ARCHIVED - Canada Communicable Disease Report

Volume 35 • ACS-8
December 2009

An Advisory Committee Statement (ACS)
Committee to Advise on Tropical Medicine and Travel (CATMAT)^{Footnote *Footnote †}

Guidelines for the Practice of Travel Medicine

Preamble

The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides the Public Health Agency of Canada (PHAC) with ongoing and timely medical, scientific, and public health advice relating to tropical infectious disease and health risks associated with international travel. PHAC 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

Guidelines for the Practice of Travel Medicine have been developed to provide some broad guidance to healthcare providers and the general public with the goal of improving the quality of travel medicine services to Canadians who seek these services. These guidelines serve to delineate the scope of travel medicine and provide a practice framework. They provide a definition of travel medicine and describe the complexities of this field of medicine. The guidelines contain recommendations for the standards and quality of travel medicine advice in Canada and discuss the attributes of the health care practitioner practicing this type of medicine. They also include a summary of the knowledge base needed and outline procedures for the management of travel clinics. In addition, the guidelines offer advice on the management of travel clinics and the maintenance of competence and certification.

CATMAT has updated its 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. The guidelines are designed to assist the health care practitioner deliver travel medical care of high quality 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 respect 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 as well as any impact on the health of the local population. The practice of travel medicine is distinct from the practice of tropical medicine as it focuses on health promotion as a means to maintain the health and well-being of travellers, as well as the health of the indigenous populace being visited; 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. Within the context of pre-travel care and in addition to the prevention of illness, both travellers and health care providers should, as stated above, discuss the environmental, cultural, health and sociopolitical impacts that travel has on the local population at the travel destination^{Footnote 1}.

Complexities of travel medicine

The field of travel medicine has grown dramatically as more people travel to exotic and remote destinations. Over 700 million travellers cross international borders annually^{Footnote 2}. Travel medicine as a discipline and practice has been described as an exciting and interdisciplinary specialty that has developed rapidly in response to the dynamic needs of travellers around the world^{Footnote 3}. It is concerned not only with prevention of infectious diseases during travel but also with personal safety and the prevention of environmental risks, it focuses primarily on pre-travel preventive care^{Footnote 1}.

Travel medicine has become increasingly complex as a result of ongoing changes in global infectious disease epidemiology, changing patterns of drug resistance and a rise in the number of travellers with chronic health conditions^{Footnote 3}. Other factors, such as the dynamic nature of disease, available prophylactic and treatment agents, the nature of travellers, the variety of geographic destinations and the increase in the number of vaccines recommended for international travel add to the complexity of this field of medicine.

Specific issues include:

1. emerging and re-emerging diseases such as tuberculosis and the worrying increase in the global distribution and incidence of drug-resistant malaria;
2. the increase in the number of travellers who have chronic diseases, are pregnant, or very young or very old; and
3. the shifting nature of the demographics of Canada's population, with a marked increase among those who are travelling abroad to visit family and relatives (VFRs).

A topic that is also of particular concern is the risk of malaria to Canadian travellers. The number of reported cases of malaria in Canada peaked in 1997 at more than 1,000 cases; this resulted in targeted education to practitioners concerning the need to be aware of current guidelines regarding the geographic risk of malaria to travellers and the need to recommend appropriate malaria chemoprophylaxis. The number of reported cases has since decreased to between 350 and 500 cases per year. It is anticipated that the cyclical increase in malaria cases will recur. However, it is estimated that only 30% to 50% of cases are reported to public health agencies, and therefore the true number of imported cases into Canada is likely to be substantially higher^{Footnote 14}. However, a recent study has shown that even in controlled situations only 32.1% of travellers take all recommended prophylactic doses as prescribed despite appropriate pre-travel preparation, including awareness of risk, filling of the prescription and willingness to take the prophylaxis^{Footnote 15}.

Who is accessing pre-travel heath services?

Canadians travel for business, pleasure, adventure and to visit family and relatives in countries of origin. They travel to urban and rural locations in exotic, tropical and remote destinations. However, studies suggest that only a very small percentage seek pre-travel health advice and typically from practitioners who are ill equipped to provide current and accurate information^{Footnote 2Footnote 4-Footnote 7}. In the past, it has been estimated that only about 10% of travellers seek travel advice from available practitioners in Canada^{Footnote 8}. More recent North American and European studies indicate that travellers seek pre-travel advice 35%-50% of the time, while a more encouraging Canadian survey indicates that 68% of travellers identified as travelling to higher risk destinations sought pre-travel consultation at a travel clinic^{Footnote 9}. A recent Canadian study presents evidence that the number of travellers accessing pre-travel consultation has increased in the last decade^{Footnote 10}; however, so has the number of international travellers. As pre-travel health services in most regions are considered to be an uninsured health service, cost has been cited as a deterrent to accessing these services. This said, there is an indication that more travellers (in Quebec) are now seeking pre-travel advice^{Footnote 10}. This may be indicative of travellers becoming aware of the perceived threat of risk from travel and valuing the importance of pretravel health interventions^{Footnote 8}.

Lack of access to pre-travel health services by Canadians who are VFRs is of particular concern, as the travel patterns of these travellers increase their risk of acquiring illness while travelling^{Footnote 11}. Barriers affecting VFR access to pre-travel services occur at:

• the systems level (pre-travel health services are uninsured, and the cost may be a barrier for some travellers),
• the client level (travellers may not have an accurate perception of the personal risk they face, and may not have sufficient knowledge to make informed decisions), and
• the provider level (practitioners may not have sufficient knowledge of travel health issues, and service delivery model)^{Footnote 12Footnote 13}.

Quality of pre-travel health services

In the past, concerns about the quality of advice provided to Canadian travellers have been raised^{Footnote 8Footnote 16-Footnote 18}. The practice of travel medicine requires that providers of these health services maintain updated and ongoing knowledge of disease patterns; required and recommended immunizations; and familiarity or knowledge of how to access information about the shifting nature of health regulations^{Footnote 19}. A Canadian survey demonstrated the need for travel medicine guidelines that support practitioners in the delivery of travel health services. This could be achieved through a standardized travel medicine curriculum^{Footnote 20}.

Recommendation for the Standards and Quality of Travel Medicine Advice in Canada

CATMAT is an advisory committee to the Public Health Agency of 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^{Footnote 21}. As this is a fairly new practice with limited research compared to other health care science, some recommendations are currently based on expert opinions. The initial Canadian Guidelines for the Practice of Travel Medicine were developed and published by CATMAT in December 1999^{Footnote 22}. Since that time there has been much progress in the field. It was identified that there was a need to establish a scope or body of knowledge in the field of travel medicine that would set a standard of practice, support professional development and could also be used to shape curricula. In 2002 The Body of Knowledge for the Practice of Travel Medicine^{Footnote 23} was published. In 2006, the Infectious Diseases Society of America published evidence based guidelines for the practice of travel medicine^{Footnote 1}.

Preparing the traveller

The "essence" of preparing the traveller has been described as including the following^{Footnote 1Footnote 23}:

1. Risk Assessment
   1. Assessment of the health of the traveller
   2. Assessment of the health risk of travel (analysis of itinerary)
2. Education about disease prevention and health maintenance
3. Vaccines identified for administration
   1. Informed consent
   2. Assessment after travel (illness management or identification and referral)

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 use 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.

The knowledge base required to practice travel medicine is complex. The International Society of Travel Medicine has defined the scope of knowledge for travel medicine. The Body of Knowledge was first published in 2002 in the Journal of Travel Medicine^{Footnote 23} with some additions being made in 2006^{Footnote 2}. Its creation can act as a guide for the development of curricula and educational programs for health professionals in travel medicine. It also has the potential to serve as a method to establish content for the purposes of credentials. It serves to support the knowledge and delivery of travel health services by physicians, nurses and other health professionals. The basic components of knowledge required by the providers of travel health include the following^{Footnote 1}:

• Provider knowledge, training and experience in the field
• Risk assessment of the traveller
• Provision of advice about prevention and management of travel-related diseases (both infectious and noninfectious)
• Ability to advise travellers of all ages and diverse conditions
• Administration of vaccines
• Recognition of key syndromes in returned travellers

Practitioners are directed to the Body of Knowledge^{Footnote 2Footnote 1} for specific content related to epidemiology, immunology/vaccinology, vaccines, recommendations for pre-travel consultation (in general and for special populations), travel-related diseases and conditions, and post-travel management.

Travel clinic management

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 current health characteristics.

Clinic facilities

Equipment, supplies and disposables:

• refrigerator and freezer that comply with national standards for storage of immunization products (e.g. temperature monitor, alarm)^{Footnote 24}
• telecommunications facilities (e.g. telephone, facsimile, and/or Internet access)
• those supplies required to provide vaccination, including appropriate disposal equipment
• resuscitation equipment standard for an office or clinic (e.g. adrenaline, antihistamines)

Travel medicine practice resources

A complete list of current resources can be found in the 2006 CATMAT statement on travel medicine resources^{Footnote 25}. What follows is a condensed list:

• Atlas and/or wall maps
• Canadian Immunization Guide, 2006^{Footnote 26} http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html
• CATMAT's Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers, 2009^{Footnote 14} http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09vol35/ 35s1/index-eng.php
• Other CATMAT statements http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/ index.html
• International Travel and Health, WHO^{Footnote 27} http://www.who.int/ith/en/
• Health Information for International Travel^{Footnote 28} (the "Yellow Book"), http://wwwn.cdc.gov/travel/contentYellowBook.aspx
• Guide d'intervention en santé-voyage, 2004^{Footnote 29} http://www.inspq.qc.ca/aspx/fr/ccqsv.aspx?sortcode= 1.50.51.53
• World Malaria Risk Chart^{Footnote 30}. http://www.iamat.org/pdf/WorldMalariaRisk.pdf
• Control of Communicable Diseases Manual^{Footnote 31}
• Redbook^{Footnote 32}
• International health recommendations/advisories (e.g. WHO and national public health organizations) http://www.phac-aspc.gc.ca/tmp-pmv/pub_e.html
• International Health Regulations^{Footnote 33} http://www.who.int/csr/ihr/en/

Documentation

• maintenance of a patient medical record standard for an office or clinic
• completion of the individual patient's vaccination record or booklet:
  • trade name, disease(s) against which it protects, date given, dose, site and route of administration, manufacturer, lot number, name, title of person administering the vaccine^{Footnote 26}
  • reporting of adverse events following immunization^{Footnote 34Footnote 35}

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 routine practices and the disposal of sharps and other hazardous materials
• proper handling, delivery and storage of vaccines and drugs^{Footnote 26}
• immunizations administered as per the current NACI guidelines
• post-immunization observation period
• client confidentiality
• criteria for telephone travel medicine 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 insecticide-treated 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 to Travellers, travel health insurance)

Maintenance of competence

Competence in the provision of pre-travel consultation is supported through training and experience in travel medicine^{Footnote 1}. Research indicates that previous training in travel medicine is the most important factor relating to the quality of advice given^{Footnote 36}. Those working in travel medicine need to have regular opportunities to advise a variety of travellers with varying health conditions, destinations and planned activities during travel. In the previous statement it has been estimated that it would be optimal to carry out a minimum of five to 10 travel medicine consultations per week^{Footnote 22}. This said there is no evidence to advise on the optimal number of consultations to maintain competence^{Footnote 1} however there is some evidence that higher volumes do improve patient outcomes in other practice settings^{Footnote 37Footnote 38Footnote 39Footnote 40}. 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. What follows is a selection of resources to support up-to-date and competent practice (a more comprehensive listing can be found in the CATMAT Statement on Travel Medicine Resources for Canadian Professionals^{Footnote 25}:

• CATMAT statements
• Comité consultatif québecois sur la santé des voyageurs
• Canada Communicable Disease Report (CCDR)
• Canadian Immunization Guide or Protocole d'immunisation du Québec
• Canadian Malaria Network (see Canadian Recommendations for the Prevention and Treatment of Malaria among International Travellers^{Footnote 14}
• International Society of Travel Medicine
• WHO Weekly Epidemiological Record, outbreak reports
• ProMED

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, Association of Medical Microbiology and Infectious Disease Canada Canada).

Certification

The International Society of Travel Medicine holds a Certificate of Knowledge examination, usually in conjunction with the biannual conference. Successful candidates are awarded a certificate attesting to proficiency in travel medicine. It is important to note that equivalent or greater training in travel medicine can be achieved through other methods, including, but not limited to, a Diploma in Tropical Medicine and Hygiene or postgraduate training in infectious diseases. In addition, the American Society of Tropical Medicine and Hygiene holds an examination for the Certificate of Knowledge in Clinical Tropical Medicine and Traveller's Health. Certification, while not expected of practitioners at this time, provides assurance that beginning practitioners meet baseline competencies as outlined in The Body of Knowledge^{Footnote 23}.

Conclusion

CATMAT presents these guidelines to support the practice of travel medicine and ensure 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 and models of health education for effective health outcomes is essential^{Footnote 41}. Health care practitioners must carry out a detailed individual risk assessment for each international traveller, including the nature of exposure, risk-taking behaviours and personal health characteristics, to be able to advise on the most appropriate intervention(s) to promote health and prevent disease or other adverse health outcomes related to the travel itinerary. These interventions may include a change in planned travel, behaviour modification, immunizations, chemoprophylaxis drugs (e.g. antimalarials) and other recommendations that 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 is a challenging specialty. Those who choose to enter this field are encouraged to be aware of the extent of their responsibility. 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 and communication skills.

References

*Members: Dr. P.J. Plourde (Chair); Dr. S. Houston; Dr. S. Kuhn; Dr. A. McCarthy; Dr. K.L. McClean; Dr. C. Beallor; Ms. A. Henteleff

Ex-Officio Representatives: Dr. M. Tepper; Dr. J. Given; Dr. R. Weinman; Dr. F. Hindieh; Dr. J.P. Legault; Dr. P. McDonald; Dr. N. Marano; Dr. P. Arguin; Dr. P. Charlebois; Dr. A. Duggan

Liaison Representatives: Dr. C. Greenaway; Mrs. A. Hanrahan; Dr. C. Hui; Dr. P. Teitelbaum; Dr. Anita Pozgay

Member Emeritus: Dr. C.W.L. Jeanes

Consultant: Dr. S. Schofield

†This statement was prepared by A. Henteleff and approved by CATMAT.