chapter 45 Travel medicine
There has been an increasing trend for people to travel internationally.1 Ease of air transportation has ensured that nearly 1 billion people travel internationally each year to every part of the globe.2 These travellers are potentially exposed to infectious diseases for which they have no immunity, as well as other serious threats to wellbeing, such as accidents and exacerbation of pre-existing medical and dental conditions. Conservatively, it is estimated that 30–50% of travellers become ill or are injured while travelling.3,4 Relative estimated monthly incidence rates of various health problems have been compiled elsewhere.3 The risk of severe injury is thought to be greater for people when travelling abroad.1,5
In terms of morbidity, infectious diseases such as respiratory tract infection and traveller’s diarrhoea, and injuries, are important concerns for travellers.1,4,5 The main health complaints of returned travellers vary considerably, depending on the country visited and the duration of the visit. Some studies have reported, based on travel insurance claims, that respiratory, musculoskeletal, gastrointestinal, ear, nose and throat, and dental conditions were the most common presenting problems,6 whereas others have found that infectious disease (43.5%), accidents involving the extremities (15.3%), psychiatric conditions (8.2%), pulmonary disorders (4.7%) and accidents involving the head (4.7%) were the most common.3,7 Fortunately, few travellers die abroad, and those who do tend to die of pre-existing conditions, such as myocardial infarction in travellers with known ischaemic heart disease. However, accidents are also a major cause of travel-related mortality.8 This chapter highlights some of the current issues in travel medicine, but excludes specific discussion concerning migrant health.
Travel medicine is a new multidisciplinary specialty area that has emerged in response to the growing needs of the travelling population worldwide. Nearly all general practitioners (GPs) will need a basic knowledge of travel medicine, some GPs will make it an area of special interest and there are medical specialists whose whole practice is travel medicine.
Travel medicine seeks to prevent illnesses and injuries occurring to travellers going abroad and manages problems arising in travellers coming back or coming from abroad. It is also concerned about the impact of tourism on health and advocates for improved health and safety services for tourists.9a
The pre-travel health consultation involves consideration of and advice about various aspects of travel-related health, including fitness to travel and the health risks of travelling in itself, including exposure to infectious diseases and diseases arising from travel. This may necessitate the provision of malaria and other chemoprophylaxis, and various vaccinations. The areas that may be covered in the pre-travel health consultation with travellers are listed in Table 45.1.
|Insects||Repellents, nets, permethrin|
|Ingestions||Care with food and water|
|Injuries||Accident avoidance, safety|
|Insurance||Health and travel insurance|
|Finding medical assistance abroad|
|First aid advice|
|Always||National immunisation schedule vaccines|
|Often||Hepatitis A, influenza|
|Pandemic influenza, e.g. pandemic (H1N1) 2009|
|Traveller’s medical kit|
Before the pre-travel consultation, a risk assessment needs to be undertaken, evaluating the risks of both the destination and the individual travelling there. Information on the exact itinerary and special medical problems of the traveller needs to be obtained early, up to 6–8 weeks before travel for most travellers, perhaps longer when travellers are going overseas for long-term employment, placement or holiday touring. In the clinic setting, it is preferable that this information is obtained well before the traveller presents for their first face-to-face consultation. It is necessary to establish:
This information may be obtained by a standardised questionnaire, which may be developed in the context of a travel clinic network or general practice network, or by individual travel health advisers. The World Health Organization (WHO) has provided an example of the types of questions to be asked in international travel and health.12 Practice or clinic staff can assist by ensuring that this information is obtained before the formal consultation. It is important that the procedure is time efficient for a practice, to improve flow and time management.
In the general practice setting, detailed records may be available to assist in assessing the traveller’s medical risks for travel. In any event, these records may need updating if the traveller has not presented to the GP for some time. Travel clinics, general practices and those in the travel industry should make it clear to prospective travellers that they should present early before travel, to obtain their travel medicine advice, immunisations and chemoprophylaxis or be referred for specialist advice, such as a pre-travel dental check. This may be best stated in a formal practice policy, so that travellers are aware of these possible requirements, which might be advertised in clinic newsletters, websites or practice updates or reminders.
It is important in travel medicine to establish the risks of the destination and the mode of travel in terms of the hazards and the potential exposure to these hazards, and to examine the traveller’s medical history to establish host risks, which may affect selection and use of interventions in the pre-travel health consultation. These are then weighed against the risks of the intervention.
The risks of the destination and any specific requirements for travel health advice may be obtained from a variety of resources. The WHO publishes a booklet entitled International Travel and Health.12 Several other publications and sources of information relevant to travel medicine are also available. Online computerised databases have long since been mooted as useful aids for providing the most up-to-date and validated information for advising on travel medicine.13
The traveller should also be advised of the possible need for follow-up and management after travel, particularly if going to a high-risk area (e.g. for malaria) or if they have any illness upon return (e.g. fever; persistent or bloody, mucous diarrhoea).14 It must be impressed upon the traveller that, in the event of any illness upon return, they should inform the treating physician of their recent travel and that they have travelled, for example, to a malaria area. It is important, if seeing a traveller with a post-travel health problem, that a risk assessment similar to the pre-travel health consultation is undertaken, guided by the presenting features of the illness or injury against a background of the patient’s general health. Even travellers who have been seen in the clinic or general practice for pre-travel health advice may need to have the risk assessment re-evaluated if any of the parameters of risk have changed (e.g. the person has travelled to a new destination). The risks of travel may also be modified by:
The effective early management of post-travel health problems early can significantly reduce morbidity and mortality, among travellers, from diseases such as malaria, which may still occur post travel as no intervention is necessarily 100% protective. Managing the risk and these travel health problems in a timely manner can also reduce the risk to local populations from this disease, and post travel it may assist in reducing the risks to the traveller’s own community (e.g. in dengue recognition and management).
Several key developments in the past two decades have ensured the continuing emergence of travel medicine as a specialty area. The development of national programs and guidelines in travel health was an important advance, as this recognised the need to develop a consensus strategy for combating commonly encountered infectious diseases and other problems encountered by travellers. Examples of these include the former Australian Government’s Travel Safe® Programme, including the publication of Australian guidelines for travel health,15 and the US Centers for Disease Control and Prevention (CDC) travel health program.16 These programs and guidelines were directed at the major providers of travel health advice, such as general practices and public health agencies, but also travel clinics and travel agents. Internationally, the World Health Organization has also been producing travel health guidelines. (Examples of major travel health guidelines can be found in the Resources list.)
Many of these challenges can be at least partially addressed through industry and government cooperation, particularly at the level of the travel agent or airline, which have initial contact with travellers. Many countries now have foreign travel advisory services that help keep practitioners advised about things such as important travel warnings and global disease outbreaks.
One of the most important factors influencing whether travellers seek health advice is the perceived risk and severity of tropical diseases,1 despite their relatively low health and safety risk to travellers compared with accidents and less exotic conditions such as traveller’s diarrhoea. In addition to the prevention of potentially lethal diseases and injuries among travellers abroad, the importance of providing travel health services is also increasingly being recognised in relation to early detection and reporting of imported infections.
The International Society of Travel Medicine (ISTM), established in 1991, has taken the lead in establishing a global professional base for travel medicine. Some of the important early initiatives of the ISTM were the provision of travel health alerts to subscribers, a journal, biennial conferences, a global listing of travel health practitioners, and a collaborative disease-reporting network (GeoSentinel) with the CDC in the United States.18 GeoSentinel has played a role regionally in examining post-travel health problems.19 More recently, the ISTM has developed a certification program based on a detailed body of knowledge in travel medicine leading to a Certificate of Travel Health.20 GeoSentinel is an excellent example of the contribution of travel medicine to the early detection and reporting of imported infections, to which several sites in Australia and New Zealand contribute.21
The Asia Pacific Travel Health Association also conducts biennial conferences in travel medicine in the Asia-Pacific region, in alternate years to the ISTM’s annual conference and in parallel with its endorsed regional conference. The two major journals in travel medicine are currently the ISTM’s Journal of Travel Medicine, published by Wiley-Blackwell, and Travel Medicine and Infectious Diseases, published by Elsevier Science. In Australia, the development of a professional body in travel medicine, the first Faculty of Travel Medicine (FTM), has been achieved22 as part of the Australasian College of Tropical Medicine (ACTM). The FTM works in close association with the New Zealand Society of Travel Medicine, established in 1997. The ACTM produces the Annals of the ACTM, which is subtitled ‘A journal of tropical and travel medicine’, reflecting the major interests of the college and its faculty. The Royal College of Physicians and Surgeons of Glasgow subsequently founded an FTM in 2006.
In addition, there are a number of valuable internet and related resources, which also provide information on disease distribution and prevention (see Resources list). Access to current policy guidelines and up-to-date health intelligence, usually provided in travel medicine from internet-based resources, is essential. Continuing research is essential for a better understanding of the epidemiology of travel-related diseases and injuries, which in turn leads to the development of improved guidelines in travel medicine and more effective preventive measures to combat infectious diseases and prevent injuries associated with travel.