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May 2018 Issue
Time flies! Although Stephen Hawkings might have disagreed. Apparently, it all depends in which space time continuum you are. In his most recent paper, it is suggested that at the time of the Big Bang several universes were created at the same time; a humbling thought.
Here in Holland it has been remarkably cold. For the first time in twenty years people were ice sailing on the frozen lakes. At the same time, it was 6°C (26°F) instead of - 30°C (-22°F) in Greenland. It seems that larger fluctuations in the jet stream caused by climate change are responsible for this anomaly.
The changing climate will inevitably have its effect on trade, travel and migration. A recent report of the World Bank estimates that 143 million people will have migrated because of this by 2050. There is also the effect on the distribution and transmission of vector-borne diseases, and changing travel patterns due to the changing geopolitical climate. It is therefore that the Scientific Program Committee (SPC) rightly chose this to be the central theme of the 2019 CISTM. Within a few weeks the SPC will start to compose the scientific program. Thanks to your help, the ambition is to make it even better than the Barcelona meeting in 2017.
At the moment, there is an ongoing epizootic outbreak of yellow fever with sylvatic transmission to man in Rio and Sao Paolo, areas of Brazil that have not seen yellow fever for a long time. Since January 2018 Geosentinel sites have reported five cases (2 deaths) of yellow fever in unvaccinated travellers returning from Brazil. In neighboring countries, Argentina and Chile, an additional five cases have been reported. In the meanwhile, travel clinics in the United States of America are confronted with a limited availability of yellow fever vaccine. Sanofi Pasteur, the company that provides the vaccine, is building a new manufacturing plant that won’t be ready until late 2018. With permission and guidance from the FDA and CDC, Sanofi Pasteur established an Expanded Access Program under an Investigational New Drug Protocol using a French-made vaccine, Stamaril. Such a program is legally required to administer the vaccine that is not FDA-licensed in the US. Because of the limited availability and cumbersome administrative procedure, only 250 instead of over 4000 designated clinics in the US can currently provide Stamaril vaccine to travellers. Many travel clinics are very unhappy with this situation, as travellers often leave unprotected. Unfortunately, ISTM has no influence on the legal requirements. ISTM has been advocating to open more sites. But because of limited resources this is unlikely to happen. Finally, ISTM is increasing its efforts to inform members and the public on the limited geographical distribution of Stamaril yellow fever vaccination centers.
In the beginning of March, we had a well-visited ISTM symposium at the International Conference of Infectious Diseases in Buenos Aires. We are very much looking forward in strengthening our ties with South American societies of Travel Medicine. We are exploring the possibility to share electronic learning modules with Spanish/English subtitles. We will continue to close the gap and to promote travel health where we can.
Finally, I want to congratulate Mike Jones and Annelies Willder-Smith with their appointments as incoming ISTM Secretary-Treasurer and Editor-in-Chief of the Journal of Travel Medicine. They will shadow Peter Leggat and Eric Caumes in the coming period, and take over in 2019.
New ISTM Secretary-Treasurer
The ISTM Executive Board has appointed Michael Jones of Scotland to serve as the next Secretary-Treasurer of the society. We were fortunate to have had a number of excellent candidates come forward, and the selection committee had the challenging task to guide the process.
Mike currently resides in Scotland. He has been an ISTM member since 1991, having served as a past Chair for the Pscyhological Health of Travellers Interest Group, as well as a member of the ISTM Leadership Council. He currently holds two part-time appointments as Honorary Consultant Physician at HealthLink360, and Consultant in Infectious Diseases at Spire Shawfair Hospital in Edinburgh. Mike was formerly the Dean of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow, and the Medical Director (and founder) at Care for Mission (now HealthLink360.)
Peter Leggat will continue to serve as the ISTM Secretary-Treasurer until June 2019, when Mike's term will begin.
New Editor-in-Chief for
the Journal of Travel Medicine
The Executive Board has appointed Annelies Wilder-Smith to be the next Journal of Travel Medicine Editor-in-Chief.
Annelies Wilder-Smith is the immediate Past-President of the ISTM and has served as an Associate Editor for the Journal of Travel Medicine and co-editor of the annual revisions of WHO's "International Travel and Health." She currently holds a guest professorship at the University of Umea, Sweden, and a part-time position at the London School of Hygiene and Tropical Medicine. Currently, Annelies is a WHO Consultant in IVR, with a focus on: Dengue, Zika, Chikungunya, Japanese Encephalitis, Yellow fever.
Annelies will begin on 1 July 2018 as Eric Caumes concludes his final term as the Editor in Chief. The ISTM appreciates and recognizes the extraordinary contributions made to the JTM by Eric over the past eight years.
Christopher Van Tilburg,
Travel Medicine News Editor
Welcome to the spring ISTM newsletter, Travel Medicine News. Hopefully you are planning to attend the Rome International Conference on Migration Health in October or are participating in one of the many ISTM interest groups, professional groups and committees.
The TravelMed forum, sometimes referred to as the ISTM Listserv, is a popular member benefit provided by the ISTM. This unmoderated discussion group allows members to communicate with other members on clinical travel medicine discussions. I find something interesting and useful every day and look forward to reading the interesting and informative contributions by members. I want to take this opportunity to give some tips about posting. Here are the basics:
- The forum is not moderated for language, accuracy, or content. No peer review takes place. This is a member driven forum that should not be relied upon as a clinical reference, but rather a place to share information, foster discussion, and trade ideas.
- Try to keep posts as accurate as possible. Some contributors add references by way of weblinks, which I find helpful.
- Consider using the private message function to reply to an author or comment — I think we all appreciate the collegiality, so it’s OK to eliminate messages that say “thanks” or “I agree” or other insubstantial posts.
- Try to keep posts neutral, if possible. Humor is sometimes misconstrued in the varied cultures, languages, and countries that are represented on the forum.
- It’s OK to be brief—readers are more likely to read the entire email if it’s short.
- Please eliminate any commercial bias from posts: which means feel free to post as an ISTM member, but not as an employee, consultant, or representative from a private or public entity.
- In your TravelMed Settings, you may modify how often you receive the posts; alerts may be received in real time, a daily digest or plain text message with html formatting removed.
- Above all, keep the posts coming: it’s a valuable service and excellent tool to share ideas, foster collegiality, and discuss problems. If you are in doubt, please contact us at ISTM! Many of you check with us before posting, and we are happy to review a potential post if you have any concerns or questions.
- Travel Medicine News is looking for an associate editor from outside North America. Contact the Editor at: firstname.lastname@example.org if interested.
Peter A. Leggat,
There are many opportunities for members to engage with their colleagues in travel medicine. The International Society of Travel Medicine (ISTM) allows global outreach to professionals working in travel medicine and perhaps this is one of the most important aspects of belonging to the ISTM. One important way that we engage is through conferences and meetings. This year, we are spoilt for choice for regional conferences in travel medicine in various parts of the world, while we are looking forward to the 16th Conference of the ISTM to be held in Washington DC, United States of America, from 5-9 June 2019.
The ISTM also needs to be responsive to emerging and re-emerging issues and this year sees the launch of the International Conference on Migration Health or ICMH2018, which is being held from 1-4 October 2018 in Rome, Italy. The increasing focus on migration and refugee health worldwide is being recognized by the ISTM and this conference represents a key next step in engagement, building on its previous work in this area over many years, including the Migrant and Refugee Health Interest Group. The conference needs ISTM member support and the support of governmental and non-governmental agencies involved with migrants and refugees. A number of these agencies are involved in the International Conference on Migration Health and this conference represents a unique opportunity for the ISTM to bring together delegates, including our ISTM members, and agencies interested in migration and refugee health for a common purpose in making a difference. The first announcement of the conference is available on the ISTM website (www.ISTM.org/ICMH2018).
Check out the ISTM website for various upcoming events in travel medicine and migration health and remember to login to MyISTM from time-to-time to check that your information is up to date as well as to view those member-only resources.
News from the Secretariat
ISTM Executive Director
Were you able to participate in the recent Member Benefit Webinar "Preventing Malaria in Paediatric Travellers"? No? Not a problem! The Society posts the webinars and other recorded educational programs on MyISTM with free access for members.
Some of the recent programs now available on My ISTM include:
- Shrinking the Malaria Map: The Long Journey to Eradication, 1900-2040
- What Can be Done to Prevent the Spread of Measles and Mumps by Travellers?
- Tick-Borne Encephalitis: What Evidence is there on the Risk and on Preventative Options?
- Rabies Single Dose PreP for Travellers: hat is the Evidence for a New Strategy?
- Fever in the Returning Traveller: Towards a Rational Work-up and Response
You are invited to explore these and all of our member benefit webinars and archived programs online at MyISTM.ISTM.org/resourcesandtools/clinicalresources/istm-member-benefit-programs. Note, you'll need to be logged into your ISTM account to access these. Maybe bookmark this page as new programs are posted regularly.
In addition to the Member Benefit programs, the society also has archived recorded sessions from CISTMs and courses. You can find the list of more than 100 modules currently available at www.ISTM.org/onlinelearningprogram. As you'll see there are programs on travel medicine tropics from the basics to the more advanced, and there are several Mock Tests available for those preparing to take the examination. Member discounts for these online programs are significant, and we hope you will take advantage of these.
ICEID International Conference on Emerging Infectious Diseases (ICEID 2018)
Atlanta, Georgia, United States of America
26-29 August 2018
Southern Cross Travel Medicine Conference
Brisbane, Queensland, Australia
7-9 September 2018
South African Society of Travel Medicine (SASTM) Pan African Travel Medicine Conference
Cape Town, South Africa
12-14 September 2018
ISTM International Conference on Migration Health
1-3 October 2018
ISTM 16th Conference of the ISTM (CISTM16)
Washington DC, United States of America
5-9 June 2019
GeoSentinel Annual Meeting took place in Porto, Portugal 15-17 May 2018
GeoSentinel, ISTM's flagship project is a worldwide surveillance and communication network for travel-related morbidity. 2017 was a busy year for the GeoSentinel project as evidenced by the growth in sites. We welcomed sites in Madrid, Spain; Hollywood, California, United States of America; Cayenne, French Guiana; Long Island, New York, United States of America; Negrar, Italy; Genova, Italy; Hong Kong; and Montreal, Canada. By of the end of 2017, the network had grown to a total of 70 sites in 31 countries.
Activities of the four GeoSentinel working groups include:
- Enhanced Clinical Surveillance Working Group:
Major activities include a longitudinal follow-up study of patients diagnosed with chikungunya, dengue, Zika, and falciparum malaria (CHIDEZIMA), evaluations of the BioFire Film Array GI panel for etiology of travellers' diarrhea, and a recently initiated evaluation of rickettsial infections in travellers.
- Tracking-Communications Working Group:
Major activities include routine monitoring of data for possible sentinel cases to identify new outbreaks (and communicate these to relevant health authorities, ProMED, and the GeoSentinel Sites and Affiliate Members) using the "GeoSentinel Alert" communication vehicle. These are now available in the public domain on the Geosentinel website (some examples include measles in a traveller returning to Canada from India with possible exposure to travellers on the flight; a Dutch volunteer worker who acquired yellow fever in Sao Paolo, a Belgian flight attendant who died from severe malaria after repeated trips to the DRC, yellow fever cases acquired on Ilha Grande). This group ensures rapid follow-up of alarming diagnoses and constant monitoring of the alarming diagnosis listing. Major accomplishments include outreach to strengthen strategic partnerships with ECDC, PubMed and Epi-Core, and other groups with shared interests such as TropNet.
- Data Management Working Group:
Major accomplishments include refinement of all diagnostic codes, enhancement of the core data collection, assistance with development and integration of forms for Special Populations studies, and substantial strengthening of measures to enhance data quality control. This Working Group also spearheaded development of a special form to collect data on antimicrobial resistance.
- Special Populations Working Group:
Major focus has been the development and piloting of enhanced data collection on migrants, refugees, and asylum seekers. Recently completed project on rabies post-exposure prophylaxis and near complete study of travellers to mass gatherings such as the Hajj. A new study on planned and unplanned medical care during travel has just started.
The 2018 GeoSentinel Annual Meeting was held in Porto, Portugal with a combined half day session with TropNet.
GeoSentinel Publications 2018
de Vries SG, Visser BJ, Stoney RJ, Wagenaar JFP, Bottieau E, Chen LH, Wilder-Smith A, Wilson M, Rapp C, Leder K, Caumes E, Schwartz E, Hynes NA, Goorhuis A, Esposito DH, Hamer DH, Grobusch MP, for the GeoSentinel Surveillance Network. Leptospirosis among returned travellers: a GeoSentinel site survey and multicenter Analysis — 1997-2016. The American Journal of Tropical Medicine and Hygiene, in press.
Davidson H. Hamer, Kristina Angelo, Eric Caumes, Perry J.J. van Genderen, Simin A. Florescu, Corneliu P. Popescu, Cecilia Perret, Angela McBride, Anna Checkley, Jenny Ryan, Martin Cetron, Patricia Schlagenhauf. Fatal Yellow Fever in Travellers to Brazil, 2018. MMWR Morb Mortal Wkly Rep 2018; 67:340–341. DOI: 10.15585/mmwr.mm6711e1.
Lin H Chen, Karin Leder, Kira A Barbre, Patricia Schlagenhauf, Michael Libman, Jay Keystone, Marc Mendelson, Philippe Gautret, Eli Schwartz, Marc Shaw, Sue MacDonald, Anne McCarthy, Bradley A Connor, Douglas H Esposito, Davidson Hamer, Mary E Wilson, for the GeoSentinel Surveillance Network, 2018. Business travel-associated illness: a GeoSentinel analysis. Journal of Travel Medicine, 25.1 (2018). DOI: 10.1093/jtm/tax097.
Migrant and Refugee Health
Interest Group Chair
Migrant and Refugee Health
Welcome to the Migrant and Refugee Health Interest Group!
Past Event: CISTM15 Barcelona
On 14 May 2017, the Migrant and Refugee Health Interest Group Council organized a Pre-Congress course during the CISTM15 with the theme "Health of Migrants and Refugees for Travel Medicine Providers". The course covered an overview of migration patterns and associated health issues, infectious and non-communicable diseases. The course closed with an open floor discussion. There were nearly 100 attendees at the course from around the world. The session helped us see there is a strong need for a much broader understanding of migrant health issues amongst travel health providers.
Upcoming Event: International Conference on Migration Health
A migration themed conference is scheduled 1-3 October 2018 in Rome, Italy. The aim of the conference is to bring together academic knowledge and experience relating to migration and health around the globe. The conference will review the different categories of mobile populations and their respective health determinants. Our Interest Group is organizing a session where we hope to engage in discussions with fellow ISTM members regarding intersections between migration health and Travel Medicine.
All ISTM Members who are interested in the health of migrant, refugee and other mobile populations are welcome to join the group. Please contact the group chair via e-mail: email@example.com.
Military Travel Interest
The ISTM Military Travel Health Interest Group is a newly formed group, open to all healthcare providers interested in or caring for service members. We are proud to announce that the ISTM Executive Board has recently approved our official logo and Latin motto (United for the Health of the Military). Additionally, an original military symposium was proposed for CISTM16 in Washington and a military pre-course is also being planned on the opening day of the same conference.
We are looking forward collaborating with you!
Welcome to our new Council Members:
Olivier Aoun, France
Mildred Casey-Campbell, Canada
Holly Doyne, United States of America
Peter Leggat, Australia
Sean Smith, United States of America
Psychological Health of Travellers
Psychological Health of
Travellers Interest Group Chair
Did you know that many standard travel health insurance plans do not cover mental health? Or that travellers are only allowed to carry limited amounts of psychotropic and narcotic medication when crossing borders? Similarly, what do expat travellers with a mental health condition do when their medication is not available in the destination country?
If you come across these issues in your practice, we want to hear from you. Our goal is to share your experience with members to build on existing clinical practice and knowledge in the field, Please email your cases to ISTM@ISTM.org.
We are currently working on a survey that will be distributed among interest group members this Spring. We want to get a better sense of your needs, including how to incorporate mental health in your consultations. Your feedback will also help us develop resources, including screening checklists and materials on travel and mental health to pass on to your travellers. Also coming soon — an updated travel and mental health bibliography and a literature review on key articles that have been published in the past year.
The steering committee welcomes your insights to ensure that the psychological health of all travellers is an integral part of travel medicine practice.
ISTM Certificate in Travel HealthTM Examination
9 September 2018
United States of America
Offering the first international certificate devoted solely to travel health, the ISTM Certificate of Knowledge Program was developed by an international panel of travel health experts representing a variety of professional disciplines. The 200-multiple choice question exam is designed to reflect the reality of day-to-day pre-travel practice.
The Certificate is a symbol of your achievement in the field – proof of your commitment to excellence. Professionals passing the exam will be granted the designation Certificate in Travel Health™ or CTH©. ISTM members who receive this Certificate will also be recognized in the ISTM Global Travel Clinic Directory of Travel Medicine Providers and the ISTM Membership Directory. The ISTM welcomes applications from all qualified professionals who provide travel medicine-related services on a full- or part-time basis.
More information is available on the ISTM website at www.ISTM.org/certificateofknowledge.
Register early as space is limited!
ISTM Call for Fellow Nominations
Charles D. Ericsson,
Special Recognitions Committee Chair
Dear ISTM Members:
ISTM encourages you to consider nominating yourself or a colleague to become a Fellow of the International Society of Travel Medicine (FISTM). ISTM has established an advanced recognition program to honor individuals who have demonstrated outstanding contributions to the field of travel medicine, those who advocate for and support the ISTM, and those who demonstrate professional excellence either in the way of clinical practice, research, education, and/or policy development.
As of April 2018, applications for fellow status in ISTM are being received in the secretariat office. The deadline for receipt of applications is 31 July 2018. Details, instructions for applying, and application form are found at www.ISTM.org/fellowsprogram.
While you are expected to obtain a letter of support from a current fellow, please note that the members of the Special Recognitions Committee (Fiona Genasi, Phyllis Kozarsky, Louis Loutan, myself, and Prativa Pandey) are note permitted to write letters of recommendation for fellow applicants. A list of 2016 and 2017 FISTM Class members are available at www.ISTM.org/fellowsprogram.
CISTM16: Travel Medicine in a Changing Climate
Scientific Program Committee
United States of America
Scientific Program Committee
United States of America
Associate Chair, CISTM16
Scientific Program Committee
Associate Chair, CISTM16
Scientific Program Committee
Associate Chair, CISTM16
Scientific Program Committee
More than 100 excellent proposals have been submitted to the CISTM16 Scientific Committee for their review. Using these ideas and proposals the Committee will identify material that is new, innovative, important and of the highest scientific caliber, and will identify speakers who have the expertise and experience to communicate this knowledge effectively. The Committee will work to achieve a balance of topics to serve the varied interests and needs of the membership. The topic of the meeting will be Travel Medicine in a Changing Climate.
The program will have a mix of plenaries, symposia, workshops, debates, and Knowledge Bytes — to allow attendees to select those sessions that fit their interests and level of expertise. The preliminary program will be developed by August 2018.
The Scientific Committee is being led by Chair Blaise Genton, Switzerland, and Co-Chair Christina Coyle, United States of America.
The 16th Conference of the International Society of Travel Medicine (CISTM16) will be held on 5-9 June 2019 in Washington DC, United States of America at the Washington Hilton.
ISTM Slide Set
The ISTM Slide Set has just been updated in 2017 and split into four chapters:
Chapter 1: Introduction to Travel Medicine
Chapter 2: Travel Topics and Special Conditions
Chapter 3: Travel Vaccines
Chapter 4: Vector-borne Diseases
Members can purchase one or all four at a discount. Visit the ISTM Website at www.ISTM.org for more information.
We would like to thank the ISTM Professional Education Committee for updating these slides.
Members in the News
Travel Medicine, with a Winery on the Side
Brian Gilbert and Lani Ramsey
Physician Brian Gilbert and nurse practitioner Lani Ramsey, a married couple, practice Travel Medicine at their clinic in Adelaide, Australia. They met while taking the 2005 ISTM CTH® exam in Lisbon, Portugal. Gilbert, an Adelaide native, has been practicing Travel Medicine at his clinic, Travel Bug, in North Adelaide since 1993; Ramsey, born and raised in British Colombia, Canada, joined the clinic in 2006. Brian possesses a soft-spoken irreverent, droll wit; Lani, the more extroverted of the two, smiles frequently.
Brian and Lani are true specialists — they practice only Travel Medicine. They each work about 40 hours per week, scheduling 30 minutes for one traveller and 40 minutes for two travellers going to the same destination. Their travellers' destinations include Bali, Thailand, Laos, Vietnam, India, Papua New Guinea (the Kokoda Trek) and countries in Central America, South America, and Africa. Brian and Lani administer the shots (to which they refer, like the British, as "jabs") themselves. They send letters detailing their Travel Clinic's services to general practitioners, pharmacists, and travel agents every year. Each year they spend over USD 8,000 on stationary alone.
The Travel Clinic is only one of their two business concerns. The other is the oxymoronically named Lofty Valley Winery. Their home, in the Misty Mountains (Misty Hills it should be called says Brian) east of Adelaide, is adjacent to their 32-acre vineyard, where they grow grapes for Pinot and Chardonnay. The wine is currently fermented in Lenswood, a small township near their home, but they are planning to build a fermentation facility adjacent to their home.
In 2013 their 2012 Steeped Pinot won first prize for drinkability in the Hot 100 Wines South Australia competition, in which 1,200 wines were entered; the subsequent favorable publicity was a boon to sales.
In a business tie-in that most Travel Medicine providers can only envy, Brian and Lani give bottles of wine from their vineyard to travel agents, travellers who refer other travellers to their practice, travellers with financial hardship, travellers who spend over USD 500, and anyone else they feel like giving wine to. On a tour of their vineyard, Brian pointed out gum trees by his house in which he frequently sees koala bears. I heard the call of a tropical bird — "koo-koo-koo" — animated, loud. Hear that? asked Brian. That's a kookaburra bird.
We hiked down a steep slope into the vineyard. Brian mows several hours per day during the green months to keep the grass down. As we walked up and down the slopes of the vineyard Brian explained that he purchases his vines young, as "sticks;" they produce grapes within a couple of years. They will continue to produce for 30 to 40 years. Grapes are often harvested the first week of March. Some years they pick grapes earlier in the season when the grapes have less sugar to make sparkling wine.
After touring the vineyard we retired to their home, a large modern structure with a tennis court on its roof and a view overlooking the vineyard, for dinner. Brian made a fire of gum trees over which he cooked lamb, and poured Lofty Valley wines for us: a silky Chardonnay with hints of wild peach; a complex, spicy blend of Shiraz plus two other reds; and a particularly good Pinot Noir with hints of plum.
Brian said that there's a myth that Aussies tell tourists: there's an indigenous bear, the drop bear — large and carnivorous version of the koala—that plummets out of trees onto unsuspecting passers-by below. Strategies to avoid drop bear attacks include placing forks in one's hair, smearing Vegemite or toothpaste spread behind the ears or in the armpits, and urinating on oneself. Brian and Lani work fifty weeks per year. It's difficult to take more time off given their ongoing practice expenses. Future plans? Perhaps sell the Travel Medicine practice in a couple of years and turn their full attentions to their winery. And travel.
University of Washington, Seattle, Washington, United States of America
Photo: Sue Ann McDevitt, ISTM 25th Anniversary Gala, Barcelona
Sue Ann McDevitt,
Nursing Professional Group Chair
Happy Spring to the Global North, and Autumn to the South. As I write this, we continue to be faced with on-going issues with the continuing yellow fever outbreak in Brazil and reports of disease in other countries of South America at a time of limited access to the vaccine in North America. The unwelcome news that Sanofi's new plant will not open until (at least) 6 months later than planned was not entirely shocking: it is a normal occurrence with construction projects. I guess the company doesn't know about “under promise and over deliver” (say it will be December and surprise everyone when the result comes about early).
Caroline Nash and Jutarmas Olanwijitwong are hosting nurses at the Asia-Pacific Conference in Bangkok and will be reporting back in the next issue. Bangkok is such a lovely city! Personally, I am off to the NECTM-7 in Stockholm in May and hope to meet my fellow members there.
Will you be taking the CTH exam in Atlanta this September? If yes, do you know that the NPG is here to support you? Please send your questions to the list serve mailbox titled "Nursing CTH Study Group."
A pre-CISTM-16 in Washington DC item to remember: the NPG has two awards
- Emerging Nurse in Travel Medicine and
- Distinguished Nurse in Travel Medicine
Application details will be forthcoming. Nominate a colleague, or yourself!
This is my last bulletin. In May, the Chair passes to Heather Connor of Canada. Heather is a dynamic clinician and I know I leave the NPG with good stewardship. Happy trails to all,
Mark P. Walberg,
Pharmacists Professional Group
Steering Council Member
Regulatory Change Requires Patience, not Perfection: Pharmacists as Travel Health Providers in California, United States of America
In February of 2013 Senate Bill 493 was put forth in the California state senate that proposed several, dare I say, sweeping changes to the practice of pharmacy in the state. Nestled among regulations on pharmacist-provided birth control and smoking cessation, administration of recommended immunizations without a physician protocol, and (what was considered the crown jewel) provider status and an "advanced practice" pharmacist designation, was a small section on travel health services. After multiple revisions and debate by both the state senate and assembly, it was signed by the California governor in October of 2013. Eight months seemed pretty quick. And for pharmacists excited about the possibilities offered by this new legislation, we were ready to implement it as soon as possible.
And this is where patience comes in… the potential for travel consults at pharmacies across the state could protect more patients traveling abroad but didn't seem a priority for the state's Board of Pharmacy. And with sterile compounding issues and an opioid epidemic at hand, it wasn't until January of 2016 that SB 493 had an actual regulation for pharmacists… and it wasn't for travel health. It was another 17 months of public hearings and additional revisions (one relatively important one making sure that prophylactic medications were included) before the regulation's final text was completed and approved by the Board in June of 2017… nearly four years after its signing into law. And yes, it was basically the last item to be dealt with from this legislation.
Despite the time lag, and in some cases gentle pressure applied relentlessly, the final regulation wasn't half bad. It stipulates that a pharmacist may provide travel health services, including the provision of prophylactic medications and medications for self-treatable/diagnosable conditions (per Centers of Disease Control and Prevention's “Yellow Book”) without a physician protocol or prescription order. Among several other requirements, it requires completion of both immunization and travel health training programs, completion of the CDC Yellow Fever Training course and two hours of continuing education in travel health biennially.
In a win for ISTM, the required 10-hour travel health training program must include the Body of Knowledge for the Practice of Travel Medicine. On a critical note, 10 hours of training seems a bit slim in light of the vast amount of knowledge required for competence in travel medicine. And ideally it would have been nice to see a Certificate of Knowledge in Travel Health as the minimum competency requirement in final regulation. I will leave the debate of training completion versus clinical competence for another day, but I am glad to see a large leap in the right direction for pharmacist-provided travel health consultations in my home state of the United States of America.
Travel safe and Godspeed.
A Big Dose of Small Person Questions
A number of interesting pediatric questions appeared on the TravelMed listserv in the past several months.
Travel Medicine News
- Insect precautions for a baby born to a surrogate mother in Kenya to parents from the United States of America? With regard to this scenario, important points were made regarding regulatory issues associated with bringing the baby back to the United States of America, and ethical issues with the use of a surrogate mother from Kenya. Concerning malaria and insect precautions, most respondents agreed that insect repellents on the baby's skin should not be used (and off-label in newborns), and that impregnated netting is more preferable; insecticide on the inside walls in addition would be ideal. If the mother's immune status is not known, maternal antibody protection is uncertain. No malaria prophylaxis was suggested as there are no data on these drugs in newborns. Sun protection was also suggested for a lighter-skinned baby.
- Travel to Nigeria and Ethiopia with an infant 8 months and 5 months old, respectively The 8- month-old was traveling to Nigeria (Benin City) with her parents as VFRs. The mother was breast-feeding. Respondents recommended Malarone for the whole family as well as delaying the trip until the child is 9 months old so she can receive yellow fever and meningitis vaccines (only MenC can be given as young as 2 months); some respondents suggested that yellow fever vaccine can be given as young as 6-8 months (www.who.int/ith/vaccines/yf/en), but another was concerned about the risk of AEs of the vaccine in this young population; there are several articles in the literature that discussed the safety of the vaccine in infants referenced in the post. MMR was also suggested (6-11 months old; www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html), as the family would be interacting with the local population. With regard to travel to rural Ethiopia (also VFRs), the use of vaccines and medications are more limited because of the infant's younger age; in addition, there were suggestions to not travel there at all due to civil unrest in that country. The same insect precautions as in the first question were recommended, although DEET (<30%) can be used in infants > 2 months. www.cdc.gov/malaria/toolkit/deet.pdf.
- Altitude precautions for a 7-year-old doing a Mt. Kilimanjaro trek (Lemosho route, 5895m/19,340 ft.; trek is 6-8 days) Kilimanjaro National Park recommends a minimum age of 10 years old for the trek, although apparently the trekking company received permission for this child to do the trek. Acetazolamide 2.5mg/kg twice daily was recommended by one respondent (in addition to malaria prophylaxis for travel to and from the mountain), and adequate hydration, rest, etc. Respondents expressed concern that a child of 7 years old would be able to appropriately verbalize symptoms of altitude illness, and questioned the motives of the parent in encouraging the child to undertake this trek, which is not without risks. A helpful reference on “Children at Altitude. Essential Advice” was provided: www.theuiaa.org/uiaa/children-at-altitude-essential-advice.
Challenging Cases: Voice Your Opinion
Nancy Piper Jenks
Welcome back to Challenging Cases: Voice your Opinion to see how your colleagues responded to the dilemma of malaria chemoprophylaxis in a dialysis patient. Then scroll down to read and weigh in on the next challenging case for Travel Medicine News.
51-year-old Nigerian born male living in the United States will be traveling to Accra, Ghana for a one week for conference. He is on hemodialysis 3 days a week after having had bilateral nephrectomies for renal cell carcinoma 5 years ago. He is up to date on all needed vaccines but presents for discussion of malaria prophylaxis. His accommodations will be the conference hotel, and no excursions outside the city are planned at this time. He has made arrangements for his hemodialysis to continue while in Accra.
What malaria chemoprophylaxis, if any, would you recommend for this patient who is on hemodialysis during his trip to Ghana?
Stephanie El-Chakieh from Montreal, Canada
Many VFR (visiting friends and relatives) travellers assume they are immune to malaria if they were born or lived a long time in a country with malaria, but any immunity disappears quickly after a person moves away. Also, there is a high risk of P. falciparum in Ghana throughout the year. The duration of his stay and his activities reduces the risk of malaria. However, considering his health condition and the possible major consequences of acquiring malaria, I would still suggest a chemoprophylaxis before his departure. There is resistance to chloroquine and sulfadoxine-pyrimethamine in the visiting area, leaving the options of atovaquone-proguanil, doxycycline or mefloquine. Atovaquone-Proguanil is contraindicated in chronic kidney disease (ClCr under 30ml/min). This contra-indication is justified with the following: The Proguanil component (70% renal elimination) and its metabolite (cycloguanil) reduce the activity of the enzyme dihydrofolate reductase, preventing the development of schizonts. In humans, this same enzyme catalyzes the reduction of folic acid to dihydrofolate and tetrahydrofolate. High concentrations of Proguanil and its metabolite can lead to a reduction of this enzyme function, therefore leading to anemia, leukopenia and thrombocytopenia. Cases of pancytopenia related to this medication have been reported in the literature. Also, renal impairment decreases the Atovaquone AUC, which can further lead to treatment failure. Acceptable choices: Doxycycline : 100 mg once a day to start 1-2 days before departure, and continue daily, and for 4 weeks after return or Mefloquine 250mg once a week, starting 2 weeks before departure, weekly, and continue for 4 weeks after return. (Both safe in hemodialysis and not requiring any additional dose). The final choice should be made according to the patient's conditions, medication and compliance, with another option being to stress the use of bug repellant (DEET 30% or Picaridin 20%), wearing covering clothing, and avoiding outdoor activities after sunset if possible.
Anne McCarthy from Ottawa, Canada
For this traveller malaria prophylaxis should be recommended along with strict adherence to insect precautions – including the use of permethrin on his clothes to decrease exposure. This is an area of high endemicity for malaria, so although he will have a short visit in the city and stay at the conference hotel there is still risk. Decisions about the use of drugs for malaria prevention need to consider the potential impact of his renal failure as well as any interactions with concurrent medication. Time should be spent emphasizing the need to urgently seek medical advise for treatment if he develops a clinical illness in keeping with malaria (fever or flu like illness within 3 months of travel). Atovaquone-proguanil would be contraindicated, due to the accumulation of proguanil and its metabolite in end stage renal disease (ESRD). Both doxycycline and mefloquine can be used in end stage renal disease, with proper attention to contraindications and precautions. If taking doxycycline special attention must be paid to taking it with (non dairy) food and plenty of liquid. In addition dosing may have to avoid antacids that may interfere with absorption, often taken by patients with ESRD.
Evangelos Papadopoulos from Patra, Greece
Doxycycline or mefloquine may be used in severe renal failure. There is no need to reduce the dose of mefloquine in renal dialysis. Atovaquone-proguanil is not recommended for patients with an eGFR of less than 30mL/minute and is not to be used in patients receiving renal dialysis. Mosquito bite prevention measures are the first step to reduce the possibility of malaria transmission. However, because all areas of Ghana are considered high risk for malaria, I would favor recommending chemoprophylaxis.
In any case, it is very important that the traveller should follow an ABCD guide to preventing malaria:
Awareness of the risk — Risk depends on the specific location, season of travel, length of stay, activities, and type of accommodation.
Bite prevention — Travellers should take mosquito bite avoidance measures.
Chemoprophylaxis — Travellers should take malaria chemoprophylaxis if appropriate for the area. No antimalarial is 100% effective but taking them in combination with mosquito bite avoidance measures will give substantial protection against malaria.
Diagnosis — Travellers who develop a fever of 38°C [100°F] or higher one week or more after being in a malaria risk area, should seek immediate medical evaluation and testing for malaria.
Now, here's your next challenging case.
PLEASE DO NOT RESPOND ON THE TravMed Listserve.
Responses should be relatively brief, 200-300 words or less.
Send all responses to firstname.lastname@example.org
A 20-year-old student comes into your office after having returned one week ago from a 2 week stay in Uganda working for a humanitarian organization. In spite of your pre-travel advice to avoid swimming in fresh water, he recounts several episodes of swimming in “beautiful lakes” with his fellow students.
He feels well, had no illness while in Uganda, or since returning, and had no rash after swimming. He is afebrile and his clinical exam is completely normal.
A fellow student told him that he needs to be screened for schistosomiasis. What laboratory test(s) would you order and when would you do that? Would you treat him empirically today?
Research and Awards Committee
Research and Awards
Research and Awards
The ISTM Research and Awards Committee which has been recently expanded to 17 active members has just completed the assessments of this year's research proposals. A whopping 27 proposals were submitted, and a record 90,000 USD were awarded to the following winners in 3 categories:
The SEVTRAV Study-Severe, undiagnosed infections in returning travellers — A GeoSentinel Collaboration — PI: Eskild Petersen, Oman
Determining optimal, equitable and cost-effective strategies to prevent cases of travel-related infections in VFRs and other travellers at risk — PI: Rachel Savage, Canada
Imported Doxycycline Responding Illness (IDRI) — PI: Daniel Camprubi Ferrer, Spain
Optimized travel clinic referrals through online international flight booking pathways — PI: Ben Coghlan, Australia
Harnessing the blood transcriptome to study the effects of multiple vaccinations in travellers — PI: Mirella Salvatore, United States of America Low and Middle Income Countries:
The Incidence and Cost of Travel Related Dengue Case Among International Travellers During Visit to Bali, Indonesia — PI: Sucipta Putri, Bali
Health Knowledge, Attitudes and Practices on Traveler's Diarrhoea among International Travellers to Kenya from Western and Asian countries — PI: Munyambu Mutonga, Kenya
Review of mobile applications for travel medicine for practitioners and patients — PI: Sheila Seed, United States of America, Pharmacist Professional Group
Other current activities of the Committee are to document outcomes and achievements of previously funded projects, and the development of a toolbox including video clips to promote external fund-raising for the research proposal.
The ISTM Research and Awards Committee just granted USD 90,000!
Vaccine Record Apps
Vaccination is a key component of pre-travel preparation, but keeping track of past vaccinations can be really tricky for travellers and their providers. While some countries maintain centralized vaccine registers, these are mostly designed for childhood vaccinations and few include travel vaccines, or vaccination records for adults.
As a provider, piecing together old vaccination information can be difficult and time consuming. It often involves trawling through registries, calling up primary care providers, and sifting through paperwork. When vaccine records are lost or not available, it can cost patients time, money and pain (in the arm) to have repeat vaccine doses.
This is where apps that assist patients in documenting and collating their vaccine records can come in handy. These are essentially digital versions of the paper-based yellow International Vaccine Record book, and allow patients to carry their vaccine records around in their pockets.
In this blog, we review mobile apps that allow travellers to store information about their previous travel vaccines. While we came across a number of other apps designed to record and track childhood vaccinations, or vaccinations for those living in a specific country in our search (e.g. Ottawa Hospital Research Institute's CANImmunize app, designed for Canadians), we have tried to stick to apps designed specifically for travellers.
If you have any vaccine record app recommendations, please let us know!
Vaccine Record (Dr Deb the Travel Doctor, Australia)
How does it work?
This app allows travellers to store their vaccination records digitally, by choosing from a list of travel vaccines and entering the date, location, vaccine brand and batch number of each vaccine. What will travellers like about this app?
This app allows travellers to carry a copy of their vaccine records in their pocket. Records are available off-line, and photos can be stored within the app (e.g. yellow fever vaccine certificate). The most powerful feature is the 'summary record', which allows travellers to email a copy of their records to themselves or their provider.
What are the limitations/what could be improved?
The interface is not always intuitive (although instructions are provided), and vaccine reminders need to be set manually. The image storage feature is limited to four photos and image quality is poor with no zoom function.
'Vaccine Record for Travellers'
Created by Dr Deb The Travel Doctor (Australia), this app helps travellers store their vaccination records in one place
Cost: Free (offers in-app purchases - backup to Dropbox AUD $2.99)
The Travel Clinic Vaccine App (Travel Clinics Australia)
How does it work?
This app allows travellers to store their vaccination records digitally, by choosing a vaccine from a pre-populated menu and entering their date of vaccination.
What will travellers like about this app?
The personal vaccination record interface is relatively intuitive and a summary list (that is available offline) can be easily generated. The app also includes a pocket guide with information about pre-travel preparation and common travel-related diseases, which is user-friendly and includes practical tips for travellers.
What are the limitations/what could be improved?The vaccine record function is very simplistic and does not include a reminder function. The app does not allow images to be stored or records to be sent digitally.
'The Travel Clinic Vaccine App'
Created by Jonathan Cohen from Travel Clinics Australia, this app helps travellers store their vaccination records and access tips on preparing for travel
TraveWell App (U.S. Centers For Disease Control, United States of America)
How does it work?
This app allows travellers to record details of their vaccine history, along with medication details and travel documents.
What will travellers like about this app?
The app is designed as a pocket companion for travellers. It allows travellers to enter the details of their planned trip and see specific CDC vaccine and malaria prophylaxis recommendations for their destination(s). Features include “Packing” and “To do” lists that are fully customizable. Travel documents (including images of vaccine records) can be stored within the app.
What are the limitations/what could be improved?
The vaccines section only allows users to record dates of hepatitis A and B, typhoid, rabies, JE, polio, meningococcal and yellow fever vaccination. There is no way to record the dates of “routine” vaccinations, such as tetanus and influenza vaccines. Some information is out of date, such as the advice that the “International Certificate of Vaccination or Prophylaxis” being “good for 10 years”.
Created by The U.S. CDC, this app is designed to help travellers plan healthy and safe international trips.
How are apps evaluated?
We have evaluated these apps using the Mobile Application Ration Scale (MARS), developed by Stoyanov et al.1 This is a simple tool for classifying and assessing the quality of mobile health apps across 5 domains: engagement, functionality, aesthetics, information, and subjective quality. Each domain has 3-7 questions, and scores are averaged across the questions to generate a rating for each domain on a 5-point scale from 1=Inadequate to 5=Excellent.
1Stoyanov SR, Hides L, Kavanagh DJ, Zelenko O, Tjondronegoro D, Mani M. Mobile App Rating Scale: A New Tool for Assessing the Quality of Health Mobile Apps. JMIR Mhealth Uhealth. 2015; 3(1): e27