Appendix A: Promoting Quality in the Practice of Travel Medicine
Travel medicine is a young area of medical practice, but even as the field continues to mature based on a growing body of scientific and medical information, there remains no recognized specialty or subspecialty of travel medicine anywhere in the world, including the United States. Clinicians offering travel medicine services are not “board certified” in travel medicine. Instead, travel medicine physicians generally have credentials in other disciplines, usually infectious diseases, internal medicine, family practice, or general practice. The same applies to nurses, pharmacists, and other allied health professionals. Clinics in the United States that offer travel medicine services are also not specifically credentialed for this purpose.
Given these circumstances, how can travelers maximize the likelihood their provider will deliver quality travel-related medical care and that the advice, preventive measures, and treatment services they are given fall within accepted standards? Similarly, how can providers assure patients they have sufficient knowledge of the subject matter relevant to travel medicine?
Research into the quality of travel health care is limited, but several studies suggest that travelers who visit a clinician with training in travel medicine are more likely to receive appropriate pre- and post-travel advice and care than if they see other clinicians for such services. Similarly, 2006 guidelines on travel medicine published by the Infectious Diseases Society of America (Box A-01) recommend that pre- and post-travel care be obtained from a clinician with expertise in travel medicine. This is especially relevant for travelers going to exotic destinations, engaging in adventure travel, or who have special needs or medical problems.
Below is a partial list of resources for clinicians who wish to enhance their knowledge of travel medicine. People seeking travel-related medical services may want to inquire about whether their provider or clinic participates in these organizations or activities.
Box A-01. Essential elements of a quality pre-travel evaluation
The following elements, adapted from Spira and IDSA guidelines, provide an overview of a quality pre-travel evaluation:
- Evaluation of a traveler’s health, including underlying health conditions and immunization history
- Careful analysis of the itinerary, including duration, season, activities, and style of travel
- Evaluation for vaccinations and other preventive measures
- Education for disease prevention and health maintenance, including access to medical care overseas
INTERNATIONAL SOCIETY OF TRAVEL MEDICINE (ISTM)
Founded in 1991, ISTM (www.istm.org) is the preeminent multinational organization dealing exclusively with travel medicine. ISTM has more than 2,500 members worldwide, slightly fewer than half of whom are located in the United States.
ISTM activities include the following:
- Journal of Travel Medicine
- An active listserv where members share information and can ask questions
- Special-interest groups that include travel medicine nurses and travel medicine pharmacists
- A biennial travel medicine meeting and annual regional submeetings
- A directory of domestic and international travel clinics affiliated with ISTM members
- An annual examination, leading to a Certificate of Knowledge in Travel Medicine, available to physicians, nurses, pharmacists, and other professionals offering travel advice
The Certificate of Knowledge in Travel Medicine has been administered by ISTM since 2003. The Body of Knowledge, which covers the scope of the specialty of travel medicine, forms the basis for examination questions. It was last updated in 2006 and is published on the ISTM website. Content areas in the Body of Knowledge include the following:
- Epidemiology related to travel medicine
- Immunology and vaccinology (including travel-related vaccines)
- Pre-travel consultation and management
- Patient evaluation
- Travelers with special needs
- Special itineraries
- Prevention and self-treatment
- Diseases contracted during travel
- Vectorborne diseases
- Diseases transmitted from person to person
- Foodborne and waterborne diseases
- Diseases related to bites and stings
- Diseases due to environmental hazards
- Other conditions associated with travel
- Conditions occurring during or after travel
- Conditions due to environmental factors
- Threats to personal safety and security
- Psychocultural issues
- Post-travel management
- General travel medicine issues
- Medical care abroad
- Travel clinic management
- Travel medicine information resources
Since it was introduced, the Certificate of Knowledge in Travel Medicine examination has been taken by more than 1,700 practitioners in 55 countries. Those who are successful in the examination are awarded a Certificate in Travel Health. The society hosts periodic examination preparation meetings. Practitioners offering travel medicine services or interested in the subject should strongly consider membership in ISTM. ISTM practitioners are listed on the organization’s website, and those who have the Certificate of Knowledge in Travel Medicine are designated as such.
AMERICAN SOCIETY OF TROPICAL MEDICINE AND HYGIENE (ASTMH)
Formed in 1951 through the merger of predecessor organizations dating back to 1903, ASTMH (www.astmh.org) has a subsection that deals exclusively with tropical and travel medicine, known as the American Committee on Clinical Tropical Medicine and Travelers’ Health.
ASTMH activities include the following:
- The American Journal of Tropical Medicine and Hygiene
- An annual meeting
- An electronic distribution list
- A tropical medicine clinic directory
- A biennial examination leading to a Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health, available to those who have passed an ASTMH-approved tropical medicine course or have sufficient tropical medicine experience
The content areas of the ASTMH Certificate of Knowledge in Clinical Tropic Medicine and Travelers’ Health are as follows:
- Basic science and fundamentals
- Infectious and tropical diseases (including parasites, bacteria, fungi, and viruses)
- Other diseases and conditions
- Diagnostic and therapeutic approach to clinical syndromes
- Travelers’ health
- Public health in the tropics
- Epidemiology and control of disease
- Laboratory diagnosis
More than 600 people who have passed the ASTMH examination are listed on the ASTMH website. The society offers a periodic intensive update course in clinical tropical medicine and travelers’ health, which is in part designed to prepare those planning to take the Certificate of Knowledge examination.
WILDERNESS MEDICAL SOCIETY
Organized in 1983, this society (www.wms.org) focuses on adventure travel, including wilderness travel and diving medicine. Its activities include the following:
- The journal Wilderness and Environmental Medicine
- Practice guidelines for emergency care in wilderness settings
- An annual meeting and subspecialty meetings
- Courses leading to certification in advanced wilderness life support
- A wilderness medical curriculum that, when successfully completed, qualifies members for fellowship in the Academy of Wilderness Medicine
INFECTIOUS DISEASES SOCIETY OF AMERICA (IDSA)
IDSA (www.idsociety.org) is the largest organization representing infectious diseases clinicians in the United States. Although IDSA does not deal exclusively with travel medicine, it maintains a strong interest in this topic. In 2006, IDSA published extensive evidence-based guidelines on the practice of travel medicine in the United States (Box A-01). It also publishes travel-related research in its 2 journals: The Journal of Infectious Diseases and Clinical Infectious Diseases.
INTERNATIONAL SOCIETY FOR INFECTIOUS DISEASES (ISID)
ISID (www.isid.org) was formed in 1986 and has approximately 20,000 members in 155 countries around the world. Like IDSA, ISID does not specifically focus on travel medicine. However, its international reach, particularly in low-resource countries, makes travel medicine an important topic in ISID and a valuable source of information for infectious diseases clinicians in many overseas travel destinations. Activities relevant to travel medicine that are supported by ISID include the following:
- International Journal of Infectious Diseases
- The biennial meeting International Congress on Infectious Diseases
- The Program for Monitoring Emerging Diseases (Pro-MED), an open-source electronic reporting system for reports of emerging infectious diseases and toxins, including outbreaks (www.promedmail.org)
AEROSPACE MEDICAL ASSOCIATION
This organization (www.asma.org) represents professionals in the fields of aviation, space, and environmental medicine who deal with air and space travelers. Its activities include the following:
- The journal Aviation, Space, and Environmental Medicine
- An annual meeting
- Continuing medical education in topics related to aerospace medicine
FINDING CARE WHILE TRAVELING OUTSIDE THE UNITED STATES
Both the ISTM and ASTMH websites contain the names of non-US-based clinics and health care providers affiliated with members of these organizations. Travelers are advised to review these lists before departure to identify health care resources at their travel destination. A number of countries or national travel medicine societies have websites related to travel medicine that also provide access to clinicians, including the following:
- Canada: Health Canada (www.hc-sc.gc.ca/hl-vs/travel-voyage/index_e.html)
- Great Britain: National Travel Health Network and Centre (www.nathnac.org) and British Travel Health Association (www.btha.org)
- South Africa: South African Society of Travel Medicine (www.sastm.org.za)
- Australia: Travel Medicine Alliance (www.travelmedicine.com.au)
- China: International Travel Healthcare Association (http://en.itha.org.cn)
Emergency travel-related medical care and medical evacuation may be accessed through a number of private companies. One example is International SOS, which operates throughout the world. Provider locations and details may be found at www.internationalsos.com.
- Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
- Kozarsky P. The body of knowledge for the practice of travel medicine—2006. J Travel Med. 2006 Sep–Oct;13(5):251–4.
- Spira A. Setting the standard. J Travel Med. 2003 Jan–Feb;10(1):1–3.