Responsibilities of Clinicians

In the United States, outbound travel by residents has increased from less than 52 million people in 1995 to over 63.5 million in 2005 (1). As more people travel and individuals travel more frequently, the specialty of travel medicine becomes more important. Thus, most clinicians need some basic information to determine the extent of health advice their patients should access prior to their journeys.

A primary responsibility of a clinician is to be an educator of the patient, and in this case, the traveling patient. Preventive health care is founded on equipping people with the knowledge that enables them to protect themselves from potential health risks. In travel medicine, areas to explore with the traveler include the medical history, the assessment of the epidemiology of endemic diseases, or health risks, at the destination, and the behavioral risks that may be taken. The pre-travel consultation can become quite complex; it encompasses far more than the provision of vaccinations and prescriptions for medications.

Before evaluating an individual for a pre-travel consultation, it is the responsibility of the clinician to determine his or her own limitations. A threshold should be set for when a referral might be made to a travel medicine specialist, considering the traveler’s best interest and the need to provide the most complete and up-to-date information. Incorporating the subject of travel medicine in one’s practice might be as basic as asking patients, particularly new immigrants, if they are planning to travel internationally, particularly to a developing country destination, and referring them to an appropriate travel medicine clinic. In this way, the clinician emphasizes the importance of a pre-travel consultation and educates the patient that international travel can pose special health risks that should be addressed. Some clinicians may feel they can offer more, such as advising travelers who are going on a short vacation to a popular tourist destination, for example, in Mexico or the Caribbean. In such cases, the consultation may involve updating routine vaccinations, providing hepatitis A coverage, and providing education about the prevention and self-treatment of travelers’ diarrhea. Other preventive behaviors should be covered as well (e.g., practicing safe sex and avoiding motor vehicle accidents). Other clinicians may broaden their knowledge of travel medicine and wish to provide more complex pre-travel consultations. To aid in preparing for these more complex types of consultations, the International Society of Travel Medicine (ISTM)(www.istm.org) provides educational resources, including the Journal of Travel Medicine, an active listserv, and a Certificate of Knowledge in Travel Health (CTH), awarded upon the completion of an exam. Numerous conferences are held throughout the year both nationally and internationally on the subject of travel medicine. The body of knowledge in travel medicine has been published, recently updated, and is available on the ISTM website (2). As the subject matter of travel medicine is quite dynamic, it is important that clinicians maintain a current base of knowledge if they will be regularly advising travelers in pre-travel consultations. Many different Internet resources and databases, although sometimes incomplete or in conflict with one another, are available for clinicians to use to keep abreast of the health issues in international travel (3). In addition to general pre-travel consultations, some clinicians may also wish to become registered yellow fever vaccine providers. This process is initiated with one’s state health department.

Another responsibility of clinicians is to provide post-travel medical care. Again, the extent of the care given by each clinician is personally determined. Knowing when one will refer a patient to a specialist and who that specialist would be are important decisions to make before patients come into the office seeking medical care, or even pre-travel health advice. Being able to recognize common disease symptoms and syndromes of international travelers is important in any practice, even if the practice is confined to pre-travel health care. For example, if a patient returns from sub-Saharan Africa with a fever and flu-like symptoms, simply asking a recent travel history is the first step in providing post-travel medical care and can be a major clue in determining the cause of the ailment. Such patients need emergency attention to rule out malaria. Clinicians must be aware that a geographic history is a crucial part of any patient encounter, when it is possible to travel from one corner of the world to another within 36 hours. Other patients with less than urgent problems can either be taken care of by the pre-travel provider or referred to a clinician in infectious diseases or clinical tropical medicine. The American Society of Tropical Medicine and Hygiene provides a listing of such clinicians on its website: www.astmh.org.

Responsibilities of Travelers

Each traveler needs to realize the value of health and the risks that traveling internationally may pose. This does not mean that people should not travel, but just as in any other activity in life, the experience will be more enjoyable if travelers are adequately prepared and equipped with the knowledge of how to protect their health. Studies have shown that the majority of travelers from the United States and other countries do not seek pre-travel health advice (4-7). In addition, it is every traveler’s responsibility to weigh the personal risk versus benefits of a particular itinerary. Some prefer to travel knowing they have little risk for illness outside the ordinary. Others seek adventure despite its risks; and even travelers with chronic illness may understand the serious nature of the risks taken at the expense of exacerbating life-threatening underlying diseases. It is critical that the health-care provider understand the traveler’s health risk tolerance and discuss openly with the traveler the wisdom of a particular itinerary.

The importance of asking questions and gathering information cannot be over-emphasized. In several recent studies, results have shown that a small portion of travelers do not even report seeking general information about their travel destination (4-7). If a traveler is using a travel agency or tour operator, it is helpful to ask questions to find out as much information about the trip as possible. Regardless of whether travelers are planning their own trips or joining a tour group, travelers should know as many details as possible about their modes of travel, their travel destinations, lodging, food, and activities during the trip.

Travelers should make certain that there is enough time to see a health-care provider and obtain any necessary vaccinations before they travel. Far less than half of all travelers who seek pre-travel health advice report obtaining information from a travel medicine specialist/travel clinic, and usually a slightly greater portion report seeking this information from their general practitioner/family doctor (4-7). Ideally, travelers should see a health-care professional about 4-6 weeks before traveling, giving an optimal amount of time for any necessary vaccines; however, if a trip is scheduled in one week or even in one day, it is always beneficial to try to seek travel health advice from an expert. A helpful resource is the travel medicine clinics section of the CDC Travelers’ Health website wwwn.cdc.gov/travel. That web page contains links to two professional medical organizations that provide travel clinic directories that can help travelers locate a convenient clinic. In addition, local or county health departments often have travel medicine clinics and can provide pre-travel consultations. The CDC Travelers’ Health website also maintains a Yellow Fever Vaccination Clinic Registry of facilities that can provide yellow fever vaccinations for travelers who need them.

Before seeing a health-care provider, it is helpful to visit the CDC Travelers’ Health website for health information. The website is kept current with latest recommendations concerning outbreaks of diseases around the world and other health-related situations, such as effects of natural disasters. The information provided in this text and on the website, along with that from a travel health advisor, will equip travelers with what they need to know to remain as healthy as possible.

One of the most important ways that travelers can protect themselves is to be prepared with helpful details when they see their health-care provider. Remember that travel health advice should be individually tailored to the person. Two travelers to Thailand may be provided different vaccines, medications, and detailed advice during their visits to the same clinic. For example, the business traveler to Bangkok with underlying heart disease staying at a 5-star resort has different risks from those of the healthy refugee camp worker who will travel throughout northern Thailand on the Cambodian border.

There is no way to include every question in this checklist that may pertain to all travelers, but the following items can be a great starting point of information for each person preparing to travel. The subject matter of these questions corresponds with the published body of knowledge in travel medicine (2).

Responsibilities of the Travel Industry

The responsibilities of the travel industry, including travel agencies, tour operators, air and cruise lines do not culminate with the final booking of the tickets or hotel rooms. These members of the travel industry, too, should learn about the basics of travel medicine as it affects the areas of the world where their customers are traveling. Customers making travel plans often look to their travel agents to advise them on all aspects of their trip, including health risks and preventive actions they should take. In recent years, studies in several areas around the world have documented that travelers report seeking general information about their travel destination and health advice from their travel agents (4-8). Although the role of the agent is not to provide personal medical consultations, acknowledging travel health risks (such as the presence of malaria or the fact that vaccinations may be beneficial) and providing resources in travel medicine can be very helpful.

Studies have shown that although members of the travel industry are generally supportive of a role in travelers’ health and many even report having policies about providing travelers with health information, the majority do not refer travelers to a travel medicine specialist/travel clinic (9-11). These studies also suggest that travel health advice is not consistent in content or in frequency.

Although it might be tempting to shy away from disclosing possible health risks, this is not the most advantageous option. People wanting to travel will most likely travel regardless of possible health risks, especially if they know that they can take actions to help prevent getting sick. Additionally, a healthy trip and a positive experience, as a result of proper preventative health behaviors, will be motivation to travel again in the future. It is prudent for members of the travel industry to be aware of the CDC Travelers’ Health website, which allows them to keep abreast of health issues globally. As well, it would be beneficial for the industry to refer travelers, particularly those with destinations in the developing world, to a local travel clinic. Travel agencies and tour operators should network with their local clinics to improve their knowledge, and travel clinics should reach out to provide educational sessions and resources to share with the traveling public through their local travel agencies.

References

1. U.S. Department of Commerce, International Trade Administration, Office of Travel and Tourism Industries [published data on the Internet]. U.S. Resident Travel to Canada, Mexico and Overseas Countries Historical Visitation Outbound: 1995 - 2005. 2006 Sep http://tinet.ita.doc.gov/view/f-2005-11-001/index.html. [cited 2006 Dec 06].
2. Kozarsky PE, Keystone JS. Body of knowledge for the practice of travel medicine. J Travel Med 2002;9:112-5.
3. Keystone JS, Kozarsky PE, Freedman DO. Internet and computer-based resources for travel medicine practitioners. Clin Infect Dis 2001;32:757-65.
4. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med 2004;11:23-6.
5. Van Herck K, Van Damme P, Castelli F, Zuckerman J, Nothdurft H, Dahlgren AL, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European Airport Survey. J Travel Med 2004;11:3-8.
6. Wilder-Smith A, Khairullah NS, Song JH, Chen CY, Torresi J. Travel health knowledge, attitudes and practices among Australasian travelers. J Travel Med 2004;11:9-15.
7. Toovey S, Jamieson A, Holloway M. Travelers’ knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport. J Travel Med 2004;11:16-22.
8. Provost S, Soto JC. Predictors of pretravel consultation in tourists from Quebec (Canada). J Travel Med 2001;8:66-75.
9. Grabowksi P, Behrens RH. Provision of health information by British travel agents. Trop Med Int Health 1996;1:730-2.
10. Provost S, Gaulin C, Piquet-Gauthier B, Emmanualli J, Venne S, Dion R, et al. Travel agents and the prevention of health problems among travelers in Québec. J Travel Med 2002;9:3-9.
11. MacDougall LA, Gyorkos TW, Leffondré K, Abrahamowicz M, Tessier D, Ward BJ, et al. Increasing referral of at-risk travelers to travel health clinics: evaluation of a health promotion intervention targeted to travel agents. J Travel Med 2001;8:232-42.

PHYLLIS KOZARSKY, AMANDA WHATLEY

Questions for Persons Preparing to Travel

• When are you traveling, and how long will you be at each location?
• Where are you traveling?
  • In what countries will you be traveling?
  • Where within the country or countries will you be traveling?
  • Are these destinations urban areas or rural areas?
  • What are the conditions of your lodging (such as hotel with air conditioning, screened cabin, or open-air tents)?
• What activities will you be doing while traveling (such as hiking, backpacking, scuba diving, sightseeing, etc.)?
• Have you traveled internationally in the past?
  • Where did you go?
  • When did you travel?
• How old are you?
• What vaccinations have you had previously?
  • When did you have these vaccinations?
  • How many doses did you have of a particular vaccine? (for example, some vaccines, such as the hepatitis A and B vaccines or the measles/mumps/rubella—MMR—vaccine, require multiple doses for long-term protection)
  • Did you have any allergies or reactions to any previous vaccines?
• Do you have any other allergies (for example, medications, foods, or environmental)?
  • In particular, do you have an allergy to eggs, latex, yeast, mercury, or thimerosal?
• What is your medical history and current health status (for example, past illnesses and surgeries, chronic health problems, or other underlying medical conditions)?
• What medications are you currently taking or have you taken in the past 3 months?
• Are you immune deficient?
• If you are a female,
  • Are you pregnant now?
  • Are you trying to become pregnant, or will you try to become pregnant in the next 3 months?
  • Are you breast-feeding?

Even with travel advice, vaccines, and medication protection, a person is not 100% protected against all diseases, and no preventive measures are 100% effective. There are many diseases for which there are no preventive vaccines or medications. Therefore, a wise traveler will remember that safe food and water precautions and hand hygiene, along with measures against insect and mosquito bites, are important ways of preventing many common travel illnesses. Many resources in this book and at the CDC Travelers’ Health website can help inform travelers of ways to prevent illness and protect against injury.