The role of the GP in travel health and the care of people with infectious diseases
As a GP your role is to:
- diagnose and manage diseases of infectious origin commonly seen in UK general practice and in the prospective or returning traveller
- recognise and appropriately refer rare but serious infectious diseases
- take a thorough social history, including country of birth and travel history, and know how this may affect differential diagnoses
- encourage self-management of benign self-limiting illnesses
- identify, assess, manage and communicate major risks, including risks associated with common or serious infectious diseases, travel, therapies and immunisation
- understand and implement the principles of infection control
- take action to reduce antimicrobial resistance
- know where to find appropriate travel health information
- recognise and manage medical emergencies (including life-threatening conditions such as sepsis) in patients with acute or chronic infectious diseases
- contribute to pandemic preparedness and response.
Background and emerging issues in travel health and infectious diseases
As demonstrated by Covid-19, infectious diseases can spread globally faster than ever before. This is due to several factors, such as environmental change and the increased mobility of people and goods. GPs therefore need to understand a wide spectrum of infectious diseases and the altered contexts in which they may present. GPs also need to be alert to novel symptoms and signs that do not fit with known diseases.
As a GP you may not be contractually obliged to provide certain pre-travel health services, or they may be delivered by other team members (such as practice nurses). Nonetheless, you should still understand general principles, know where to find relevant information and be able to signpost or refer patients appropriately. Conversely, you are likely to be the first port of call for a returning traveler, therefore you should be competent in diagnosing and managing common and important conditions related to travel and infectious disease. You should know what your statutory and contractual responsibilities are in terms of providing care.
You should be aware of advances in diagnosing and monitoring infectious disease, such as genome sequencing of pathogens in outbreak detection (for example, salmonella, coronavirus variants) or in tuberculosis (TB) diagnosis.
Patients may be entering the UK or going abroad against their will (for example, for trafficking, forced marriage or female genital mutilation (FGM)) or to participate in criminal activities, and you should be familiar with General Medical Council (GMC) guidance and the law around these issues. GPs have a wider leadership and advocacy role that includes promoting better health systems, services and policies (such as effective local and global responses to international health emergencies and planetary health), antimicrobial stewardship and addressing health inequalities. See the Population and planetary health topic guide for further information.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring, emergency care and end-of-life care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs
Infectious diseases may be asymptomatic or present with atypical symptoms. Symptoms and signs include:
- cardiac symptoms
- fatigue and non-specific symptoms
- fever
- gastrointestinal symptoms such as diarrhoea, vomiting, abdominal pain
- genitourinary symptoms
- hepatosplenomegaly
- joint pains
- lymphadenopathy
- neurological and neuropsychiatric symptoms
- pruritus
- respiratory symptoms such as cough, shortness of breath, haemoptysis
- skin and mucosal signs (including pathognomonic rashes)
- weight loss.
Common and important conditions
Many infectious diseases are multisystemic, therefore many of the conditions listed below will also appear in several other RCGP topic guides. You should read the relevant section of each topic guide for further information. Conditions seen less frequently in the UK may be more common abroad, and you should consider this when interpreting symptoms and signs.
- Bone, joint and soft tissue infections (for example, septic arthritis, osteomyelitis, necrotising fasciitis)
- Cardiovascular infections (for example, endocarditis, rheumatic fever)
- Common and serious childhood infections (including viral, bacterial, fungal)
- Common ear, nose and throat (ENT) infections
- Covid-19 (including ongoing symptomatic Covid-19 and post-Covid-19 syndrome)
- Fever in the returning traveler and its potential causes (for example, malaria, dengue, typhoid or paratyphoid, chikungunya, other viral haemorrhagic fevers)
- Gastrointestinal infections (for example, amoebiasis, amoebic dysentery, food poisoning (including causative organisms), giardiasis, hydatid disease, travelers’ diarrhoea, typhoid
- Genitourinary infections including sexually transmitted and urinary tract infections
- Healthcare-associated infections (HCAIs) (such as methicillin-resistant staphylococcus aureus (MRSA), Clostridium difficile)
- Helminth infections (for example, schistosomiasis, hookworm, strongyloides)
- Hepatitis of infectious origin
- Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), including prevention, testing, transmission (including mother-to-child transmission), therapies, prophylaxis and associated diseases (such as pneumocystis jirovecii, cryptococcus spp., cytomegalovirus, candida)
- Immune deficiency: infectious disease in the immune-compromised patient
- Malaria (including malarial prophylaxis)
- Multisystemic infections, including bacterial (for example, staphylococcal, streptococcal), viral (such as Epstein-Barr virus), fungal and parasitic (for example, toxoplasma, Chagas disease)
- Neurological infections (such as meningitis, encephalitis)
- Occupational infections and their management (for example, needlestick infections)
- Ocular infections (such as conjunctivitis, ophthalmia neonatorum)
- Pandemics (such as pandemic influenza)
- Post-operative infections
- Respiratory disease (for example, pneumonia, Legionnaires’ disease, influenza)
- Sepsis and the deteriorating patient
- Skin infections (such as bed bugs, cutaneous larva migrans, exanthemata, flea, louse, ringworm, scabies, threadworm, orf, leishmaniasis)
- Tick-borne diseases, including Lyme disease
- Trauma, including injuries, animal bites and wounds
- Tuberculosis and its different manifestations
- Travel-related conditions (for example, altitude related sickness, deep vein thrombosis (DVT), pulmonary embolism (PE), motion sickness, sun or cold exposure, water activities)
- Vaccine-preventable communicable diseases, including cholera, Covid-19, diphtheria, Haemophilus influenzae b (Hib), hepatitis A, hepatitis B, human papillomavirus (HPV), influenza, Japanese encephalitis, measles, meningitis ACWY, meningitis B, meningitis C, mumps, pertussis, pneumococcus, poliomyelitis, rabies, rotavirus, rubella, shingles, tetanus, tick-borne encephalitis, tuberculosis, typhoid, varicella, yellow fever
- Zoonotic diseases (such as leptospirosis, brucellosis)
Examinations and procedures
- Features of infectious diseases through relevant, focused systems examination
- Rashes related to, or pathognomonic of, infectious diseases (such as meningococcal meningitis, erythema chronicum migrans, erythema multiforme, erythema nodosum, viral exanthemata)
- Assessment of an acutely unwell patient with possible infection (including signs of sepsis)
- Safe remote assessment skills
- Home self-monitoring for patients (for example, pulse oximetry in Covid-19 and pneumonia)
- Intramuscular injection administration (such as benzylpenicillin, immunisations)
Investigations
- Use, limitations and interpretation of investigations, such as serological testing, swabs, blood films, urine and stool microscopy and culture, point-of-care testing (also known as near-patient testing), such as C-reactive protein (CRP) test
- Use, limitations and interpretation of the main types of tests for SARS-CoV-2 (coronavirus)
- Common laboratory tests e.g., haematology (including significance of eosinophilia in travellers or those born outside the UK) and biochemistry (including normal parameters)
- Diagnostic imaging, such as chest X-ray
- Screening in asymptomatic patients (for example, chlamydia, HIV, TB)
Service issues
National and international
- Systems of care for people with infectious disease (including primary and secondary care, specialist services, voluntary sector organisations, shared care arrangements and multidisciplinary teams)
- UK's health protection agencies and other major local, national and international organisations involved in emergency planning for, and control of, outbreaks of infection
- UK screening and reporting programmes for infectious diseases
- Statutory notification of diseases
- Contact tracing and treatment of contacts
- Key national policies influencing healthcare provision for patients with infectious diseases
- NHS travel health service provision and the role of the independent sector
Individual, practice and community level
- Antimicrobial resistance (AMR), including causes and relevant measures to reduce it (such as appropriate use of antimicrobial therapy and patient education)
- Fitness to travel documentation
- Immunisation, including:
- understanding how common vaccines work, along with their major benefits and risks
- childhood immunisation schedules
- immunisation in pregnancy, travellers and other important situations, such as contact tracing
- vaccinations available through the NHS
- mandatory vaccinations for travel to certain areas
- vaccine hesitancy, vaccine inequity and measures to address these
- Local emergency response plans and emergency preparedness
- Safe working practice in personal, clinical and organisational settings (including principles and practice of infection control and safe approaches to remote consultations)
- Safe and effective evidence-informed prescribing, including prophylaxis
- Translation services
Additional important content
- Diagnostic overshadowing (for example, assuming that illness in returning travellers is solely related to travel, or that a patient's symptoms during the Covid-19 pandemic are due to Covid-19)
- Diseases likely to affect prospective or returning travellers and those who were born or have lived outside the UK
- Ethical and legal considerations (such as around confidentiality and disclosure, data protection, consent, immunisation, inequalities, rights of migrants to healthcare, capacity and competence)
- Health advice for travellers (including vaccination and other precautions, use of electronic resources and signposting to appropriate services)
- Health inequalities relating to infectious disease (such as differential outcomes in Covid-19)
- Health of refugees, asylum seekers, people born or have lived outside the UK, victims of human trafficking, homeless and traveller populations
- Infectious diseases during pregnancy, birth and breastfeeding, and in older adults, immunosuppressed patients and drug or alcohol users
- Links between planetary health and infectious diseases
- Local and global epidemiology, modes of transmission, incubation periods and periods of communicability of common and important infectious agents
- Non-judgemental conversations and approaches to differing beliefs about infectious diseases (such as acquisition, prevention, treatments and self-care)
- Pre- and post-exposure prophylaxis
- Psychosocial impact of infectious diseases on individuals and their wider social networks
- Relevant guidelines and legislation (such as from the UK Civil Aviation Authority, National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), national patient safety initiatives, local antimicrobial guidelines)
- Risk–benefit conversations (for example, around screening and testing for infectious diseases, immunisation and specific vaccines, infection control practices, travel, and therapies) based on the patient's current and past health and individual circumstances, including health literacy
- Travel health during pregnancy (including specific risks, fitness to fly certification)
- Safe and appropriate use of clinical decision aids and scoring systems in people with infectious diseases
- Use of appropriate language or tools to communicate the status of a deteriorating patient (for example, to other health professionals such as ambulance staff)
- Use of local disease prevalence data to determine what conditions are common in your area and in various demographic groups, and interpretation of symptoms and signs accordingly.
- Use of personalised care principles such as Making Every Contact Count (MECC), for example, relating to vaccine uptake
Case discussion
Alex Campbell, a 20-year-old university student, is planning to travel to Southeast Asia for two months. She visits you for travel advice as the nurse who runs the travel clinic is absent.
She has no significant past medical history. Her only medication is the combined oral contraceptive pill (COCP), which she uses for contraception and dysmenorrhoea. She is concerned about her DVT risk when flying while on the COCP but is reluctant to stop it. Her childhood immunisations are up to date, and she is fully vaccinated against Covid-19.
Using the NHS Fit for Travel website and other accredited resources, you provide Alex with country-specific and general travel advice, such as on the risk of infectious diseases, vaccinations needed, malaria prophylaxis, sun exposure and travel insurance.
After six months, you see her as an emergency appointment. She returned to the UK three days ago and has been having diarrhoea and vomiting for five days. On further exploration, she also admits to having unprotected sexual intercourse with a fellow traveller over a month ago and is worried about sexually transmitted conditions.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis of a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are my beliefs and assumptions about infectious disease and its acquisition? How might they impact on my consultations with Alex? How do I take care of my own health? Are there any significant risks to my health at work, or risks to patients because of my health? How might these be addressed? |
An ethical approach This is about practicing ethically with integrity and respect for equality and diversity. | What ethical issues should I consider in relation to sexually transmitted infections (STIs) (including HIV) testing? What additional issues might arise if Alex says that she has a partner? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How might I optimise consultations involving sensitive issues, including when the patient does not speak English? How can I involve Alex in shared decision-making in this case? How confident am I based on the consultation that Alex will come back to see me? What techniques could I use to improve rapport and build trust? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How confident am I in taking a sexual history and conducting a risk assessment? What further information do I need about Alex’s travel plans to give advice about infectious diseases and vaccinations? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What equipment does my surgery have for STI testing in women and men? What methods can be used to test for chlamydia? What factors should be taken into account regarding the timing of STI testing? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How can I decide which vaccinations to recommend to Alex? What resources can I use to assist me? What signs and symptoms would have influenced me to refer to secondary care when Alex presented with diarrhoea and vomiting? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What should I tell Alex about her risk of DVT? What investigations would have been appropriate to initiate when Alex presented as an emergency? What factors would have influenced me to prescribe antibiotics or antimotility agents when Alex presented with gastroenteritis? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What factors would I have had to consider if Alex had been pregnant? If Alex had been born or grown up in Southeast Asia, would this have altered my travel advice? How would I arrange contact tracing for STIs? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How are patients requiring travel advice or STI testing managed in my practice? What alternative options are there for STI testing in my locality? How can patients access these? Where can my patients receive travel vaccinations such as yellow fever if my practice does not offer it? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What is the guidance on management of STIs in primary care? What is the guidance on management of diarrhoea and vomiting in a returning traveler? Where can I seek up-to-date travel advice? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What policies, protocols or systems are there in my practice relating to infection control (such as needlestick injury, biohazards, disinfection and sterilisation of equipment, infectious patients in communal areas)? How would I know if Alex’s immunisations were up to date? Could either of the consultations have been safely conducted remotely? Why or why not? How are patients invited and recalled for non-travel vaccinations (such as flu, shingles)? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What other issues might be relevant to discuss in the consultation (such as smoking cessation, long-acting reversible contraception (LARC))? Are there any potential differences between the doctor’s and patient’s agenda in this case? How would I promote safer sex and travel advice for the future? What social, cultural, religious, sexual and environmental factors might I need to take into account? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What local initiatives exist to prevent patients acquiring travel-associated conditions (such as free malaria prophylaxis)? Where can I access local public health advice about infectious diseases (including outbreaks)? What are my organisation’s pandemic response plans? As a GP, how can I contribute to reducing antimicrobial resistance? How can I best support and empower populations most vulnerable to infectious diseases? |
How to learn this area of practice
Work-based learning
The Covid-19 pandemic significantly changed ways of working in general practice and many of these systemic changes, such as remote consultations, remain. General practice is an excellent setting in which to experience, among other things:
- common childhood and adult infections
- first presentation of novel infectious diseases
- infection control practices
- immunisation delivery, including mass population vaccination
- safe use of telephone triage and digital consulting in people with suspected infectious disease
- opportunistic screening of asymptomatic patients
Within on-call, urgent care and out-of-hours settings you will see more acute conditions, which may present differently in primary care than in the hospital. A key skill is to pick out serious pathology from the large numbers of benign, self-limiting conditions, and you should make sure that you see as many unselected patients as possible to give you the experience and confidence to do so.
You may wish to sit in travel or vaccination clinics within the surgery, attend the local genitourinary medicine or sexual health clinic, or spend some time with your local health protection team. You could also try to find out about local initiatives to improve detection and awareness of communicable diseases (such as TB), which may involve third-sector organisations in partnership with local councils or the NHS. You could find out about or visit other local NHS services such as acute care hubs, hospital at home and Long Covid clinics.
During your hospital rotations you are likely to see acute presentations of adult and childhood infectious diseases, along with exacerbations of chronic diseases. You may wish to attend the infectious diseases clinic or ward, along with any other specialist clinics that serve local population needs in this context.
Self-directed learning
Resources include (but are not limited to):
- NHS Fit for Travel, TravelHealthPro, which is part of the National Travel Health Network and Centre (NaTHNaC), and TRAVAX
- RCGP Covid-19 resources
- the Royal College of Physicians and Surgeons of Glasgow Faculty of Travel Medicine has educational resources, including good practice guidance for providing a travel health service
- UK Health Security Agency guidance on health protection
- Public Health Scotland
- Public Health Wales
- Public Health Agency (Northern Ireland)
Learning with other health care professionals
As well as interacting with doctors, nurses, health visitors and public health specialists in the UK, you may wish to speak to health professionals or patients who have trained in or used a health system outside the UK to understand the similarities and differences compared with your own system, including potential differences in disease spectrum and presentation.
Structured learning
Various universities offer diplomas or short courses in tropical/travel medicine. The Royal College of Physicians and Surgeons of Glasgow Faculty of Travel medicine offers additional qualifications in travel medicine.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Appropriate antibiotic therapy for specific infections
- Recognition and management of skin infections
- Interpretation of abnormal blood results
Simulated Consultation Assessment (SCA)
- A student has been travelling in Southeast Asia and returned last week with a high fever, headache and exhaustion. A thick film for malaria was negative yesterday
- An elderly woman has an itchy rash over her body and limbs. Symptoms are worse at night and persist despite a recent prescription of emollients
- A newly registered patient with HIV wants to discuss shared care arrangements with the local hospital and is concerned about the confidentiality of his medical records
Workplace-based Assessment (WPBA)
- Consultation Observation Tool (COT) about a request for antibiotics to take on holiday in case they are needed for gastroenteritis
- Learning log about managing a man who had a spider bite while on holiday and is now unwell with an ulcerated skin lesion
- Learning log about your involvement in the practice travel clinic