You are in: eMedicine Specialties > Emergency Medicine > INFECTIOUS DISEASES Travel Medicine and VaccinationArticle Last Updated: Jan 9, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Bret A Nicks, MD, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Wake Forest University Health Sciences Bret A Nicks is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Christian Medical & Dental Society, Society for Academic Emergency Medicine, and Wilderness Medical Society Coauthor(s): Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital Editors: James Li, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School Author and Editor Disclosure Synonyms and related keywords: public health, tropical medicine, wilderness medicine, malaria, traveler's diarrhea, general vaccinations, vaccinations before travel, travel illnesses, adventure travel, ecotourism, exotic disease, overseas travel, travel-related diseases, travel-related illness, cruise ship medicine INTRODUCTIONSection 2 of 11
  An estimated more than 800 million travelers worldwide cross international boundaries each year. However, whether associated with tourism, humanitarian efforts, globalization of industry, or migrant workers, studies suggest only a small number seek pre-travel health advice. In addition, the composition of those traveling continues to become more diverse and medically complex, creating a vastly different perspective on travel-associated medical concerns, preparations, and required medical knowledge. So, whether you are a humanitarian aid worker in Tanzania, an educator in Latin America, a tourist, or a businessperson for a multinational corporation, understanding the dynamics of travel and the interplay of healthcare will minimize the adverse effect of travel-related illnesses and concerns while maximizing enjoyment and success for the trip. TRAVEL MEDICINE: THE BIG PICTURESection 3 of 11
The specialty of travel medicine is dynamic and vast in its medical knowledge requirements. Areas of expertise include vaccinations, epidemiology, region-specific travel medicine, pre-travel management, travel-related illnesses, and post-travel management. PRE-TRAVEL MEDICAL PREPARATIONSection 4 of 11
Annually, Americans make more than 300 million trips to other countries. An increasing number of these trips are to developing countries, and, according to the CDC, 30-60% of these travelers, estimated at greater than 10 million people, become ill as a result of their travel. With a heightened interest in adventure travel, international destinations, and ecotourism, more patients return from vacations with presentations of possible exotic disease that are beyond the scope of an emergency physician's daily practice. However, much of the illnesses encountered could be eliminated with adequate pre-travel education and preparation. In the circumstance when prophylactic treatment and lifestyle modification fail, physicians need to know what to look for and where to find information on exotic diseases beyond the scope of daily practice. Further information can be quickly and easily accessed through the CDC Yellow Book, an online resource providing country-specific information. Pre-travel preparation Whether the physician is on an excursion to Travelers should ascertain the associated travel health information for their specific itinerary several months in advance of departure. This should include general health information such as vaccine requirements, prophylactic medications, disease outbreaks, political environment, and medical resources. Prior to departure for any extended or overseas travel, the following information should be obtained:
Basic health travel kit A medical kit is an essential item that should be carried by all travelers to developing countries or where local availability of such resources remains in doubt. The kit should include standard first-aid items, simple medications for common ailments, and any items specific for that traveler. In addition, consider having a list of medications along with a medical attestation signed by a physician authenticating the need of those medications for personal use. Standard toiletry items sufficient for the entire travel period are recommended.
Resource utilization Unique circumstances Physicians planning to serve as an expedition physician are advised to take a course provided by the WMS or a similar course by other providers. Detailed logistical planning, skills, equipment, medications, and resources for varied groups and destinations are beyond the scope of this article. Such information is readily available in both courses and textbooks from the WMS and the International Society of Travel Medicine (ISTM). Almost any expedition has a unique set of possible emergencies, varying by destination and by the types of participants. Possible injuries and risks range from unusual envenomations and exotic flora and fauna to bear or shark attacks to snakebite or frostbite. Below is a list of possible scenarios that foster preparatory thought:
Requisite emergency skills may vary based on location, weather, activities, and availability of medical care. A physician may need knowledge of unusual diseases and injuries specific to certain activities or locations. These could include extrication and rescue skills in various environmental situations and improvisational skills and treatment of many medical emergencies. Many of these skills can be easily identified with adequate travel preparation and an understanding of the environment in which one will be traveling. However, regardless of the level of preparation, unplanned emergencies often occur, and one's level of preparation may dictate the success with which care is provided. VACCINATION AND IMMUNIZATIONSection 5 of 11
In anticipation of upcoming travel, it is essential that one is well educated regarding the regions that will be visited and how one's current level of health may be impacted. Vaccinations are a vital part of any preparatory process. Once the regions of anticipated travel are identified, scheduling a visit to one's doctor or a travel medicine provider is essential—ideally 4-6 weeks before the trip because most vaccinations require a period of days or weeks to become effective. Reviewing current recommendations for the region of travel is recommended prior to the scheduled medical appointment. Special considerations for aging, immune compromised, pregnant, immigrant, chronically ill, students, and disabled travelers are essential. Required vaccinations COMMON MEDICAL CONSIDERATIONSSection 6 of 11
Whether dealing with altitude sickness, malaria, cholera, or dengue fever, having a basic understanding of the common illnesses specific to the region of travel is essential. However, the list of potential considerations globally is enormous and far beyond the scope of this section. A great resource to identify more specific information can be found online through the Diseases Related to Travel section of the CDC. However, one of the most commonly experienced illnesses related to travel is diarrhea. By far, the most common health risk for travelers, especially those visiting developing countries, is traveler's diarrhea (TD), which can range from mildly annoying to prolonged, painful, and debilitating. According to the US CDC, high-risk destinations include the developing countries of Latin America, Africa, the Middle East, and Common symptoms of TD include the following:
Treatment of TD Most cases are benign and resolve in 1-2 days without treatment. TD is rarely life threatening. Infectious agents are the primary cause of TD. Bacterial enteropathogens cause approximately 80% of TD cases. The most common causative agent isolated in countries surveyed has been enterotoxigenic Escherichia coli (ETEC). The natural history of TD is that 90% of cases resolve within 1 week, and 98% resolve within 1 month. Although nearly 90% effective, antibiotics are not recommended as prophylaxis. Routine antimicrobial prophylaxis increases the traveler's risk for adverse reactions and for infections with resistant organisms. Antibiotics provide no protection against either viral pathogens or parasitic pathogens; therefore, they can give travelers a false sense of security. As a result, strict adherence to preventive measures is encouraged, and bismuth subsalicylate should be used as an adjunct if prophylaxis is needed. Because TD is usually self-limiting, oral rehydration is often the only treatment recommended. Clear liquids are routinely recommended for adults. If a traveler develops 3 or more loose stools in an 8-hour period and has associated nausea, vomiting, abdominal cramps, fever, or blood in stools, they may benefit from antimicrobial therapy. Antibiotics are usually given for 3-5 days. Currently, fluoroquinolones remain the drugs of choice. LEGAL ISSUESSection 7 of 11
Malpractice and Good Samaritan laws differ from state to state and in foreign countries. Whether contracted to provide care for an expedition or volunteering at a medical clinic in a developing country, legal protection can vary as much as one's moral obligation to treat. Before understanding the specific nuances and details of medical liability with regard to wilderness and travel medicine, an understanding of the general framework is essential. However, this is a complex topic beyond the scope of this article. It is highly recommended to review the malpractice environment where care will be delivered, confirm the medical coverage, and assess the medical liability associated with the planned undertaking. In general, physicians are required by law to keep a medical record of any prescription or treatment rendered anywhere. This includes prescriptions for a family member or giving an adhesive bandage for a blister to a stranger. In the unfortunate circumstance of a poor treatment outcome, a patient's signed release often will not protect a physician from a good lawyer or from a poorly informed jury. In the situation of unplanned medical care, one legal argument used against the Good Samaritan defense has been that possession of any medical equipment showed that the physician had planned to practice medicine and therefore was not protected by the Good Samaritan law. Situations may arise in which physicians feel a moral obligation to help but have no legal protection. Decide ahead of time where to draw the line. Physicians who are paid to provide care to a group have increased liability and must ascertain the level of malpractice coverage. Even then, the insurer may limit coverage to a specified group, leaving the physician unprotected if he or she should treat an outsider dragged to the tent because someone heard that the group had a doctor. CRUISE SHIP MEDICINESection 8 of 11
Travel by cruise ship often congregates large groups of people from different parts of the Historically, cruise ships were poorly staffed and equipped. Today, most cruise ships require a ship physician to have some emergency medicine experience. Many ships have minimal medications and few, if any, have laboratory or radiographic capabilities. However, some have mini–critical care units complete with monitors, ventilators, defibrillators/pacers, and appropriate medications. In general, the lack of resources can exhaust a physician's diagnostic and medical skills on a regular basis. Common medical conditions include the following:
Anyone who becomes ill while on a cruise ship should seek medical attention on board and see a health care provider upon returning home. Persons who are ill should limit contact with the general population on board as much as possible to reduce further spread of disease. Ship authorities should report infectious diseases of public health significance to state or federal health officials. People planning cruise ship travel, especially those older than 65 years, those with acute or chronic illnesses, or those who are pregnant or breastfeeding should consult with a health care provider prior to travel for advice and possible preventive medication. Other measures to prevent the spread of infectious diseases on cruise ships include obtaining appropriate immunizations prior to leaving and frequent handwashing throughout the trip. On the up side, cruise ship medicine is not all work and no play. Travel and entertainment opportunities are endless. The volume of patients seen and the level of illness may vary. Conversely, cruise ship epidemics may require the physician and staff to remain quarantined at sea for weeks. For more information on serving as a cruise ship physician, contact the ACEP Cruise Ship and Maritime Medicine Section. SUMMARYSection 9 of 11
Travel medicine is a dynamic field because conditions worldwide are subject to rapid change. Clinicians must maintain a current base of knowledge encompassing a wide variety of disciplines including epidemiology, infectious disease, public health, tropical medicine, immigrant and refugee health, and occupational medicine. As a unique and growing specialty, it has become necessary to establish standards of practice in the field. These standards have been established to identify the scope of competencies expected of travel medicine practitioners, guide their professional training and development, and ensure a uniform level of patient care.
USEFUL RESOURCESSection 10 of 11
Available resources
Preparation for nonmedical emergencies Recommended texts
REFERENCESSection 11 of 11
Travel Medicine and Vaccination excerpt Article Last Updated: Jan 9, 2008 |
