New travel medicine guidelines issued by the Infectious Diseases Society of America clearly illustrate that the field has expanded far beyond simply giving a few exotic immunizations.
“An awareness has developed among practitioners that prevention of illness in travelers includes not only the provision of vaccines and chemoprophylaxis but also a discussion of topics such as personal behavior and safety during travel, prevention of altitude illness, and access to medical care in the event of illness,” said guideline lead author Dr. David R. Hill and his associates (Clin. Infect. Dis. 2006; 43:1499–1539).
The comprehensive 40-page document comprises a standard for the practice of travel medicine as well as specific recommendations for pretravel risk assessment, immunizations (including updates of routinely recommended vaccines such as hepatitis A and B, and influenza), diarrhea and malaria prophylaxis, guidance on personal safety, and posttravel medical care.
Although most travel medicine should be provided in specialized travel clinics by professionals who have training in the field, primary care physicians should be able to advise travelers who are in good health and who will be visiting low-risk destinations with standard planned activities, according to the document.
“Each section has merit to both the specialist and the generalist. … Many generalists have been doing some travel medicine for their patients but not really understood how pretravel risk assessment and provision of advice, immunizations, and prophylaxis fits into the larger picture of travel medicine,” Dr. Hill, director of the National Travel Health Network and Centre Hospital for Tropical Diseases, London, said in an interview.
The field of travel medicine has developed rapidly in recent decades, for several reasons. The number of travelers crossing international borders grew from 457 million in 1990 to 763 million in 2004. This increase in global travel has led both to more frequent illness during travel and to importation of disease back to the United States, with potential transmission to susceptible individuals living here.
“The failure of health care professionals to accurately advise the traveler of health risks and the failure of the traveler to either seek or follow pretravel advice may lead to excess morbidity and mortality from diseases such as malaria,” the authors noted.
At a minimum, all travelers should be informed about vaccine-preventable illness, avoidance of insects, use of malaria chemoprophylaxis, prevention and self-treatment of traveler's diarrhea, personal behavior and safety, the importance of obtaining travel and evacuation insurance policies, and access to medical care during travel. Additional information should be tailored to the particular itinerary, they advised.
Primary care physicians should be able to provide pretravel services to healthy patients, other than young infants or very elderly individuals, who will be visiting relatively low-risk areas like the Caribbean or a Mexican resort.
However, “as soon as the traveler has complex health conditions, or one is considering administering specialty vaccines—e.g., Japanese encephalitis and yellow fever, or malaria prevention to someone with a seizure disorder—then the level of expertise needs to be greater,” Dr. Hill explained.
But, he added, “this does not stop a generalist from seeking additional education and training in the field so that they can advise the more complex traveler. Indeed, we would encourage them to do so.”