Perspectives: Risk Management Issues in Travel Medicine
CDC Yellow Book 2024Preparing International Travelers
Travel medicine providers, just as practitioners in other medical specialties, are at risk for legal action. Claims for medical negligence could involve failure of duty of care; failure to uphold the standard of practice; care resulting in physical, financial, or psychological loss; and loss caused directly by the failure to reach the standard of care.
Although travel medicine practitioners come from many backgrounds, in the travel medicine arena they are preventive medicine specialists. As such, in giving advice, travel medicine practitioners provide education and not generally “hands on” patient care. Although misunderstandings and legal action might occur despite best efforts, certain guidance is helpful.
Communication. The likelihood of a lawsuit is lessened by good communication between the provider and the traveler. Providers should verbally cover all elements of a pretravel consultation during the visit or provide written material for the patient to take home. Because time is a limitation, clinics should provide handouts on how to avoid common health problems not discussed during the consultation. Written information about medications being given or prescribed also is helpful.
Documentation. Clinics should have a method for documenting all aspects of the consultation and include an area within the record for the provider to comment on the patient’s questions or responses to recommendations. Many electronic medical records enable the provider to add items unique to travel health and to add comments regarding the consultation.
Identification of problems. Providers should consult with their risk management personnel or legal advisors in the event of a contentious office visit or exchange after the visit. Nonjudgmental documentation of all communications between traveler and provider is critical.
Examples of Risk Management Issues in Travel Medicine
Fluoroquinolone use can be associated with central nervous system adverse events, peripheral neuropathy, and tendinopathies (e.g., tendinitis, tendon rupture). Lawsuits regarding these problems occur, and whether a single dose of a fluoroquinolone used for the self-treatment of travelers’ diarrhea can lead to such events is unknown. Thus, even though prescriptions come from pharmacies with directions and adverse event information, discuss these potential adverse events with patients.
Mefloquine can cause serious neuropsychiatric adverse events, including visual hallucinations, psychosis, insomnia, seizures, dizziness, nightmares, and motor and sensory neuropathies. These adverse events can persist after the drug is discontinued. Do not prescribe mefloquine to patients with a seizure disorder or a psychiatric disorder (e.g., depression, generalized anxiety disorder, psychosis, schizophrenia). The Centers for Disease Control and Prevention (CDC) also recommends against mefloquine use in patients with cardiac conduction abnormalities. Travelers receiving a prescription for mefloquine should receive a copy of the US Food and Drug Administration (FDA) medication guide [PDF].
Because of its low cost and convenient weekly dosing, however, mefloquine remains an attractive option for some travelers. Therefore, when recommending mefloquine for malaria prophylaxis, document clearly and carefully the reasons for selecting this drug over other antimalarial drugs. Review the medical history for potential contraindications and include a note to that effect in the patient’s record.
Primaquine & Tafenoquine
Primaquine and tafenoquine can cause potentially fatal hemolysis in glucose-6-phosphate dehydrogenase (G6PD)–deficient patients. Screen for G6PD deficiency in anyone receiving a prescription for either of these medications. People who are pregnant or lactating should not receive primaquine or tafenoquine.
Drug–drug interactions can occur among medications prescribed for travelers, and clinicians should include medication reconciliation as an essential part of the traveler’s history. Electronic medical records and other pharmacy aids are useful to alert clinicians of drug interactions when they are making decisions about travel medication prescriptions. Use caution when prescribing fluoroquinolones and macrolides for travelers taking other QT interval–prolonging agents. Concurrent use of antibiotics with cholera or oral typhoid vaccines can diminish the body’s immune response to the vaccine. Antibody-containing products might affect live attenuated vaccines.
Providers sometimes find it useful to recommend medications to travelers that are not approved by the FDA for the specified purpose. Examples include use of primaquine alone for malaria prophylaxis and rifaximin to prevent travelers’ diarrhea. Providers will sometimes recommend medications for uses other than those considered standard of care; document the discussion with the traveler prior to prescribing, along with the traveler’s acceptance.
Vaccine Side Effects & Contraindications
To deliver effective and safe vaccinations, carefully review the patient’s past medical history, allergies, and vaccination history. Failure to administer a vaccine correctly can cause an adverse event or result in a traveler acquiring a preventable disease abroad. If a patient refuses a vaccine, discuss with them the reasons why and then document any relevant conversations regarding the risk of acquiring a disease. Counsel travelers known to be immunocompromised, or whose immune status precludes a protective antibody response to vaccination, about the possibility of decreased vaccine-related immunity.
Serious vaccine-associated adverse events could be due to a variety of causes. Allergic reactions to vaccine components are possible. Immunocompromised travelers might suffer adverse events after receiving live vaccines. Inquire about the traveler’s allergies, history of pregnancy, breastfeeding status, immunosuppressive medications, and immunocompromised status—information that is crucial to minimizing vaccine-associated adverse events. Have vaccine information statements available, and provide these to each vaccinated traveler.
Document each patient’s history and the data used to make decisions, especially when a vaccine is not given or when administering a vaccine despite precautions about its use. Make certain patients understand any risks associated with deviating from Advisory Committee for Immunization Practices–recommended dosing schedules (e.g., those used for the accelerated delivery of some vaccines). Document the discussion in the patient’s record.
Deep Vein Thrombosis
Long-distance air travel increases the risk for deep vein thrombosis (DVT) and pulmonary embolism by approximately 3-fold. The association is stronger with flights of longer duration. Counsel patients about DVT, recommend measures to decrease risk for DVT (e.g., occasional walking, selecting an aisle seat, exercises), and document this discussion in the medical record (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism).
Medical Clearance for International Assignments
Providers should be aware of the potential legal entanglements incurred when a prospective international business traveler who is unfit for international assignment is cleared, and then a negative outcome ensues. See a more complete discussion of this topic in Sec. 9, Ch. 1, The International Business Traveler.
Summary & Recommendations
Maintaining a standard of care in one’s practice is important protection for both patient and health care provider. Clinic providers should have adequate training in travel medicine and engage in continuing education. Travel medicine clinics should have at least 1 provider who has earned the Certificate in Travel Health (CTH) awarded by the International Society of Travel Medicine (ISTM) upon successful completion of the CTH examination. Providers also should remain current in the field of travel medicine by accessing continuing education programs offered by CDC and ISTM (see Sec. 1, Ch. 4, Improving the Quality of Travel Medicine Through Education & Training). Following standards of care and the recommendations in this chapter could help reduce the risk for legal action against the provider and the travel medicine clinic.
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Hinrichs-Krapels S, Bussmann S, Dobyns C, Kácha O, Ratzmann N, Holm Thorvaldsen J, et al. Key considerations for an economic and legal framework facilitating medical travel. Front Public Health. 2016;4:47.
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Lapostolle F, Surget V, Borron SW, Desmaizières M, Sordelet D, Lapandry C, et al. Severe pulmonary embolism associated with air travel. N Engl J Med. 2001;345(11):779–83.
. . . perspectives chapters supplement the clinical guidance in this book with additional content, context, and expert opinion. The views expressed do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).