Don’t ask me what travel vaccines you need!

Those of you who have done a Travel Health course delivered by me will probably have heard me recount the story about my 2006 South Africa trip when I’m discussing how to approach the question of ‘what vaccines do I need?’.

I tell the story because it is a very fitting example for:

1. Illustrating why it’s important to know about the vaccines you DON’T give
2. Demonstrating why you have to be so careful about the language you use when advising a traveller about travel vaccinations
3. Explaining why asking questions and probing is important, especially with travellers who may not realise just how risky their planned activities are.

Many people still think that there is simply one standard list of vaccines for each country that EVERYONE needs to get (or NOT get) in order to go there. But it’s just not as easy as this is it? There are, of course, lists showing which vaccine preventable diseases are present, or are potential risks in that country, beautifully presented on the wonderful NaTHNaC and TRAVAX databases. But, these risks have to be carefully interpreted and discussed with travellers, along with the preventative options and advice for what to do if a traveller chooses NOT to have the vaccinations. And that’s what I am going to talk about today.

Here’s me in South Africa, looking very much more youthful than today (not a nurse at this point, let alone a travel health nurse).

Have a quick go at risk assessing this trip:

24 year old female, normally works as a HCA, medically fine. Two weeks in South Africa, Limpopo province. Doing some ‘volunteering’ with the locals.

Using Travel Health Pro, which diseases would you mention?

The above description of the trip is what I told my travel health advisor (who was my practice nurse) at the time.  

And I asked the standard question; “What vaccines do I need?”. She looked at her screen and said “ahhh yes here’s what you need”, gave me a hepatitis A vaccine, and advised me to buy some malaria tablets. I asked if I would need anything else and she said “oh no, it’s only a short trip, just be careful with your food and drink and have fun!”. She sent me on my merry way to South Africa feeling invincible (as travellers often do after a ‘jab’ and some meds).

I felt I had done my bit for my health as I packed up my rolls of 35mm camera film and Walkman while pondering what ‘careful’ actually meant with regards to food and drink. Ah maybe it meant take some Imodium…

Now, you can probably tell from the photo that the type of ‘volunteering’ I was doing was working with monkeys. The nurse didn’t actually ask me what kind of volunteering I was doing, and likewise, I didn’t offer this information not thinking it was particularly relevant. I just wanted to know which ‘South Africa’ based jabs would protect my entire-being from everything on the trip like a lot of people do. I didn’t really think there was more to it than just knowing the country. Like many lay people, I just imagined a magic list somewhere with ‘South Africa’ at the top and a list of vaccines with no discernible categorisation based on these odd things called ‘risk factors’.

Anyway, here’s what happened on that trip.

• Animal-related injuries were frequent. I got bitten, scratched, mauled by the little cuties the whole time. This was largely because I was in monkey enclosures covered in them daily.
• My clinical skills expanded. I learned how to suture monkey skin during that time on live subjects.
• It wasn’t just about the monkeys. I played with the cute on-site puppy every day, stroked a mongoose, held a snake and a baby crocodile.
• The owners took me on a trek in the mountains
• I was driven around in the back of a pick-up truck with no seat belts at 70 MPH.
• I was told by the locals that I didn’t need to take my malaria tablets (because the hospitals were ‘excellent’). So, to fit in, I stopped taking the over the counter Chloroquine I had bought (incorrectly, but it was cheap and the only one I could find without a prescription). This part, by-the-way is a WHOLE OTHER BLOG waiting for me to write.
• I swam in the river.
• Mosquito’s love suckers like me. I got many mosquito bites because I only applied my repellent once a day when I woke up. There were no bed nets. There wasn’t even a light in my room. I slept in an outdoor structure that was pretty much open to the elements the whole time.
• For two nights I bivouacked in the South African bush.
• I climbed a tree holding a chainsaw.
• My electrical skills developed. I fixed up live 250v electrical fences without turning the electricity off.
• I was pretty rural. Arrived in a 10-seater plane; that’s how rural.
• It was a blast. And, I must admit, a blessing to be so ignorant to all those risks at the time!

I know what you’re thinking.

Yes, I was stupid and naive to not learn a bit more about protecting my health. I didn’t research it all properly, being swept away by the glossy STA brochure with pictures in like the one above of happy travellers covered in cute happy monkeys. I kind of thought: How dangerous can it be if there’s a brochure? And look at the monkeys they are so cuuuuute….

And this is my point. There are more like me out there.

I was just like some of the naïve first-time travellers that most of us inevitably encounter in our consults at some point; the ones who are only concerned with; ‘what vaccines do I need?’ and feel like the travel health part is ticked off once the achy arm sets in. (Enter: the person who comes in asking for ‘THE TRAVEL JAB’ or ‘THE DIARRHOEA JAB’).

Here’s what else happened.

Two weeks after I had returned back to the UK I got a letter from the organisation. The letter said this:

“We are writing to inform you that our puppy, Beni, has sadly died of rabies. If you came into contact with Beni at any point on the trip, please seek some treatment urgently. You could be infected with rabies which is fatal if untreated. Thanks for your stay with us, hope to see you again soon!“

Came into contact with him? I thought.  He licked me on the eyeball! And I let his little sharp puppy teeth sink into my arm constantly while playing. I KISSED HIM ON THE MOUTH!!!! Loved that little (now dead) dude.

I then looked down at my still very visible puppy scratches. The panic set in.

I called the GP.

It went something like this:

“Help”, I said. “I might die. I need rabies treatment do you do that?”

“Do you mean rabies vaccines?”, the receptionist said.

I said; “I don’t know, do I need vaccines?”

She said; “I don’t know, I’ll check for you”.

So, she went off to ask someone and came back saying; “‘no, we don’t do rabies vaccines here, and even if we did you won’t get an appointment now. You sound very last minute if you want them right now. Maybe try the pharmacy?”

So what did I do? Did I NEED any vaccines?

I did what any other not-very-sensible-but-average person would do and called my friend (Google still wasn’t really my go-to at this point in time but it was for her). She said; “oh don’t worry, it says here on Google that the vaccines are BEFORE you go and you have already gone and come back so there’s no point. You’re OK, it says here that you CAN die, but you’re NOT dead so you will be fine. Don’t worry, I was bitten LOADS by a kitten in Turkey and look at me, I’m fine”.

Relieved, and happy to settle with that prognosis, I carried on with my life for many years (whilst somehow not dying of rabies).

In 2011 after gaining RGN status and also surviving a stint in A and E, I developed a desire to enter the world of primary care and health promotion. It seemed more appealing than continuing to pick up the pieces from those (who behaved like me) appearing in the ED after various preventable things had gone wrong. So, I stalked a fabulous travel health company (Nomad) until they kindly gave me a job.

It was there that I:

• First learned how irresponsible I had actually been and how at risk I actually was
• Started to feel angry at my pre-travel health adviser
• Vowed never to tell someone going to a rabies endemic area that they didn’t ‘need’ rabies vaccinations even if it is a ‘short trip’ or ‘not working with animals’ (the puppy was a household pet it wasn’t even one of the client-animals ironically)
• Learned how important it is to try to drag it out of someone exactly what risks they will be exposing themselves to and not settling for believing the traveller has already correctly pre-selected the relevant parts to tell me.
• Realised the value of decent risk assessment
• Recognised that there’s an amazing option to purchase privately available life-saving vaccines if desired.
• Had my post exposure rabies vaccines. Embarrassingly, 5 years after the event.  

Have a go at this quick question and test your knowledge about what my likely post exposure treatment was:

So, ‘what vaccines do I need?’ I suppose the moral of the story is this:

1. Some travellers suck at risk assessing themselves and need a bit of guidance with how to take care of themselves. That’s why travel health is a (very valuable) specialism.
2. A traveller can still ‘need’ something even if they are low risk. Being low risk in a high risk country is more like ‘medium risk’ when they meet in the middle. And LOW risk is never NO risk or it would say ‘NO risk’ on the database (or not even mention it at all).
3. Just because one does not ‘do’ the vaccine in question there still needs to be an understanding of it and how to advise on it and where to signpost to. And not just before the trip. Some vaccines are ‘needed’ after the trip too.
4. Post-travel advice should feature in a portion of the pre-travel discussions. What would happen if….. where would you go if…. What would you do if… if this particular thing happens do this….
5. Using the internet to get medical advice is one thing, but knowing how to use it properly is quite another. That’s why travel health nurses are trained to be experts in using NaTHNaC and other brilliant databases.

Ultimately, what makes travel health advisors most afraid about answering the question of; ‘what vaccines do I need’ while allowing quite a liberal sprinkling of choice in the matter?

For a start, a lot of health professionals tend to worry that they might end up giving a vaccine for a disease that is too ‘low risk’ to warrant the risk of the vaccine. But a vaccine being riskier than the disease it prevents is generally a rare scenario when it comes to inactivated vaccines such as rabies. So, there’s usually going to be adequate clinical justification for the vaccine if the disease exists at the destination.

Plus, reassuringly, I’ve never had someone come marching back into the clinic demanding their money back for their pre-exposure rabies vaccines because they were NOT bitten by a some kind of cute mammal they bonded with while away.

I think people are much more likely to be mad at us (or dead) in a situation where they WERE exposed and they hadn’t been advised that they had options to prevent bad stuff ensuing even if they were perceived as ‘low risk’ at the time. OR worse still, categorically told they ‘didn’t need’ the thing that could now actually be saving their bacon.

When people ask me ‘but do I REALLY need it?’ for a seemingly ‘lower risk’ trip, my response is often based around the seat belt analogy: You don’t ‘need’ to wear your seat belt. Well, not until you get in an accident: Then you would be glad you wore it.

Basically, you don’t technically ‘need’ ANY vaccines. Until you’re exposed to the disease. But it’s sadly often too late by then. So, after the seatbelt analogy, I go on to answer ‘what do I need’ with a more thorough explanation of the disease itself so the traveller can make up their own mind about the level of risk they are willing to accept. I often wonder how my initial pre-travel South Africa consultation would have gone differently if someone had explained the risks to me rather than just dismissing rabies on the back of one sentence about my trip?

We should always consider the ‘what if’ scenario.

Because of this experience, I always encourage the traveller to make the decisions themselves so they truly grasp the risks and don’t sit their passively just being told what to do or not do. So, I encourage them to picture themselves in a situation that is realistic to their trip and how it might feel to be vaccinated or not in that instance. I want them to get in the mindset of how I felt getting that letter. Of course, then there are mitigating factors such as budget and side effects, but who am I to say what people should spend their money on, or how much of an achy arm they are willing to put up with? I’m here to discuss their options and present factors for consideration.

I’d strongly urge anyone practicing travel health in whatever capacity to do a course, learn about the diseases you don’t provide in the same way you learn about those that you do vaccinate for. And if you don’t know a fair amount about rabies post-exposure treatment and why the pre-exposure vaccines are so beneficial please please please find out. I promise it will help you to answer that question of ‘what vaccines do I need?’.

and you might just save someone’s life in that short ‘what-vaccines-do-I-need’ appointment.

How do I answer the question of ‘What do I need?’

Health Academy have developed a tool for you to use in your practice so that you never ‘need’ to feel pressured in to telling a traveller what they ‘need’. Even better, the tool is free and so is the short course on how to use it:

The Travel Vaccine Traffic Light Tool

The Travel Vaccine Traffic Light Tool can be downloaded, printed, and laminated to use in travel health consultations to help you and your traveller.

Download or print tool

Download user guide

Free – Travel Vaccine Traffic Light Course

Bonus tips and suggestions:

Try this short quiz to test your knowledge of rabies

For an insight into the rabies treatment guidelines this is a fabulous resource to explore and is updated regularly:

Consider how your front-of-house teams handle post-exposure rabies requests. Are your team approaching this right?

Watch this fabulous video about rabies created by Health Academy using the ‘5T’s of tropical disease’ approach.

Why not try using the 5T’s approach in your consultations to help with concise explanations? For a quick free course on the technique go here.

Want to hear me explaining this story (and telling you all about rabies) in person? If so, why not sign up for one of the Introduction to Travel Health, or Travel Health update courses that I predominantly teach on (please don’t be disappointed if you don’t get me though, ALL the tutors have their own ‘being-irresponsible-abroad’ travel horror stories to share)