Discussion

This is the first study to examine patients’ pretravel preparation in conjunction with HCPs’ experience and confidence at providing this advice. The majority of patients with IBD feel their disease affects both travel in general and destination; however, surprisingly despite some concerns, patients still travel abroad even if they have suffered a recent flare and few seek prior expert medical advice.

Our study found that a quarter of all HCPs do not feel confident to provide pretravel advice to patients with IBD and of these, the vast majority would refer to a specialist centre for this information. Interestingly, similar findings were also seen in those who felt they had adequate knowledge to give such advice; with 80% also stating they would refer to a travel clinic or general practitioner rather than provide the information themselves. This suggests that HCPs are happy to provide IBD-specific travel information regarding medication and managing symptoms, but would refer to specialist travel clinics for destination-specific information such as vaccination and other travel health risks. The majority of the HCPs in our survey were IBD nurses from various countries within Europe, where there are recognised country-specific variances in role, title, salary and level of training of IBD nurses.20 Outpatient visits to the IBD clinic average approximately three per year in the UK,21 with patients tending to have longer appointment times with the IBD nurse compared with the physician. This will impact on the content and detail of any discussions that take place during the appointment, particularly limiting the time available to discuss travel health.

With regard to vaccinations, we found that more than half of the patients receiving immunomodulator therapy are unaware that they should avoid live vaccines, and only 55% of HCPs reported being confident at giving vaccination advice. Low counselling rates for avoidance of live vaccines and inadequate understanding and knowledge of vaccinations have been cited in previous research.10 ,11 ,22 Possible explanations for this include HCPs’ lack of awareness, ambiguity regarding who should assume responsibility for vaccine administration and concerns regarding safety and efficacy of vaccinations, including fear of vaccine-induced exacerbations of IBD.3–5 ,9–11 The European Crohn's and Colitis Organisation guidelines1 recommend that travel consultations should be provided jointly by a gastroenterologist and expert travel clinic. Deficiencies in the advice provided by such clinics have been highlighted in previous research,17 which found 27% of patients were incorrectly given the yellow fever vaccination while receiving immunomodulator therapy. This highlights the need for travel clinics to have increased vigilance when prescribing live vaccinations. In the UK, advice regarding travel health is sought mainly in primary care from dedicated travel clinics or GPs. Travel medicine is an emerging field, but not currently a speciality that is recognised in the UK.23 There are several independent associations offering support and qualifications for those working in travel medicine, but to our knowledge, these are not compulsory.24–26 No national UK guideline exists specifically for pretravel advice, although recommendations for practice have been developed.27 ,28 This may impact on the quality and accessibility of travel advice and is an area that should be further explored to investigate the content and accuracy of information given by primary care or specialist travel clinics and whether they appropriately address the issues relevant to patients with IBD. This is an important finding from our research and suggests that improved awareness regarding the importance of obtaining and providing adequate pretravel consultations can potentially lead to prevention of infectious complications while travelling.

A minority of patients sought pretravel consultation and those who did were more likely to do so if they had, or were recovering from, a flare at the time of travel. A reason for our observed low rates of travel preparation could be explained if the destination had previously been visited and information sought prior to an earlier trip; this was not surveyed in the present study. Although vaccination, insurance and general advice regarding IBD were the main areas of interest in these patients, low numbers of patients in this group actually went on to obtain travel insurance to cover their IBD, meaning most are possibly underinsured or not insured. Travel insurance in the UK covers many aspects of travel, but there are often caveats for chronic disease, particularly if the traveller is under regular specialist follow-up. Obtaining adequate insurance can often be difficult and incur additional premiums, but travelling without adequate cover carries the risk of the individual incurring significant personal medical costs in the event of illness overseas.29 It is worth noting that both vaccination and travel insurance advice are among the areas that HCPs in our study report feeling least confident to advise on. This demonstrates that there is ambiguity in the information patients seek and what HCPs feel confident to provide and that despite education and counselling, there are still barriers preventing patients from taking correct measures to protect themselves abroad. This again could be explained by inadequacies in the information given at the time of consultation, lack of knowledge regarding how to source adequate information such as travel insurance and external factors including increased premiums for those with pre-existing medical conditions, particularly when recovering from a period of illness.

Previous research found that generally patients with IBD travelling to low-income or middle-income countries are no more at risk of developing enteric infections compared with healthy counterparts, although many individuals with IBD would avoid these destinations for this reason.2 We found similar results with most individuals citing concerns over toilet facilities, sanitation and greater risk of contracting enteric infections as the main reasons for avoiding particular destinations. Recent research has also linked journeys and flights at high altitude to an increased risk of IBD flare within 4 weeks of travel due to hypoxia-induced inflammation,30 although further studies are needed in this field. Overseas travel is becoming more prevalent and forms part of maintaining a balanced quality of life. The overall impact of IBD and restrictions posed on daily life have been documented in a recent European survey31 and indicates that most individuals faced disruption in their daily life caused by the current status of their disease, but over half avoided cancelling or rescheduling plans. The availability of toilets remains one of the main concerns of individuals with IBD31 and is again mirrored in our findings.

There are several limitations to this study. First, the retrospective survey design may introduce recall bias regarding specific details of the respondents’ last overseas trip. Similarly, we asked for the individual's self-reported disease activity within the last 6 months using a symptom-based assessment, but did not use standardised classification criteria. It is difficult, therefore, to define the onset of some symptoms as a definite relapse. The most recent episode of travel may not be representative of travel behaviour generally. For example, 10% of our sample travelled for business or study, meaning they may have had no option, but to travel during a flare of disease. Finally, the sample of HCPs who responded was likely to have included individuals with an interest or some knowledge in this subject and was skewed towards IBD nurses and therefore the results may not be generalised to other IBD professionals. The inclusion of a matched control group of healthy subjects would have helped to underline the burden of IBD in determining new symptoms when compared with the healthy traveller. Our study was conducted in a single-centre university hospital with a wide variety of socioeconomic groups and tertiary referrals from the surrounding areas, and therefore, our results could be generalised to the rest of the UK.

In conclusion, our findings suggest individuals with IBD do not always receive the recommended pretravel medical advice, including the need to avoid live vaccinations if immunosuppressed, and support the need for further research on travel behaviour in IBD. We suggest there is a need for greater IBD-specific travel education and awareness for both patients and HCPs in primary and secondary care.