now we know who we are and what we do…, where do we go from here?

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EDITORIALS Where DoWe Go From Here? Jay S. Keystone The discipline of Travel Medicine is concerned with the prevention and management of illness in trav- elers. In the past two decades the discipline has devel- oped from a “cottage industry” into a well-recognized specialty in which, increasingly, research provides a sci- entific basis for disease prevention and treatment guide- lines.’ In this issue of the _loumul, the excellent survey by Hill and Behrens of travel clinics throughout the world adds another piece to the puzzle of “who we are and what we do.”The authors define globally the cur- rent practice of travel medicine, and provide a compre- hensive overview of clinic demographics, categories of available advice and immunizations, and the educational background of staff.Although there are few surprises in the review, the wealth of information provided by this study, the first of its kind, will help to provide the basis for the development of guidelines for the practice of travel medicine. Some of the more interesting aspects of the Hill and Behrens study were the problems identified by travel clinic personnel as presented in Table 6. Unfortunately, it was not clear from these data whether these problems were universal or specific to a particular geographic region. In North America, where the high cost of health care is already causing the user to take on a greater share of the financial burden, concern about the cost of services and immunizations and the failure of insurance carriers to cover pretravel advice will almost certainly become a greater problem in the future. More efficient use of clinic time and the development of innovative, alterna- tive sources of information for the traveler,such as audio- visual devices or computer-generated printouts, may be the only way to survive health care budget cuts. J.S. Keystone, MD:Tropical Disease Unit, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada. Reprint requests: J.S. Keystone, MD, Tropical Disease Unit, The Toronto Hospital, 200 Elizabeth St., ENG-212, Toronto, Ontario, Canada M5G 2C4 J Travel M e d 1996; 3:5-6. The issue of assessing patient compliance and com- prehension of given recommendations is an age-old problem, for which there are little good data available. It is here that collaborative research among travel clinic practitioners could be most beneficial in helping us to understand the perceptions and needs of travelers and in demonstrating the efficacy and effectiveness of pro- posed disease prevention measures.2 Since patient com- pliance may be dependent upon important cultural factors (compare the Swiss with the North American responses to mail-in questionnaires!), the results of such research are, for the most part, likely to apply only locally or regionally. A number of clinics indicated their concern with travelers who present with a short time interval before planned departure. Although those who need to travel on short notice will always be an issue, I suspect that the bulk of the problem is with travelers who consider their health needs only as an afterthought,just prior to depar- ture.The travel industry could be very helpful in this regard by indicating to travelers, at the time of ticket pur- chase, that health advice should be sought from a travel clinic or other health care provider. Recently, in Canada, with the help of an educational grant from SmithKline Beecham, travel agents across the country have received, free of charge, small passport sized travel advice book- lets to hand out to travelers. The information booklet answers basic questions and directs the traveler, in a nonthreatening way, to seek more detailed advice from a travel clinic or health care provider. In addition, a short “Travel Healthy” column, written by travel med- icine advisors from across the country, has been devel- oped for publication in a national travel agent newsletter to help those in the travel industry understand the importance of pretravel health counseling. As a result of these efforts, each week thousands of booklets are being requested by travel agents for their clients. It is this type of collaboration between the health care profession and the travel and pharmaceutical industries that is benefi- cial to all concerned. The conflicting and unreliable advice given to trav- elers outside of the travel clinic setting, and the need for 5

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Page 1: Now We Know Who We Are and What We Do…, Where Do We Go From Here?

EDITORIALS

Where DoWe Go From Here? Jay S. Keystone

The discipline of Travel Medicine is concerned with the prevention and management of illness in trav- elers. In the past two decades the discipline has devel- oped from a “cottage industry” into a well-recognized specialty in which, increasingly, research provides a sci- entific basis for disease prevention and treatment guide- lines.’ In this issue of the _loumul, the excellent survey by Hill and Behrens of travel clinics throughout the world adds another piece to the puzzle of “who we are and what we do.”The authors define globally the cur- rent practice of travel medicine, and provide a compre- hensive overview of clinic demographics, categories of available advice and immunizations, and the educational background of staff. Although there are few surprises in the review, the wealth of information provided by this study, the first of its kind, will help to provide the basis for the development of guidelines for the practice of travel medicine.

Some of the more interesting aspects of the Hill and Behrens study were the problems identified by travel clinic personnel as presented in Table 6. Unfortunately, it was not clear from these data whether these problems were universal or specific to a particular geographic region. In North America, where the high cost of health care is already causing the user to take on a greater share of the financial burden, concern about the cost of services and immunizations and the failure of insurance carriers to cover pretravel advice will almost certainly become a greater problem in the future. More efficient use of clinic time and the development of innovative, alterna- tive sources of information for the traveler, such as audio- visual devices or computer-generated printouts, may be the only way to survive health care budget cuts.

J.S. Keystone, MD:Tropical Disease Unit, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada.

Reprint requests: J.S. Keystone, MD, Tropical Disease Unit, The Toronto Hospital, 200 Elizabeth St., ENG-212, Toronto, Ontario, Canada M5G 2C4

J Travel Med 1996; 3:5-6.

The issue of assessing patient compliance and com- prehension of given recommendations is an age-old problem, for which there are little good data available. I t is here that collaborative research among travel clinic practitioners could be most beneficial in helping us to understand the perceptions and needs of travelers and in demonstrating the efficacy and effectiveness of pro- posed disease prevention measures.2 Since patient com- pliance may be dependent upon important cultural factors (compare the Swiss with the North American responses to mail-in questionnaires!), the results of such research are, for the most part, likely to apply only locally or regionally.

A number of clinics indicated their concern with travelers who present with a short time interval before planned departure. Although those who need to travel on short notice will always be an issue, I suspect that the bulk of the problem is with travelers who consider their health needs only as an afterthought,just prior to depar- ture.The travel industry could be very helpful in this regard by indicating to travelers, at the time of ticket pur- chase, that health advice should be sought from a travel clinic or other health care provider. Recently, in Canada, with the help of an educational grant from SmithKline Beecham, travel agents across the country have received, free of charge, small passport sized travel advice book- lets to hand out to travelers. The information booklet answers basic questions and directs the traveler, in a nonthreatening way, to seek more detailed advice from a travel clinic or health care provider. In addition, a short “Travel Healthy” column, written by travel med- icine advisors from across the country, has been devel- oped for publication in a national travel agent newsletter to help those in the travel industry understand the importance of pretravel health counseling. As a result of these efforts, each week thousands of booklets are being requested by travel agents for their clients. I t is this type of collaboration between the health care profession and the travel and pharmaceutical industries that is benefi- cial to all concerned.

The conflicting and unreliable advice given to trav- elers outside of the travel clinic setting, and the need for

5

Page 2: Now We Know Who We Are and What We Do…, Where Do We Go From Here?

6 Journa l o f Trave l Med ic ine , Volume 3, Number 1

standardized, up-to-date advice for clinic personnel, were two problems identified by respondents to the Hill and Behrens questi0nnaire.Thes.e problems raised the cru- cial issue of “quality of travel advice” that was partially and indirectly addressed in this paper f h m the assessment of time spent with clients, information resources used, and educational qualifications of staff. Although the respondents indicated concern about conflicting advice @ven outside of travel clinics, recent studies suggest that we &odd clean our own house first, since si@cant vari- ation in the reliability of advice offered to travelers was found to exist among public health departments and clin- ics that specialize in the dissemination of travel a d ~ i c e . ~ . ~

How can we assure travelers that they are receiving accurate, up-to-date, appropriate, and comprehensive advice in a manner in w h c h they WLU understand and, hopefllly, with which they can comply? Should we be developing international standards for travel clinics so that more uniform and rational advice will be given? Should we develop a method to certify the expertise of travel clinics, as the American Society for Tropical Med- icine has done for practitioners of tropical medicine? How do we provide a certificate of knowledge when formal training programs in travel medicine do not exist (U.K. excepted)? Since, according to the Hill and Behrens paper, almost half of those running travel clinics have no train- ing in infectious diseases or tropical medicine, should we expect expertise in travel medicine to include posttravel evaluation of ill persons? How do we develop interna- tional standards of practice among nations which do not agree on what type of antimalarial advice is appropriate and the need for certain types of immunizations?”’

No, I do not believe that uniform, international recommendations for travel advice will be seen in my life- time.What I do see is the development ofpractice guide- lines, such as those recently published by the Wilderness Medicine Society. Travel clinics might use these guide- hnes as a basis for their standard ofpractice.8Also, we need to develop a syllabus, or less ambitiously, an information resource for travel clinics, with the full understanding that national public health bodies will be advising health care providers from a local perspective. The uniformity of travel advice comes not with rules handed down from

above, but rather from the kind of dialogue and educa- tional process which our society has endeavored to pro- vide through our journal, newsletter, and biannual conferences. Consider for example, how recommenda- tions for mefloquine use have, over the past 2 years, become more uniform around the world.

The description of travel clinic practices by Hill and Behrens provides us with an important understanding of the global practice of travel medicine and the prob- lems encountered by its practiti0ners.h the authors point out, the next step is to debate the answers to the issues raised by their paper among ourselves and other inter- ested groups. In the meantime, the International Soci- ety ofTravel Medicine will move forward to develop collaborative public education programs with the travel and pharmaceutical industries, to stimulate and fund importantly needed research in our discipline, to pro- duce a comprehensive information resource for our practitioners, and, finally, to establish guidelines for the practice of travel medicine.

References

1. Kozarsky PE, Lobel HO, Steffen R.Trave1 medicine 1991: new hntiers [editorial].Ann Intern Med 1991; 115:574-575. Mann J. Emporiatric policy and practice. JAMA 1983;

Keystone JS, Dismukes R, Sawyer L, Kozarsky PE. Inade- quacies in health recommendations provided for international travelers by North American travel health advisors. J Travel Med 1994; 1:72-78. Pesch M, Haitaian KP, Lernan J. Band JD. Health advice pro- vided to international travelers; a statewide survey. In: Lobel HO, Steffen R, Kozarsky PE, eds.Trave1 Medicine 2.Atlanta, G A International Society of Travel Medicine, 1991 :284-285.

5. Lobel HO, Keystone JS. Confusion on malaria chemopro- phylaxis petter]. Lancet 1994; 343:183.

6. Behrens R H , Roberts JA. Is travel prophylaxis worthwhile? Economic appraisal ofprophylactic measures against malaria, hepatitis A and typhoid in travellers. BMJ 1994; 309.

7. Hill DR. Immunizations. In: Gardner P, ed. Health issues of international travelers. Infect Clin North Am 1992; 6:291-312.

8. Gorgey WW, ed.Wilderness Medical Society practice guide- lines for wilderness emergency care. Merrillville, IN: ICS Books, 1994.

2. 249:3323-3325.

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