria
  • Medical Tourism
  • Visiting friends and relatives in a developing country
  • Volunteer, missionary, or aid work including disaster relief
  • Adventure travel including diving, caving, extreme sports, climbing, rafting
  • Risk of yellow fever, Japanese Encephalitis or tickborne encephalitis
  • Risk of exposure to Zika virus
  • Increased risk of animal bite, or poor or delayed access to post-exposure rabies prophylaxis

Do any of the following apply to the traveller?

  • Pregnancy
  • Breastfeeding
  • Disability
  • Immunocompromise or immunosuppression (including splenectomy)
  • Traveller is aged 65 years or more
  • Traveller is an infant or young child
  • Surgery or hospitalisation within last 3 months
  • Underlying chronic health conditions e.g., mental health, cardiac, epilepsy, respiratory, diabetes
  • Past history of deep vein thrombosis or pulmonary embolism
  • Prescription medication may be needed for the trip (prevention or emergency treatment of malaria, altitude sickness medication, seasickness medication​, medications for jet lag, antibiotics etc)
Current as at: Monday 27 May 2024
Contact page owner: NSW Health