Millions of children travel overseas from the US every year. More than half of these children are affected by travel-related illness, and some require medical attention. In countries with poor hygiene, 25% to 90% of visitors develop travelers’ diarrhea, the most frequently encountered ailment of travelers abroad. Malaria risk is significant for travelers to endemic areas and, without chemoprophylaxis and subsequent rapid diagnosis and treatment, may be fatal. Up to 30,000 European and North American travelers import malaria infections annually.1,2,3 In the US, 1,200 cases of malaria and up to 13 deaths from the disease are reported yearly.4
Besides infectious diseases, other travel-related health risks leading to morbidity and mortality in international travelers include motion sickness, high-altitude sickness, injuries, exacerbation of underlying disease, and motor vehicle accidents.1 Primary care providers are generally the first stop for questions regarding all aspects of personal health, including travel-related health issues. Studies indicate that general practitioners may not have adequate clinic time, up-to-date knowledge, and appropriate vaccines that international travelers may need.5–7
Travel medicine clinics are able to provide these services while working together with the primary care provider to optimize compliance with recommendations and ultimately encourage safe, healthy practices during international travel. This review provides a summary of the literature’s most relevant data regarding travel-related epidemiology, services offered by travel clinics, specific populations for whom referral to travel clinics may be most appropriate, models of care, and the benefits of specialized expertise.
Worldwide international tourist arrivals in 2009 reached 935 million, a nearly 7% increase from 2008, and close to 100 million more tourist arrivals than in 2006.8 Half of the 61 million outbound travelers from the US in 2009 went to Mexico and Canada; the other half traveled overseas. The 2.4 million children who traveled overseas in 2009 comprised approximately 8% of the 30 million overseas travelers from the US.9
Travel-related illness may arise either during or after travel. In one survey, 75% of travelers to developing countries reported some degree of travel-related health impairment.1 In another survey, 22% to 64% reported a health complaint, where destination and season of travel may have played a role.10 A third study prospectively evaluated children and their parents traveling to the tropics from 2000 to 2004. About 60% of both children and their parents reported at least one episode of illness during travel; 50% of these episodes occurred during the first 8 days of travel.11 Although many of these impairments may have been mild, 8% of travelers to these regions were ill enough to seek medical attention either during their stay abroad or on returning home.1,10
What Travel Clinics Offer
Since the 1990s, travel medicine has evolved into a well-defined field in which travel clinics are the point of contact for many international travelers. The Infectious Diseases Society of America (IDSA), in its 2006 practice of travel medicine guidelines, describes travel medicine as a discipline “devoted to the health of travelers who visit foreign countries.”12 Besides prevention of infectious diseases during travel, personal safety and environmental health help form the foundation for travel medicine advice.12,13 A combination of education, expertise, and therapeutics in a variety of clinical settings comprise the foundation of a travel clinic.
Education in travel clinics is typically focused on four main areas: 1) immunization recommendations; 2) malaria prevention; 3) prevention and self-treatment of travelers’ diarrhea; and 4) safety advice. The pretravel visit generally begins with an individual health-risk assessment. The travelers’ medical history and immunization status along with the details of the planned trip, including destination, length of stay, means of travel, and planned activities, are assessed to define potential travel health risks.2,12–14 Travel clinics also offer readily available written material about destination-specific and disease-specific topics of interest to the traveler.
During this assessment, an immunization schedule is outlined and, in most cases, is initiated during the visit. Many vaccine-preventable diseases (VPDs) are more prevalent in developing countries. Infections with hepatitis A and B, Haemophilus influenzae type b (Hib), measles, Streptococcus pneumoniae, Neisseria meningitidis, and varicella may be endemic in some parts of the world; accordingly, routine childhood immunizations should be brought up-to-date during this visit.2 The initial travel-clinic visit may also be an opportunity to determine whether accelerating the routine childhood immunization schedule would be worthwhile based on the specific itinerary, planned dates of travel, and duration of stay. Although hepatitis A rarely is fatal in otherwise healthy individuals, the associated morbidity may be significant. The virus is shed in the stool for weeks and can be very contagious.
True Dangers Defined
A considerable proportion of travel-medicine literature focuses on the prevention and treatment of infectious diseases encountered abroad. In international travelers, however, 20% to 25% of deaths overseas are caused by accidents, whereas only 2% are due to infection.15 Motor vehicle accidents are the most commonly reported fatal injury in overseas travelers, followed by drowning deaths. Non-fatal motor vehicle accidents also are a common cause of injury abroad. Worldwide, an estimated 1.2 million deaths occur yearly due to road accidents; of those, 70% take place in developing countries. An astounding 65% of traffic-related deaths involve pedestrians and 35% of pedestrian deaths are in children. The pre-travel visit is an opportune time to discuss personal safety issues in travelers.16–19
Aside from road and pedestrian safety, other important issues include injury prevention; animal-bite avoidance; climate effects (including sun, cold, and altitude); first-aid; emergency services; and evacuation procedures. While touring a foreign environment or one that may no longer be their primary country of residence, a parent may already be feeling a sense of vulnerability. Traveling with children in this setting increases the parents’ need for vigilance for the whole family. The decision of whether to take children along on an international trip is a personal one, but a pre-travel discussion about safety measures and preventive practices can help arm parents for safer travel planning. Specific topics may include bringing car seats for young children, close monitoring of children in non-childproofed homes, and rigorous hand-hygiene emphasis during travel.
Assessment of Referrals
Although any international traveler can benefit from travel clinic advice, pediatric or adolescent travelers with specific risks or complex itineraries undoubtedly warrant a referral. Rural and adventure travelers, those visiting friends and relatives (VFRs), travelers to malaria risk zones, those requiring specific vaccines only available in a travel clinic (eg, yellow fever), and long-term travelers should be considered for travel clinic referrals. Ideally, travelers should be seen at least 4 to 6 weeks before travel to ensure that recommended and required vaccinations are completed. An international traveler still should be encouraged, however, to visit a travel clinic, even at the last minute, for specific travel advice and to ensure appropriate immunization status.
One group of patients of which clinicians should be aware is VFRs, a population of individuals who may be at higher risk for travel-related illness. VFRs are travelers who were born in developing countries and now live in industrialized nations who return to their home countries, often with their children, to visit friends and relatives. VFRs are at higher risk than standard travelers of acquiring VPDs abroad because generally they are in close contact with the local population and have prolonged stays, sometimes in settings of poor sanitation.20 In addition, VFRs often perceive a lower personal risk for these travel-related diseases, presumably due to cultural and geographic familiarity with the destination country and its endemic diseases.21
The issue of compliance is particularly significant in the VFR population of travelers. In an observational prospective study of African immigrants living in France and traveling back to Africa to visit friends and relatives, 94% of the pre-travel cohort planned to use malaria chemoprophylaxis. This group was seen pre-travel in either a travel clinic or travel agency. Post-travel follow-up revealed that only 57% actually used an appropriate antimalarial prophylactic agent during their travel. Some of the travelers in the pre-travel group were lost to follow-up; thus, the actual percentage who took the chemoprophylaxis may have been even lower. In the post-travel group, adequate use of chemoprophylaxis, including correct drug, dosage, and adherence even after travel, was reported in only 29% of patients.22 However, the VFR population accounts for approximately 40% of reported malaria cases in the United States.23 This highlights the importance of rigorous pre-travel education in this population. The aim should be focused at identifying VFRs and other international travelers before travel and ensuring close follow-up after travel, with emphasis on adequate chemoprophylaxis use and immediate evaluation for post-travel fever.
Benefits of Specialized Expertise
Historically, general practitioners have provided travel medicine advice in primary care clinics. Some studies, however, show discrepancies in the information and advice provided in these settings as compared with specialized travel medicine clinics.5,6 In a survey of Canadians traveling internationally, 70% sought pre-travel advice from family physicians; an inappropriate drug regimen was more likely to be prescribed by these primary care practitioners than by travel clinics or public health centers.7
As the practice of travel medicine grows, there has been an increased effort to define a body of knowledge and standards for its practice. The International Society of Travel Medicine (ISTM) has developed a body of knowledge in travel medicine that helps define the elements of a travel medicine practice and the services provided. Certification exams focusing on travel medicine (ISTM) and travel and tropical medicine (American Society of Tropical Medicine and Hygiene) help demonstrate a competency in these areas and are encouraged.12,13
One of the areas of expertise in travel medicine includes the knowledge of travel-related vaccinations and appropriate prescribing practices. Proper handling and storage of vaccines is paramount to their efficacy; a travel clinic must have the resources and equipment necessary to store safely and deliver these vaccines. In a primary care practice, the infrequent delivery of certain vaccines, such as yellow fever or rabies, may make it quite costly and often impractical for these vaccines to be stocked. Additionally, the travel medicine practitioner must take into account the indications, contraindications, pharmacology, immunology, drug interactions, and adverse events associated with each vaccination. Availability of travel-related vaccinations is generally more readily found in a travel clinic than in a primary care clinic due to frequency of use and comfort with prescribing. A reliable surveillance system is important to monitor for adverse events.12,20 Vaccinations that are initiated before travel and that require subsequent doses after travel can generally be administered at the same locale after return.
Models of Care
Various models of care are seen in travel clinics worldwide. Travel medicine generally is provided by physicians, nurses, nurse practitioners (NPs), physicians’ assistants (PAs), pharmacists, or any combination of these. Multiple surveys of travel clinics assessing the practice have been conducted over the years. One survey, in which 57% of the participating clinics were located in North America and 41% of all travel clinics were private, provision of vaccinations and information regarding malaria and travelers’ diarrhea prevention was almost universal.24 Travel clinics were directed by physicians 94% of the time and the rest were directed by nurses, NPs, PAs, or other personnel.
In the US, nurses or NPs were the sole providers of travel advice in 22% of the clinics and collaborated with physicians in another 36%. Physicians were the sole practitioners in 41% and other health professionals provided advice in about 3% of travel clinics. Worldwide, more than 60% of the travel clinic physicians were trained in infectious diseases and/or tropical medicine. In the US, most were trained in internal medicine (25%) or infectious diseases (52%); in Canada, 54% of physicians trained in general medicine or family practice.24
In most US cases, therefore, infants and children are being seen by internists, family physicians, or nurses. Pediatric expertise is not always available onsite. In an international travel clinic in Utah, about 9% of the visits during a 2.5-year period involved individuals 18 years or younger. Pediatric travel medicine specialists evaluated 29% of these travelers and the rest were seen by non-pediatric-trained travel medicine specialists. Although the study concluded that a coordinated team with good communication can provide similar care to all ages, there are clear advantages to an integrated travel clinic that includes pediatric expertise. Specialized recommendations for young travelers with specific pediatric issues and the experience with and knowledge of medications and immunizations used in a pediatric practice are some of these important benefits.25
Uitlity of Travel Clinics
For travelers visiting low-risk destinations with standard planned activities, the primary care provider may be well-equipped to offer travel advice. However, travelers with complex itineraries or special health care needs may be better served in a designated travel medicine clinic (see Sidebar). A survey in Australia of travel health advice provided by general practitioners found that there was a paucity of information conveyed regarding safety issues and travel insurance; rarely was routine written information given to travelers.5
- Adequate time for practitioners to address specific itineraries, individual health-related issues, and standard travel-related information.
- Availability of travel-specific vaccines (eg, yellow fever, typhoid, rabies).
- Up-to-date information on the changing documentation and vaccination requirements and recommendations.
- Knowledge of emerging local-resistant malaria, travelers’ diarrhea, and other infectious diseases.
- Awareness of recent outbreaks, epidemics, and local strife at travel locales.
- After return, familiarity with key syndromes in returned travelers based on their constellation of symptoms and the locations visited.
Another study compared travelers who sought international travel advice from a general practitioner and those who attended a travel clinic. The travelers seen in specialized clinics were more often traveling to high-risk destinations, but were less likely to develop travel-related illness than travelers consulting a general practitioner (22% and 48%, respectively). Twenty percent of returning travelers in the non-travel clinic group sought post-travel illness care from a general practitioner, whereas 4% of the travel clinic attendees did so; this suggests an increased workload on general practitioners from ill-returned travelers by those not visiting a travel clinic before travel.26
Adequate time to address specific itineraries, individual health-related issues, and standard travel-related information generally is available in specialized travel clinics. Staying up-to-date on the changing documentation and vaccination requirements and recommendations is essential. Knowledge of emerging local-resistant malaria, travelers’ diarrhea, and other infectious diseases is necessary to guide travel chemoprophylaxis and treatment of illness in returned travelers. An awareness of recent outbreaks, epidemics, and local strife helps to direct travel education and safety discussions during the travel clinic visit. After return, providers must recognize key syndromes in returned travelers based on their constellation of symptoms and the locations visited. These issues are fundamental to the travel clinic visit.
Travel-related illness among children is common. Travel clinics can help to reduce the risk for infectious disease and other causes of morbidity and mortality among adult and pediatric travelers. Practitioners in these clinics provide a variety of services, from education to prophylaxis to treatment. Travel clinics may be especially helpful for people traveling to endemic areas, those with complex itineraries, individuals with special health care needs, rural and adventure travelers, VFRs, travelers to areas where malaria is endemic, and those requiring special vaccines. Travel medicine clinic locations can be found at: wwwn.cdc.gov/travel/contentTravelClinics.aspx.
- Steffen R, deBernardis C, Baños A. Travel epidemiology - a global perspective. Int J Antimicrob Agents. 2003; 21: 89–95. doi:10.1016/S0924-8579(02)00293-5 [CrossRef]
- Maloney SA, Weinberg M. Prevention of infectious diseases among international pediatric travelers: considerations for clinicians. Semin Pediatr Infect Dis. 2004;15:137–149. doi:10.1053/j.spid.2004.05.002 [CrossRef]
- Lobel HO, Baker MA, Gras FA, et al. Use of malaria prevention measures by North American and European travelers to East Africa. J Travel Med. 2001;8:167–172. doi:10.2310/7060.2001.22206 [CrossRef]
- Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United States. JAMA. 2007;297(20):2264–2268. doi:10.1001/jama.297.20.2264 [CrossRef]
- Seelana ST, Leggat PA. Health advice given by general practitioners for travellers from Australia. Travel Med Infect Dis. 2003;1:47–52. doi:10.1016/S1477-8939(02)00004-2 [CrossRef]
- MacDougall L, Gyorkos T. Promoting travel clinic referrals: exploring partnerships for healthier travel. Soc Sci Med. 2001;53:1461–1468. doi:10.1016/S0277-9536(00)00433-0 [CrossRef]
- dos Santos CC, Anvar A, Keystone JS, Kain KC. Survey of use of malaria prevention measures by Canadians visiting India. CMA.J1999;160:195–200.
- UNWTO World Tourism Barometer. 2008;6(1):1–4. Available at: www.unwto.org/facts/eng/pdf/barometer/UNWTO_Barom11_1_key_trends_web_en.pdf. Accessed April 7, 2011.
- ITA Office of Travel & Tourism Industries. Available at: tinet.ita.doc.gov/outreachpages/download_data_table/2009_US_Travel_Abroad.pdf.
- Freedman DO, Kozarsky PE, Weld LH, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006;354:119–130. doi:10.1056/NEJMoa051331 [CrossRef]
- Newman-Klee C, D’Acrémont V, Newman CJ, et al. Incidence and types of illness when traveling to the Tropics: a prospective controlled study of children and their parents. Am J Trop Med Hyg. 2007;77(4):764–769.
- Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1499–1539. doi:10.1086/508782 [CrossRef]
- Shaw M. Running a travel clinic. Travel Med Infect Dis. 2006;4:109–126. doi:10.1016/j.tmaid.2005.06.006 [CrossRef]
- Angell SY, Behrens RH. Risk assessment and disease prevention in travelers visiting friends and relatives. Infect Dis Clin N Am. 2005;19:49–65. doi:10.1016/j.idc.2004.11.001 [CrossRef]
- Rack J, Wichmann O, Kamara B, et al. Risk and spectrum of diseases in travelers to popular tourist destinations. J Travel Med. 2005;12:248–253. doi:10.2310/7060.2005.12502 [CrossRef]
- Leggat PA, Fischer PR. Accidents and repatriation. Travel Med Infect Dis. 2006;4:135–146. doi:10.1016/j.tmaid.2005.06.008 [CrossRef]
- Grenfell R. Travel-related injury. In: Zuckerman J, ed. Principles and practice of travel medicine. Chichester, England: Wiley;2001:291–296.
- Guse CE, Cortés LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. 2007;14(5):279–287. doi:10.1111/j.1708-8305.2007.00133.x [CrossRef]
- Road Safety Overseas. Available at: travel.state.gov/travel/tips/safety/safety_1179.html. Accessed April 26, 2011.
- Giovanetti F. Immunisation of the travelling child. Travel Med Infect Dis. 2007;5:349–364. doi:10.1016/j.tmaid.2007.09.004 [CrossRef]
- Angell SY, Cetron MS. Health disparities among travelers visiting friends and relatives abroad. Ann Intern Med. 2005;142(1):67–72.
- Pistonea T, Guibertc P, Gayc F, et al. Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2007;101:990–995. doi:10.1016/j.trstmh.2007.05.009 [CrossRef]
- Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med. 2002;347(7):505–516. doi:10.1056/NEJMra020118 [CrossRef]
- Hill DR, Behrens RH. A Survey of Travel Clinics Throughout the World. J Travel Med. 1996:3:46–51. doi:10.1111/j.1708-8305.1996.tb00696.x [CrossRef]
- Christenson JC, Fischer PR, Hale DC, Derrick D. Pediatric travel consultation in an integrated clinic. J Travel Med. 2001;8:1–5. doi:10.2310/7060.2001.5137 [CrossRef]
- Reed JM, Mclntosh IB, Powers K. Travel illness and the family practitioner: a retrospective assessment of travel-induced illness in general practice and the effect of a travel illness clinic. J Travel Med. 1994;1:192–198. doi:10.1111/j.1708-8305.1994.tb00594.x [CrossRef]