Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999

An Advisory Committee Statement (ACS) Committee to Advise on Tropical Medicine and Travel (CATMAT)*+
GUIDELINES FOR THE PRACTICE OF TRAVEL MEDICINE
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Preamble
The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides Health Canada with ongoing and timely medical, scientific, and public-health advice relating to tropical infectious disease and health risks associated with international travel. Health Canada acknowledges that the advice and recommendations set out in this statement are based upon the best current available scientific knowledge and medical practices, and is disseminating this document for information purposes to both travellers and the medical community caring for travellers.
Persons administering or using drugs, vaccines, or other products should also be aware of the contents of the product monograph(s) or other similarly approved standards or instructions for use. Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) or other similarly approved standards or instructions for use by the licensed manufacturer(s). Manufacturers have sought approval and provided evidence as to the safety and efficacy of their products only when used in accordance with the product monographs or other similarly approved standards or instructions for use.
Introduction
As more Canadians travel to exotic, tropical, or remote destinations, there is an increased need for travel medicine services. The practice of travel medicine has become more complex due to the dynamic nature of changes in global health risks, increases in population mobility, and various host factors important in the determination of health. Some examples of these are: a marked increase in the global distribution and incidence of drug resistant malaria; emergence and re-emergence of tuberculosis; more travellers with concurrent diseases (e.g. diabetes, HIV, cancer, cardiovascular, or pulmonary disease), pregnancy, or at the extremes of age; and the rapid expansion in new vaccines targeted to travellers. It is estimated that out of 1,000,000 Canadians who travel to tropical destinations annually, <> 1,000 cases of malaria were reported in Canada, compared to 430 cases in 1994.
Concerns about the quality of advice provided to Canadian travellers have been presented(2-9). Anecdotal reports and several studies suggest that many Canadians are receiving pre-travel advice from health-care practitioners who are ill equipped to provide up-to-date advice; in fact, incorrect advice provided to some Canadian travellers has led to severe consequences, including death(7-9).
The Committee to Advise on Tropical Medicine and Travel (CATMAT) is an advisory committee to the Assistant Deputy Minister, Health Protection Branch, Health Canada. As one of its activities, CATMAT develops recommendations related to the standards and quality of the travel medicine advice provided to travellers in Canada. When possible, these recommendations are evidence based(10). By describing the strength of each recommendation and providing the quality of evidence on which the recommendation is made, health-care professionals can be in a better position to apply the recommendations to the individual Canadian traveller. Currently, no general travel medicine practice guidelines are available. Therefore, CATMAT has developed these guidelines on the qualifications, knowledge, skills, and attributes of a travel medicine practitioner - as well as the facilities, equipment, and resources required for the practice of travel medicine. While these guidelines are not evidence based, they are designed to assist the health-care practitioner deliver quality travel medical care and thereby help protect the health of Canadian travellers.
Definition of travel medicine
Travel medicine is the field of medicine concerned with the promotion of health and the prevention of disease or other adverse health outcomes in the international traveller.
The practice of travel medicine is distinct from the practice of tropical medicine. Travel medicine focuses on health promotion as a means to maintain the health and well-being of travellers; tropical medicine focuses on the diagnosis and treatment of illness associated with travel. For example, travel medicine may include advice on how to prevent malaria and other vector-borne diseases, travellers' diarrhea, sexually transmitted diseases, injuries, and accidents, as well as information on acclimatization and adaptation to hostile environments.
Attributes and qualifications of a travel medicine practitioner
Individuals who practice travel medicine should be licensed health-care practitioners (e.g. a registered nurse and a physician working collaboratively) with a background in family practice, internal medicine, pediatrics, public health, or infectious diseases. They should utilize currently available guidelines in their practice of travel health promotion and follow provincial and territorial regulations.
It is recognized that practitioners of travel medicine may not have expertise in tropical medicine; however, they should be able to recognize urgent as well as non-urgent post-travel medical problems and have an established mechanism of timely referral to experts who can manage such problems.
Knowledge
The knowledge base required to practice travel medicine is complex. It includes a basic knowledge and understanding of the following:
geography
global distribution, epidemiology, mode of transmission, prevention and, if appropriate, self-treatment of travel-associated infectious diseases, such as
waterborne diseases (e.g. schistosomiasis and leptospirosis)
enterically transmitted diseases (e.g. travellers' diarrhea, giardiasis, and amoebiasis)
vector-borne diseases (e.g. malaria, Japanese encephalitis, dengue)
sexually transmitted diseases (including HIV)
vaccine-preventable diseases (e.g. polio, measles, hepatitis A and B)
zoonoses (e.g. rabies)
immunology and the immune system
indications, contraindications, pharmacology, drug interactions, and adverse events of available travel-related drugs and vaccines
prevention and management of non-infectious disease risks for travellers, including
effect of travel on intercurrent medical conditions (e.g. diabetes mellitus, cardiopulmonary disease)
travel-associated illnesses (e.g. motion sickness, jet lag, barotrauma)
environmental illness (e.g. sun, heat, cold, pollution, altitude)
threats to personal security
modes of transportation and their dangers (e.g. motorcycles, private vehicles, public transport)
trauma (e.g. injuries, accidents)
psycho-social issues of long-term travel (e.g. culture shock, adaptation)
availability of appropriate information resources (see maintenance of competence)
Skills
All pre-travel consultations should include the following:
a basic health assessment, including
evaluation of any underlying health problems
individual risk assessment to determine the traveller's health risks based on
travel itinerary
location of travel within the country(ies) (rural or urban)
style of travel (e.g. first class, adventure)
anticipated travel activities (e.g. animal contact, fresh water exposure, sexual contact)
duration of travel (short- or long-term)
underlying health (e.g. pregnancy, chronic illness, immunodeficiency)
age (child or elderly)
current immunization status
status of infectious diseases and other health risks at destinations during the proposed time of travel
risk-reduction strategies, including recommended vaccines and behavior modification to maintain health
strategies for the management of illness while travelling
All post-travel consultations should be managed by a physician and should include the following:
recognition of any travel-related illness
timely medical assessment, with referral if required, for the management of travel-related illnesses
All travel medicine practitioners should use effective communication to facilitate the retention of and compliance with the information provided. This may be accomplished by ensuring that the information provided is sensitive to any language, educational, or cultural barriers, and corrects any misconceptions. Multiple tools can be used to reinforce the information provided (e.g. brochures, flyers) and questions should be asked to verify that the traveller fully understands the advice provided(11).
Practice issues
Consultation
Assessing all relevant issues (nature of planned travel, personal travel characteristics, and personal health relevant to travel) in a travel medicine consultation will usually require 15 to 30 minutes. Additional time may be required (30 to 60 minutes) depending on the complexity of the geographic exposures, and the traveller's risk-taking behaviors and inter-current health characteristics.
Clinic facilities
Equipment
refrigerator and freezer which comply with standards for storage of immunization products (e.g. temperature monitor, alarm)(12)
telecommunications facilities (e.g. telephone, facsimile, and/or Internet accesses)
Supplies and disposables
those required to provide vaccination, including appropriate disposal equipment
resuscitation equipment standard for an office or clinic (e.g. adrenaline, antihistamines)(13)
Documentation
maintenance of a patient medical record standard for an office or clinic
completion of the individual patient's vaccination record or booklet
Consent
informed, voluntary consent for vaccination, testing and treatment
Office facilities
waiting room/reception area and clinic rooms for immunization
room suitable for teaching/counseling clients
resources for laboratory testing (internal or external)
Office policies
infection control practices for universal precautions and the disposal of sharps and other hazardous materials
proper handling, delivery and storage for vaccines and drugs
immunizations administered as per current National Advisory Committee on Immunization (NACI) guidelines
post-immunization observation period
client confidentiality
criteria for telephone advice
management of emergencies (e.g. allergic reactions)
research
Products
ready access to vaccines and biologics including the procedures for obtaining non-licensed vaccines
written material (e.g. flyers, pamphlets) concerning preventive measures such as bed nets, insect repellents, water treatment (sale of products not required)
educational materials including information for travellers with special needs (e.g. pregnant or diabetic travellers)
information on resources for health-care coverage for the traveller (e.g. International Association for Medical Assistance Travellers, travel health insurance)
Maintenance of competence
To maintain clinical expertise, it would be optimal to carry out a minimum of five to 10 travel medicine consultations per week. In order to be effective, the health-care practitioner must be willing to keep up with new developments in the field and remain current with the most up-to-date travel medicine resource references, including the following:
CATMAT and NACI guidelines and updates
United States Centers for Disease Control and Prevention or World Health Organization guidelines and updates
Canadian Immunization Guide or Protocole d'immunisation du Québec
geographic reference (atlas)
public-health publications (e.g. Canada Communicable Disease Report, Mortality and Morbidity Weekly Report)
access to outbreak information (e.g. Health Canada's Web page <www.hc-sc.gc.ca>, PROMED <majordomo@usa.healthnet.org>)
Continuing education related to travel medicine is essential for all travel medicine health-care practitioners. Examples include regular attendance at related conferences and seminars (e.g. public-health, immunization, travel medicine, and infectious diseases conferences) as well as membership in at least one related organization (e.g. International Society for Travel Medicine, American Society of Tropical Medicine and Hygiene, Canadian Public Health Association, or Canadian Infectious Diseases Society).
Conclusion
CATMAT presents these guidelines to serve as a stimulus for discussion and a blueprint for the practice of travel medicine. Ultimately, they may be used as a set of standards for the provision of travel health advice, thereby ensuring that Canadians receive appropriate and up-to-date information prior to international travel.
CATMAT firmly believes that travel medicine requires more than a "cookbook" approach. Up-to-date knowledge about the global epidemiology of infectious and non-infectious health risks is essential. Health-care practitioners must carry out a detailed individual risk assessment which includes nature of exposure, risk-taking behaviours, and personal health characteristics to be able to advise the most appropriate intervention(s) to promote health and prevent disease or other adverse health outcomes related to travel itinerary. These interventions may include a change in planned travel, behaviour modification, immunizations, chemosuppressive drugs (e.g. antimalarials), and other recommendations which are important to maintain the health of the international traveller.
With the continuously changing distribution of drug-resistant infections, epidemics of disease and advances in our therapeutic repertoire, travel medicine has become a complex specialty. Those who choose to enter this exciting field are cautioned to take the responsibility seriously. Since travel medicine is primarily a form of preventive health care, the client's health and safety depend to a large extent on the health-care practitioner's level of expertise, communication skills, and enthusiasm for the subject.
References
Gushulak B, Bodie-Collins M, Litt M et al. Canadian travel medicine providers' survey. In: Programs and abstracts of the Fifth International Conference on Travel Medicine, 24-27 March 1997, Geneva, Switzerland. Abstract 23.
MacPherson DW, Stephenson BJ, Keystone JS et al. Travel health information by public health departments. In: Programs and abstracts of the Fourth International Conference on Travel Medicine, 23-27 April 1995, Acapulco, Mexico. Abstract 23.
Beallor C, Gamble K, Keystone J. Travel health recommendations provided by family physicians -are they adequate? In: Programs and abstracts of the Fifth International Conference on Travel Medicine, 24-27 March 1997, Geneva, Switzerland. Abstract 255.
Bodie-Collins M, Paulson E, St John R. How current is your travel health information? Can Fam Physician 1998;44:346-49.
Kain KC, Harrington MA, Tennyson S et al. Imported malaria: prospective analysis of problems in diagnosis and management. Clin Infect Dis 1998;27:142-49.
dos Santos CC, Anvar A, Keystone JS et al. Pre-travel advice and chemoprophylaxis use among Canadians visiting the Indian subcontinent. CMAJ. In press.
Wittes RC, Constantinidis P, MacLean JD et al. Recent Canadian deaths from malaria acquired in Africa. CDWR 1989;15:199-204.
Sharma S, Kain K, Zoutman D. Fatal falciparum malaria in Canadian travellers. CCDR 1996;22:165-68.
Quach C, Kain K, MacPherson D et al. Malaria deaths in Canadian travellers. CCDR 1999;25:50-53.
Macpherson DW. Evidence-based medicine. CCDR 1994;20:145-47.
Nobel L. Communicating risks to the traveller. Travel Medicine International 1997;15:111-15.
LCDC. National guidelines for vaccine storage and transportation. CCDR 1995;21:93-97.
National Advisory Committee on Immunization. Anaphylaxis: initial management in non-hospital settings. In: Canadian immunization guide. 5th ed.Ottawa, Ont.: Health Canada, 1998:9-13. (Minister of Public Works and Government Services Canada, Cat. No. H49-8/1998E.)
* Members: Dr. B. Ward (Chairman); Dr. K. Kain (Past Chairman); H. Birk; M. Bodie-Collins (Executive Secretary); Dr. S.E. Boraston; Dr. H.O. Davies; Dr. K. Gamble; Dr. L. Green; Dr. J.S. Keystone; Dr. K.S. MacDonald; Dr. J.R. Salzman; Dr. D. Tessier.
Liaison Representatives: Dr. R. Birnbaum (CSIH); Dr. V. Marchessault (CPS and NACI); Dr. H. Onyette (CIDS); Dr. R. Saginur (CPHA); Dr. F. Stratton (ACE).
Ex-Officio Members: Dr. E. Callary (HC); Dr. M. Cetron (CDC); R. Dewart (CDC); Dr. E. Gadd (HC); Dr. H. Lobel (CDC); Dr. A.E. McCarthy (DND); Dr. M. Parise (CDC).
Member Emeritus: Dr. C.W.L. Jeanes.
Guidelines on Travel Health Committee: Dr. J. Keystone (Chairman); H. Birk; Dr. V. Marchessault; Dr. A.E. McCarthy; Dr. H. Onyett; Dr. D. Tessier. CATMAT acknowledges the contribution of Dr. D. MacPherson to these guidelines.
+ This statement was prepared by Dr. A.E. McCarthy and approved by CATMAT.
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