Giving travel advice in the uncertain age of COVID-19

Box 1.COVID-19 guidance in the UKLinks to recent and upcoming changes in guidance for all 4 areas of the UK (England, Scotland, Wales and Northern Ireland) - https://www.gov.uk/coronavirusScotland

• COVID-19 - https://publichealthscotland.scot/our-areas-of-work/covid-19/
• COVID-19 health protection guidance - https://publichealthscotland.scot/our-areas-of-work/covid-19/covid-19-health-protection-guidance/overview-and-latest-guidance/

Wales

• Coronavirus (COVID-19) - https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-covid-19/
• Coronavirus (COVID-19) - Information for the Public - https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-covid-19/information-for-the-public/

Northern Ireland

• Health and Social care Public Health Agency - https://www.publichealth.hscni.net/
• COVID-19 (coronavirus) - https://www.publichealth.hscni.net/covid-19-coronavirus

England

• Public Health England - https://www.gov.uk/government/organisations/public-health-england

The COVID-19 pandemic is a global health crisis with countries across the world facing diverse epidemiological situations with varying response capacities and access to life saving tools (World Health Organization (WHO), 2021). It is well documented that the travel of populations within and between countries is a contributory factor in the spread of infectious disease (Abdullah et al, 2020), causing governments worldwide to impose restrictions on international travel as a mitigation policy. In addition to formal restrictions, it has also been observed that fear of infection and perceived risk also have a significant influence on individual travel behaviour (Abdullah et al, 2020). The COVID-19 pandemic has led to a dramatic drop in people travelling to other countries for pleasure (Ugur and Akbiyik, 2020); however, now that restrictions across the UK are easing more people are seeking a break and a long-awaited holiday overseas.

The WHO recommends that national governments continue to apply a risk-based approach when implementing policies related to COVID-19 and international travel, while respecting the dignity, human rights and fundamental freedoms of travellers (WHO, 2021). This approach should consider the risk posed by travel in the context of the evolving epidemiology, including the emergence and circulation of virus variants of concern, the expansion of vaccination programmes and the public health effectiveness of local strategies.

The Foreign, Commonwealth and Development Office (FCDO) first advised against all non-essential overseas travel from the UK on 17 March 2020 and this advice has been subject to various changes since, with the relaxation of some restrictions and the implementation of quarantine-free travel corridors (Office for National Statistics, 2021).

Changing UK rules on international travel

Practice nurses should ensure that individuals carefully assess all the available information prior to providing clinical advice about international travel. This includes checking the information in relation COVID-19 as well as other health risks present in their intended destination. Table 1 provides a summary of the topics to cover when providing advice to travellers in relation to COVID-19.

The Foreign, Commonwealth and Development Office (FCDO) (Gov.uk, 2021a) provides clear information relating to the Entry Requirements for each country, defining the testing required, exemptions from testing post-vaccination or infection as applicable, and confirming countries from which visitors are currently not accepted.

Planning travel during the COVID-19 pandemic

Before travel is planned it is important to note that government advice is prone to changing at short notice all over the world which can affect travel plans. If someone is planning to travel during the pandemic it is essential that they explore the pre-travel requirements for the country they are planning to visit, the restrictions imposed in the destination country and the latest advice for returning to the UK. Some countries are not accepting any travellers except returning citizens, while other countries require travellers to isolate on arrival.

On 4 October 2021, the rules for international travel to England changed from the red, amber, green traffic light system to a single red list of countries and simplified travel measures for arrivals from the rest of the world. The rules for travel from countries and territories not on the red list will depend on the traveller's vaccination status. Prospective travellers should be encouraged to check the guidance frequently (Department for Transport and Department of Health and Social Care, 2021) as the status of countries and territories is updated frequently. Given these frequent changes it is advised that travellers sign up for email alerts that will inform them of any travel advice changes while they are away.

Pre and post travel testing requirements

From 4 October, fully vaccinated travellers from non-red list countries are no longer required to show proof of a negative test performed 48-72 hours prior to departure. If the traveller is booking their trip via a travel agent, they should be able to provide advice regarding this, but it is also essential that individuals check relevant websites regularly for any updates. For those who are not fully vaccinated, travellers must take a pre-departure COVID-19 test in the 3 days before travel to England. There are many companies offering pre- and post-travel COVID-19 testing kits but travellers need to be aware that there can also be a vast difference in cost. Government approved suppliers are listed on https://www.gov.uk/find-travel-test-provider. Pre-travel tests (sometimes known as ‘Fit to Fly’ tests) can be PCR, LAMP or lateral flow device (LFD) tests but must meet the minimum requirements for sensitivity and specificity (Department for Transport, 2021a).

All fully vaccinated returning travellers are required to pre-book day 2 COVID-19 tests, with those not fully vaccinated required to book day 2 and day 8 PCR tests. By law, all day 2 and day 8 COVID-19 tests privately provided for international arrivals must meet minimum standards as outlined in the guidance on the GOV.UK website. Providers must also complete a declaration that their tests meet all of these standards. Who is required to test is also subject to change, so travellers are advised to consult the government website for up to date guidance. Travellers should be advised to book any tests or quarantine hotel packages that are required before returning to England.

Returning from travel

All arrivals will need to complete a Passenger Locator Form prior to arrival in the UK (Gov.uk, 2021b). When returning home to the UK travellers will need to follow the requirements set by the Department for Transport (DFT) regarding testing and possible isolation.

Red country arrivals

It is mandatory for all arrivals to the UK from a ‘Red’ country to isolate in a Managed Quarantine facility for 10 days, this must also be arranged pre-departure at the traveller's own expense (Department of Health and Social Care, 2021). These facilities are usually hotels close to the airport and can be quite expensive. ‘Red’ country rules also apply if a traveller has been in a ‘Red’ country during the 10 days prior to arrival in the UK. The possibility for a country to change to ‘Red’ at short notice means travellers must be prepared for the possibility of having to organise and fund Managed Quarantine.

Rest of the world arrivals

Recently there has been a change to simplify travel measures for arrivals from the rest of the world. The rules for travel from countries and territories not on the red list will depend on the traveller's vaccination status. Travellers will be required to provide proof of vaccination status so should be advised to make sure that passports and NHS COVID Passes are up to date with their latest details. If the details do not match, they may have to complete another passenger locator form, face delays, or even be denied boarding.

Those who are fully vaccinated will need to take a day 2 COVID-19 test. They will no longer need to take a pre-departure test or a day 8 COVID-19 test, or quarantine at home or in the place they are staying for 10 days after they arrive in England.

Those who are not fully vaccinated will need to take a pre-departure COVID-19 test, take a day 2 and day 8 COVID-19 test, and quarantine at home or in the place they are staying for 10 days.

What happens on return and if there is a case on the flight

If somebody on the flight/international train tests positive within 2 days of arrival, co-travellers on the same transport may be identified as contacts of a case and required to isolate (regardless of country of departure or vaccination status) (Department for Transport, 2021b). The isolation period will begin from the date of the flight and travellers must quarantine at home for 10 full days. This is a legal requirement and there is no option for ending isolation early such as the Test to Release scheme, so it is advisable to inform travellers to consider this outcome prior to booking their trip.

Travel insurance

Travellers should be advised to ensure they have comprehensive travel insurance to cover the duration of their trip, bear in mind any excess premiums that might be required to cover risks such as skiing and mountain climbing, as well as health cover including COVID-19. Insurance will need to cover repatriation in the event of severe illness. The traveller should also consider any factors relating to travel guidance and warnings from the government such as the current advice against all but essential travel to a ‘Red’ list country which may affect insurance. The Association of British Insurers (2021) state that people who travel against advice are likely to nullify their travel insurance, for example if FDCO advises against travel to the country.

General travel advice

Travel medicine in the UK is widely accepted as a ‘nurse-led’ specialty and the vast proportion of travel health services is provided by practice nurses in GP surgeries and travel clinics (Royal College of Nursing (RCN), 2014). COVID-19 has changed the way we travel, as quarantine or self-isolation when entering a country are now commonplace (Bielecki et al, 2021), but it is important to remember general travel health principles while travelling internationally.

Due to COVID-19 the health requirements of travellers have become much more complex and diverse, and it is the duty of the health provider advising travellers to complete detailed travel health risk assessments and make every contact count (MECC) using the opportunity to promote travel health, relevant immunisations and prophylaxis, especially with those in vulnerable groups returning home to visit family and friends (RCN, 2021; Wilson and Chen, 2021).

Up to one-third of travellers contract an illness during their trip or immediately after their return, and practice nurses have a key role in providing pre-travel advice on topics such as preventing gastroenteritis, mosquito bites leading to malaria, and blood borne viruses such as hepatitis B and HIV (Paudel et al, 2017). All travel health providers should offer vaccinations for travel purposes such as typhoid and hepatitis A, and pre-travel appointments are also a good time to ensure that travellers are up to date with routine immunisation schedules. To reduce the risk of other potential hazards, travel health risk assessments conducted by practice nurses should also include other preventative measures (Bechini et al, 2021) such as ensuring travellers have insurance, take their routine prescriptions with them and advice on food and water safety as well as hygiene (TravelHealthPro, 2021).

The authors would advise practice nurses to clearly document all the advice they have provided to prospective travellers in line with Nursing and Midwifery Council (NMC) Code of Practice Item 10.1 ‘complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event’ (NMC, 2015).

Conclusion

COVID-19 may have had a huge impact on the travel industry since early 2020, but international travel is now increasing as vaccination strategies have started to bear fruit and provide a degree of freedom of movement. The pandemic illuminates the pivotal role that travellers play in emerging infectious diseases and their spread (RCN, 2021). Travellers are at high risk for acquiring infections and potentially bringing these back to their home country (RCN, 2021). As the world continues to open to international travel, it is important to remind travellers of the various health risks depending on the characteristics of both the traveller and the area they are travelling to (RCN, 2014). Signposting travellers to useful resources about their country of travel and the health risks is an important part of the practice nurses' role; and highlights the importance of practice nurses in prevention and control of spread of infectious diseases, including COVID-19.

Further guidance and information:

• Foreign, Commonwealth and Development Office (FCDO): https://www.gov.uk/government/organisations/foreign-commonwealth-development-office
• National Travel Health Network and Centre (NaTHNaC): https://travelhealthpro.org.uk/
• Travel abroad from England during coronavirus (COVID-19): https://www.gov.uk/guidance/travel-abroad-from-england-during-coronavirus-covid-19
• Coronavirus (COVID-19): safer air travel for passengers - How to travel safely in airports and on aircraft during the coronavirus (COVID-19) outbreak: https://www.gov.uk/guidance/coronavirus-covid-19-safer-air-travel-guidance-for-passengers?step-by-step-nav=8c0c7b83-5e0b-4bed-9121-1c394e2f96f3
• Travel to England from another country during coronavirus (COVID-19): https://www.gov.uk/guidance/travel-to-england-from-another-country-during-coronavirus-covid-19
• NHS. Other travel vaccinations: https://www.nhs.uk/conditions/travel-vaccinations/
• World Health Organization. Travel advice. https://www.who.int/travel-advice

KEY POINTS:

• The COVID-19 pandemic has led to a dramatic drop in people travelling to other countries for pleasure; however, now that restrictions across the UK are easing more people are seeking a break and a long-awaited holiday overseas
• Practice nurses should ensure that individuals carefully assess all the available information prior to providing clinical advice about international travel
• Before travel is planned it is important to note that government advice is prone to changing at short notice all over the world which can affect travel plans
• Due to COVID-19 the health requirements of travellers have become much more complex and diverse, and it is the duty of the health provider advising travellers to complete detailed travel health risk assessments and make every contact count using the opportunity to promote travel health, relevant immunisations and prophylaxis, especially with those in vulnerable groups returning home to visit family and friends

CPD reflective practice:

• What does the traveller need to consider with regards to travel insurance?
• Where can you find up to date information to signpost travellers to?
• How can you make every contact count in a travel health consultation?