Travel and COVID-19: what the practice nurse needs to know

On 31 December 2019, the World Health Organization (WHO) was informed of a cluster of pneumonia cases of unknown cause in Wuhan City, Hubei Province in mainland China. On 12 January 2020, it was announced that a novel coronavirus had been identified in samples obtained from these pneumonia cases. Initial analysis of virus genetic sequences suggested that this novel corona virus was the cause of the outbreak. This virus is referred to as SARS-CoV-2, with the associated disease known as COVID-19 (Public Health England [PHE], 2020a).

The vast majority of people infected with COVID-19 experience mild-to-moderate respiratory illness and recover without requiring special treatment. However, older people and those with underlying medical problems, such as cardiovascular conditions, diabetes, chronic respiratory disease and cancer, are more likely to develop serious illness (WHO, 2020a).

On 30 January 2020, WHO declared this outbreak a ‘public health emergency of international concern’. During the following weeks, a number of countries implemented entry screening measures for arriving passengers from China and several major airlines suspended their flights to and from China. In early March 2020, many countries worldwide mandated strict public health ‘lockdown’ measures, including social distancing. On 11 March 2020, WHO's Director General declared COVID-19 a global pandemic. By 25 March 2020, more than 150 countries worldwide were affected, including the UK and other European countries (European Centre for Disease Control and Prevention, 2020).

As of 28 August 2020, a total of 24 299 923 confirmed COVID-19 cases, including 827 730 deaths have been reported to WHO globally since 31 December 2019 (WHO, 2020b).

The UK government imposed lockdown measures in England on 26 March 2020. The four UK nations closely co-ordinated their initial response to the pandemic in putting lockdown restrictions in place (Institute for Government, 2020). This included a global advisory against ‘all but essential’ overseas travel (Foreign and Commonwealth Office [FCO], 2020a).

The UK government can only change ‘lockdown’ regulations in England; respective devolved governments are responsible for making any changes to the rules on social distancing in Scotland, Wales and Northern Ireland. Since the UK began easing lockdown restrictions in May 2020, the four nations have differed in their approach to easing restrictions, with the UK government easing restrictions in England more rapidly (Institute for Government, 2020).

UK overseas travel advice

On 4 July 2020, UK travel advice changed, with exemptions for travelling to certain countries and territories no longer considered to pose an unacceptably high risk for UK travellers. The UK Government continue to advise against non-essential international travel for all destinations, except those countries and territories listed as exempted (see section below). They also currently advise against cruise ship travel (UK Government, 2020).

Exempt countries and territories

The UK's FCO publishes a list of countries and territories that have been assessed as no longer presenting an unacceptably high risk to UK people travelling abroad. FCO travel advice is based on risks to UK nationals, including in-country public health assessments, and is updated regularly in response to the latest situation in each country (FCO, 2020b). Table 1 contains resources providing guidance on exemptions and travel corridors for each country of the UK.

Travellers need to be aware that countries or territories can be removed from the exemption list at short notice. For example, the latest update from the UK Government on 27 August 2020 states that the following countries will be removed from the exempt list at 4am, Saturday 29 August 2020:

• Czech Republic
• Jamaica
• Switzerland.

Travellers arriving in England from the Czech Republic, Jamaica or Switzerland after 4am on 29 August 2020, will need to self-isolate (Department of Transport, 2020b). Current self-isolation guidance for travellers is available from the Department of Health and Social Care (2020).

Advising UK travellers

As lockdown eases worldwide, including the UK, and global travel slowly resumes, general practice nurses advising UK residents planning travel should ensure that such travellers understand that the global coronavirus pandemic is ongoing. No travel is risk-free, and disruption is still possible (FCO, 2020a). It is most likely that travellers visiting friends and relatives (VFR) and short-notice travellers, such as aid workers, will access travel advice at this time.

When advising UK residents considering travelling abroad, general practice nurses also to need make sure they are aware that travel advice differs, depending on which UK country they live in (Table 1).

The FCO advises that travellers will have to comply with coronavirus requirements in the country they travel to. This could include self-isolating for a specified period or providing contact details to local authorities. The FCO travel advice includes information on any specific health measures in place for visitors to a country or territory. These can include a requirement to self-isolate, quarantine or undergo testing for coronavirus, or even restrictions on entry (FCO, 2020a). FCO country specific advice is available online.

Travellers with existing health problems

Some underlying health conditions put individuals at increased risk of severe COVID-19 disease. Clinically vulnerable people are those who are (Cabinet Office, 2020):

• Aged 70 years or older (regardless of medical conditions)
• Under 70 years old with an underlying health condition where they are eligible for an annual flu jab on medical grounds.

Expert doctors have identified specific medical conditions that place some people at greatest risk of severe illness from COVID-19. Clinically extremely vulnerable people include (Public Health England, 2020b):

• Solid organ transplant recipients
• People with severe respiratory conditions including cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease
• People with rare diseases that significantly increase the risk of infections such as severe combined immunodeficiency, homozygous sickle cell
• People on immunosuppression therapies sufficient to significantly increase risk of infection
• Pregnant women with significant heart disease
• People with specific cancers: those undergoing active chemotherapy; lung cancer; those undergoing radical radiotherapy; cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment; those on immunotherapy or other continuing antibody cancer treatments; targeted cancer treatments that can affect the immune system, such as protein kinase inhibitors or PARP inhibitors; bone marrow or stem cell transplants in the last 6 months or those who are still taking immunosuppression drugs.

Black, Asian and minority ethnic travellers

In the UK, current evidence indicates there is a higher risk of infection and severe disease for people from Black, Asian and minority ethnic (BAME) backgrounds. The causes of this (and how it is affected by other factors like environment, occupation, medical conditions or obesity) are unclear. However, when undertaking a travel risk assessment, consideration should be given as to how a traveller's ethnicity may increase the risk of severe disease (TravelHealthPro, 2020a).

Pregnancy

Pregnant women are considered to be clinically vulnerable to severe illness from COVID-19. Pregnant women with serious heart conditions are considered to be clinically extremely vulnerable, alongside anyone that has a condition that would place them in the very high risk category. Women more than 28 weeks pregnant are advised it is especially important to follow the current coronavirus-related pregnancy NHS advice (TravelHealthPro, 2020a).

COVID-19 travel risk assessment

A comprehensive pre-travel risk assessment should be undertaken with individuals planning to travel during the COVID-19 pandemic. All travel-related risks should be considered, including prevention advice and provisions, such as insect bite avoidance, vaccines and, if appropriate for the destination, malaria prophylaxis recommendations (Royal College of Nursing [RCN], 2018; TravelHealthPro, 2020a).

Individuals should be encouraged to consider their reasons for travel carefully. Both the COVID-19 risk at the destination and any intrinsic issues relating to their medical history, age or other factors that might increase their risk of significant illness if they caught COVID-19 should be discussed. All travellers should be directed to guidance on how to protect themselves against respiratory infections during travel and at their destination (TravelHealthPro, 2020b).

Comprehensive travel insurance should be obtained and travellers should be aware that travelling to a particular destination when the FCO advises against it could invalidate insurance.

COVID-19 risk at destination

TravelHealthPro Country information pages provide destination-specific travel health advice. They also classify countries as having a high, moderate or low risk of exposure to COVID-19. This is based on currently available information assessed by Public Health England and the National Travel Health Network and Centre.

High risk

All travellers are advised to avoid non-essential travel to these countries/areas. Travellers should discuss their plans with a health professional, this is particularly important for those at increased risk of severe COVID-19. Individuals entering or returning to the UK from these countries/areas will be required to follow additional UK border measures, which includes self-isolation, for 14 days.

Moderate risk

Travellers at increased risk of severe COVID-19 should consider avoiding non-essential travel to these countries/areas. Travellers should consider discussing their plans with a health professional, this is particularly important for those at increased risk of severe COVID-19. Travellers returning to the UK may be required to follow additional UK border measures, which may include self-isolation, for 14 days.

Low risk

There are no additional health advisories for these countries/areas. Travellers are reminded that on return to the UK they may be required to follow additional UK border measures, which may include self-isolation, for 14 days (TravelHealthPro, 2020a).

Those at increased risk of COVID-19 complications

An individual traveller may not be aware that their pre-existing condition increases their risk of severe illness if they caught COVID-19. General practice nurses can play a crucial role in helping a traveller recognise if any underlying medical issues and/or other factors are a concern in relation to COVID-19. TravelHealthPro have produced a specific COVID-19 travel risk assessment (2020a).

General practice nurses can use this document as a tool when undertaking the COVID-19 assessment process with the traveller. Realistically, even if a significant concern regarding COVID-19 is established, an individual may be reluctant to change their travel plans. It is the general practice nurse's role to highlight travel-related hazards and advise travellers how they can mitigate such hazards. However, they cannot make decisions on behalf of the traveller but should ensure that the traveller is well informed and given supporting COVID-19 related resources.

As with all medical records, the importance of accurate documentation should not be underestimated as part of the risk assessment process (RCN, 2018).

Malaria and COVID-19

Travel to many malaria risk countries may not currently be recommended, due to the COVID-19 pandemic. However, if the traveller considers that travel is essential, they must be advised to follow all the important steps for malaria prevention:

• Awareness of malaria risk at destination
• Bite prevention
• Chemoprophylaxis (appropriate antimalarial medication and compliance with regime)
• Diagnosis (prompt diagnosis and treatment without delay).

All travellers returning from a malaria area in the last 6 months with a fever, need an urgent malaria test (called a blood film) the same day the fever starts. These travellers must seek urgent medical advice and inform the health professional that they have been to a malaria risk region in the last 6 months. If they phone NHS 111 for advice during the current pandemic, they must state they have returned from a malaria area—and state which one—and need an urgent malaria test (TravelHealthPro, 2020c).

Malaria is a medical emergency and should be considered in every ill traveller returning from the tropics in the past year. Fever on return from the tropics should be considered to be malaria until proven otherwise (Public Health England, 2019).

All returning travellers being assessed for possible COVID-19 must be asked if they have travelled abroad in the last 6 months. If their itinerary included a malaria risk country, they must have a malaria blood test on the same day (TravelHealthPro, 2020c).

Conclusion

General practice nurses advising individuals planning travel abroad need to encourage these travellers to consider both the COVID-19 risk at the prospective destination and their risk of severe disease or complications during their travel abroad. As with any travel plans, practice nurses are not responsible for decisions made by travellers during this ongoing COVID-19 pandemic, but must ensure they are well-informed. Practice nurses have a role in guiding travellers, directing them to appropriate sources of advice and ensuring they understand the hazards associated with travel at this time.

The importance of comprehensive travel medical insurance should be stressed to all travellers, regardless of their medical history.

Resources

• Foreign and Commonwealth Office. Foreign travel insurance: https://www.gov.uk/guidance/foreign-travel-insurance
• Foreign and Commonwealth Office. Travel advice: coronavirus (COVID-19) Guidance for British people travelling overseas during the coronavirus (COVID-19) pandemic: https://www.gov.uk/guidance/travel-advice-novel-coronavirus
• NaTHNaC TravelHealthPro website: https://travelhealthpro.org.uk/
• NHS Coronavirus (COVID-19): https://www.nhs.uk/conditions/coronavirus-covid-19/
• Public Health England COVID-19: guidance for health professionals: https://www.gov.uk/government/collections/wuhan-novel-coronavirusege
• Royal College of Obstetrician and Gynaecologists. Coronavirus infection and pregnancy - Information for pregnant women and their families. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/
• TravelHealthPro COVID-19 Resources - Current coronavirus advice from NaTHNaC, PHE and FCO, with links to international information source: https://travelhealthpro.org.uk/factsheet/92/covid-19-resources
• UK Government: Coronavirus (COVID-19): cruise ship travel: https://www.gov.uk/guidance/cruise-ship-travel

CPD reflective practice

• What advice would you give a pregnant traveller planning to visit her terminally ill aunt in Trinidad?
• What are the implications for travellers planning to visit destinations that the UK government currently advises against all but ‘essential travel’?
• Which groups of UK residents are potentially at increased risk of COVID-19 complications?
• UK Government guidance on travel restrictions and quarantine can change at short notice. What resources should practice nurses encourage travellers to use to ensure they are accessing current guidance?

KEY POINTS

• COVID-19 continues to be a world-wide risk
• UK residents planning travel abroad need to consider both the risk at their destination and any intrinsic risk relating to their underlying health
• UK Government guidance on travel restrictions and quarantine can change at short notice