Abstract
Objective To define the practice of travel medicine, provide the basics of a comprehensive pretravel consultation for international travelers, and assist in identifying patients who might require referral to travel medicine professionals.
Sources of information Guidelines and recommendations on travel medicine and travel-related illnesses by national and international travel health authorities were reviewed. MEDLINE and EMBASE searches for related literature were also performed.
Main message Travel medicine is a highly dynamic specialty that focuses on pretravel preventive care. A comprehensive risk assessment for each individual traveler is essential in order to accurately evaluate traveler-, itinerary-, and destination-specific risks, and to advise on the most appropriate risk management interventions to promote health and prevent adverse health outcomes during travel. Vaccinations might also be required and should be personalized according to the individual traveler’s immunization history, travel itinerary, and the amount of time available before departure.
Conclusion A traveler’s health and safety depends on a practitioner’s level of expertise in providing pretravel counseling and vaccinations, if required. Those who advise travelers are encouraged to be aware of the extent of this responsibility and to refer all high-risk travelers to travel medicine professionals whenever possible.
Rates of international travel continue to grow substantially, with an unprecedented 1 billion travelers worldwide crossing international boundaries in 2012.1 This increasing globalization in travel increases the risk of travel-related illnesses and other health exposures; therefore, health care professionals need to accurately advise travelers about these potential risks. However, evidence suggests that the pretravel care provided to Canadian travelers, particularly immigrant travelers visiting friends and relatives (VFR), is likely suboptimal.2,3 Only a small number of travelers seek pretravel health advice4–6 given that there is a general lack of awareness of travel health issues and that travel health services are not insured under government health plans. Furthermore, travelers who do typically seek advice do so from practitioners who are not specifically trained to counsel patients on travel-related health risks.7
The objective of this review is to define the practice of travel medicine, provide health care professionals with the basics of a comprehensive pretravel consultation for patients traveling internationally, and assist these clinicians in identifying patients who might require referral to travel medicine professionals.
Case
Mr D. and his family will be traveling to both rural and urban areas in northern Uttar Pradesh, India, in 3.5 weeks (during the summer months) to visit friends and family. Mr D. and his wife, aged 38 and 35 years, respectively, were born in India, and their children, aged 7 and 4 years, were born in Canada. This will be the children’s first trip to India. The expected duration of travel is 1 month.
Sources of information
Guidelines and recommendations on travel medicine and travel-related illnesses from key travel health authorities including the International Society of Travel Medicine, the Committee to Advise on Tropical Medicine and Travel, the World Health Organization, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America were reviewed. MEDLINE and EMBASE searches (from 2001 to January 2013) for English-language articles using the terms travel medicine, guidelines, pretravel consultation, vaccine-preventable diseases, and vaccinations were also performed. In addition, reference lists of identified guidelines and studies were examined, and a group of experts in travel medicine from across Canada was convened to further identify key literature and topics.
Main message
Definition of travel medicine
Travel medicine can be defined as follows:
[T]he field of medicine concerned with the promotion of health … for the peoples, cultures and environment of regions being visited in addition to the prevention of disease or other adverse health outcomes in the international traveller .... [I]t focuses primarily on pretravel preventive care.7
Travel medicine is a rapidly evolving, highly dynamic, multidisciplinary specialty that requires expertise on various travel-related illnesses, as well as up-to-date knowledge on the global epidemiology of infectious and noninfectious health risks, health regulations and immunization requirements in various countries, and the changing patterns of drug-resistant infections (Table 1).8 It is highly recommended that pretravel care be rendered by practitioners who hold a certificate of knowledge in the field (eg, such as that provided by the International Society of Travel Medicine) and who have regular experience in advising travelers with varying and complex health conditions, destinations, and itineraries.7,9
Pretravel consultation basics
The goal of the pretravel consultation is to reduce the traveler’s risk of illness and injury during travel through preventive counseling and education (Table 2), medications (Table 3), and immunizations (Tables 4 and 5), as required.9–24 A comprehensive risk assessment is the foundation of this consultation and allows the practitioner to individualize care based on the traveler-, country-, and itinerary-specific risks.7–10,25 A questionnaire designed to collect such data is an essential tool for supporting this process and for determining if more specialized care by a travel medicine professional is required. A sample of a pretravel risk assessment questionnaire is available from CFPlus.* Figure 1 provides a triage algorithm that can assist clinicians in determining the extent of pretravel health advice required and when referral to a travel medicine professional is advised.
Traveler-specific risks:
A thorough evaluation of the traveler’s health status and medical history is required.7–10,25 Certain travelers are considered high risk and should be evaluated by a travel medicine professional, such as immunocompromised patients, pregnant or breastfeeding women, young children, the elderly, patients with pre-existing medical conditions or chronic illnesses (eg, diabetes mellitus, chronic cardiac or pulmonary conditions, renal disease, mental health or psychiatric illness, thymus disorders, cancer, epilepsy or history of chronic convulsions or seizures, blood or clotting disorders), and those VFR (travelers that have migrated from a developing country to an industrialized region, and who are now returning to their country of birth). Compared with other groups of international travelers, those VFR (particularly children) experience a higher incidence of travel-related infectious diseases owing to their travel to higher-risk destinations, duration of travel, lack of awareness of risk and misconceptions regarding immunity, financial barriers, lack of access to pretravel health care, and cultural and language barriers.3,26,27
Destination-specific risks:
Determining destination- specific risks during the pretravel consultation is also essential and requires a basic understanding of the common illnesses specific to the region of travel. Practitioners should be aware of the most recent information on the disease endemicity of the destination, current outbreaks, and any recommended or required immunizations. Table 6 lists resources for up-to-date information on the geographic distribution of various travel-related illnesses.
Itinerary-specific risks:
Assessment of the patient’s itinerary should include data on countries and regions to be visited; visits to urban versus rural areas; dates and length of travel in each area; purpose of travel; types of accommodations; and modes of transportation. It is also important to assess for possible high-risk activities during travel (eg, hiking, rafting, spelunking, scuba diving) or animal contact. Travelers participating in recreational water activities, such as white-water rafting, might be at increased risk of leptospirosis, particularly if these activities occur after heavy rainfall or flooding.28 Cavers are at an increased risk of diseases such as rabies and histoplasmosis.29–33 Schistosomiasis is common in the developing world, and swimming in fresh water, even for a short duration, in areas where schistosomiasis is prevalent can lead to transmission of this parasitic infection.34 Travel to destinations more than 2500 to 3500 m above sea level (eg, Cusco, Machu Picchu, Peru; La Paz, Bolivia; Lhasa, Tibet; Everest base camp in Nepal) carries the risk of altitude illness, which, if not appropriately managed, can progress to ataxia, coma, and even death.9,35
Risk management
Following the risk assessment, counseling on risk management is imperative: suggest personal protective measures against insect-borne diseases and strategies for reducing water and food-borne illnesses; advise on itinerary-specific risks; counsel on sun or climate effects, the psychological effects of travel (eg, culture shock), and personal behaviour risks (eg, sexually transmitted diseases, illegal drug use); provide self-management strategies for diarrhea; discuss the preparation of a travel health kit (Box 110); and advise on obtaining travel insurance and accessing medical care abroad. Prescriptions for the prophylaxis of malaria and altitude sickness, as well as antibiotics for the self-treatment of traveler’s diarrhea, might also be required. When considering antimalarials, clinicians require up-to-date knowledge on antimalarial drug effectiveness and resistance patterns, and should also be aware of the potential liabilities associated with the provision of inappropriate antimalarials. Table 2 suggests the basic preventive and prophylactic strategies that should be provided to travelers based on their individual travel-associated risks.9–15
Preparation of a travel health kit
Basic items in a travel health kit include the following:
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Additional items according to destination:
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Data from Centers for Disease Control and Prevention.10
Vaccines
Vaccinations must be personalized according to the individual traveler’s immunization history, the countries to be visited, the type and duration of travel, and the amount of time available before departure. Ideally, the health care provider should be consulted 2 to 3 months in advance of travel in order to allow sufficient time for optimal immunization schedules to be completed.
Vaccines for travelers can be divided into 3 categories: routine, required, and recommended (Table 4).10 The pretravel consultation provides an excellent opportunity to ensure that travelers are up-to-date on their routine immunizations according to the Canadian Immunization Guide.16 Currently, yellow fever is the only vaccine required as a condition of entry into certain countries in Africa and South America under the World Health Organization’s international health regulations.17 In Canada, the vaccine is available only at designated Yellow Fever Vaccination Centres. (Visit www.travelhealth.gc.ca for a list of centres.) The quadrivalent meningococcal vaccine (conjugate preferred) is also required by the government of Saudi Arabia for all pilgrims visiting Mecca for the Hajj (annual pilgrimage) or Umrah.15,18 Table 510–24 lists other vaccines that might be considered based on travelers’ risks; these might include hepatitis A and B vaccines, typhoid immunization (particularly for those VFR traveling to the Indian subcontinent),36,37 and immunization against Japanese encephalitis or tick-borne encephalitis, among others.
Practitioners administering vaccinations must follow accepted immunization practices as outlined in the Canadian Immunization Guide,16 and should also be able to prioritize risks for travelers who might only be able to afford limited vaccinations or schedules. The latter requires a strong knowledge base on immunizations and the current epidemiology of travel-related illnesses and, therefore, referral to a travel medicine professional is recommended.
Roles and responsibilities of family physicians and community pharmacists
Because family physicians and community pharmacists are often the first point of contact for patients who will be traveling abroad, they play a pivotal role in identifying at-risk travelers and emphasizing the importance of obtaining a pretravel consultation. At a minimum, all presenting patients should be routinely asked whether they plan to travel internationally, particularly to a developing country. Before deciding whether or not to provide a pretravel consultation, practitioners should determine their level of competency and comfort in performing this consultation. Both the Committee to Advise on Tropical Medicine and Travel and the International Society of Travel Medicine recommend that all high-risk travelers be referred to travel medicine professionals with expertise in providing individualized care and addressing the unique needs of these travelers.7,9
Case discussion
Mr D. and his family are high-risk travelers owing to the presence of multiple risk factors: VFR, being last-minute travelers (< 2 months), involving children, and going to a high-risk destination (Figure 1). Unless their health care provider is competent in travel medicine, they should be referred to a travel medicine professional.
Routine vaccinations need to be updated for all parties. The clinician needs to be aware of the risks associated with travel to India, including food and water risks (eg, hepatitis A, typhoid fever, traveler’s diarrhea), as well as mosquito-borne (eg, dengue fever, malaria, Chikungunya, Japanese encephalitis) and other diseases (eg, hepatitis B, rabies). The choice of specific interventions will depend on the details of the itinerary and travelers’ demographic profiles. Proper counseling on food and water hygiene, insect protection, safety, medical insurance, and evacuation strategies also need to be provided.
Selection of an appropriate antimalarial for chloroquine-resistant Plasmodium falciparum malaria is essential, as is comfort in antimalarial dosing for both children and adults. Owing to the high rate of fluoroquinolone-resistant bacteria causing traveler’s diarrhea in India, an appropriate antibiotic, such as azithromycin, should also be offered, with an awareness of pediatric and adult dosing and indications for use. The oral vaccine for traveler’s diarrhea should also be discussed. This vaccine provides short-term protection only (approximately 3 months) against enterotoxigenic Escherichia coli (ETEC) diarrhea. However, it is important to note that vaccine protection against ETEC diarrhea is approximately 50%. Also, less than 50% of cases of traveler’s diarrhea are caused by ETEC bacteria.
Given that the family is planning to depart in less than 1 month, accelerated vaccine options (eg, hepatitis B and rabies in this case) need to be offered where applicable. If hepatitis B coverage is advised, accelerated combination hepatitis A and B options for the children and parents should be considered. The monovalent hepatitis A vaccine would also be an option in patients who had previously completed the hepatitis B vaccine series. In adults born in countries endemic for hepatitis A (such as India), serologic testing for natural hepatitis A immunity might be helpful in guiding vaccine choices; if, for example, the patient is immune, then hepatitis B immunization alone (in an accelerated format) would be an option.
Conclusion
Travel medicine is a challenging specialty that requires up-to-date knowledge on the global epidemiology of infectious and non-infectious health risks, the changing distribution of drug-resistant infections, and both international and local health regulations and immunization requirements. Because travel medicine is primarily focused on preventive health care, the traveler’s health and safety will depend on the practitioner’s level of expertise and proficiency in providing pretravel counseling, as well as the required or recommended vaccinations. Practitioners should be skilled in performing a detailed risk assessment for each individual traveler in order to accurately evaluate traveler-, itinerary-, and destination-specific risks, and to advise on the most appropriate interventions to promote health and prevent adverse health outcomes during travel. Those who advise travelers are encouraged to be aware of the extent of this responsibility and to refer all high-risk travelers to a travel medicine professional whenever possible.
Notes
EDITOR’S KEY POINTS
Travel medicine is a multidisciplinary specialty that requires expertise in travel-related illnesses, as well as up-to-date knowledge of the global epidemiology of infectious and noninfectious health risks, health regulations and immunization requirements in various countries, and the changing patterns of drug-resistant infections.
During pretravel consultations, practitioners can assess travel-related risks and advise patients on appropriate interventions to promote health and prevent adverse health outcomes during travel. However, if practitioners are not competent in travel medicine, high-risk travelers (eg, patients with chronic illness, those visiting high-risk destinations) should be referred to travel medicine professionals.
A traveler’s health and safety will often depend on a practitioner’s level of expertise and proficiency in providing pretravel counseling and the required or recommended vaccinations.
Footnotes
↵* A sample of a pretravel risk assessment questionnaire is available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.
This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
This article has been peer reviewed.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de décembre 2014 à la page e571.
Contributors
All authors have contributed substantially to the conception and design of this paper, have revised it critically for important intellectual content, and have provided approval of the final version submitted for publication.
Competing interests
Dr Aw has received research grants, travel fees, chairman fees, and honoraria for continuing medical education (CME) and media events from Sanofi Pasteur; honoraria for CME events from Merck and GlaxoSmithKline; fees for media educational events from Crucell Vaccines Canada (Janssen); and honoraria for chairing CME events and reviewing Mainpro talks from Pfizer. Dr Boraston has received a grant from Sanofi Pasteur. Dr Botten has participated in advisory boards for Sanofi Pasteur and has provided travel health consultancy services to Sobeys Pharmacy Ltd. Dr Cherniwchan has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group. Dr Kelton has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group and has participated in speaking engagements and received honoraria from Sanofi Pasteur, Crucell Vaccines Canada, Pfizer Canada, and the Ontario Pharmacists Association. He is also Medical Director of the Complete Traveler’s Clinic, which provides comprehensive pretravel advice and offers a variety of immunizations; these vaccines are purchased from various pharmaceutical companies and offered to travelers when appropriate as part of the pretravel consultation. He has received rebates or discounts on vaccine orders from Sanofi Pasteur, Merck, GlaxoSmithKline, Novartis, and Crucell Vaccines Canada. Dr Libman has received consulting fees from Sanofi Pasteur and CME course sponsorship from GlaxoSmithKline. Dr Saldanha has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group; honoraria for CME events and rebates or discounts on vaccine orders from Sanofi Pasteur, Merck, and Crucell Vaccines Canada. Dr Scappatura has received non-financial support from Sanofi Pasteur for patient handouts and vaccination materials. Mr Stowe has received honoraria from Sanofi Pasteur for his contributions to the Canadian Travel Medicine Working Group.
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