International Society of Travel Medicine
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October 2018 Issue

President's Message

Leo Visser
Leo Visser,
ISTM President

I am writing you from Fumicino airport in Rome returning from the First International Conference on Migration Health. It was a vibrant meeting with excellent speakers, lively discussions and 270 very enthusiastic, highly motivated and involved participants from 34 countries. This conference was the first in its kind: a unique collaboration between ISTM, American Society of Tropical Medicine and Hygiene (ASTMH), U.S. Centers for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), European Society of Clinical Microbiology (ESCMID), International Organization for Migration (IOM), and with support from the Italian government and Vatican.

The personal stories of the migrants in the "Through the eyes of the migrant" session made a deep impression on the audience.

In the "Confronting challenges" session, five groups of ten participants discussed dilemmas within migration and migration medicine. The results and subsequent actions were discussed in the wrap-up session at the end of the conference.

It is clear that ISTM has a pivotal role in fostering migration medicine within the society. Migration is inevitable, necessary and desirable. With our medical knowledge on population mobility we can play our part. I encourage you to have a look at the handouts of Conference that are available on the ISTM website here.

Since July 2018, Annelies Wilder Smith has been working extremely hard to restructure the editorial board. I am proud to learn that publication time of Journal of Travel Medicine (JTM) has been reduced to a mere three days. JTM is the flagship of our Society. I sincerely hope that you are willing to publish your high-quality papers on travel and migration medicine in our journal.

The scientific program committee is on full swing with the preparation for the 16th Congress of the International Society of Travel Medicine (CISTM16) in Washington DC, United States of America. We have received program proposals from several interest groups. In addition, there are ten proposals for pre-conference meetings. I am happy to learn that the first registration came in immediately after opening the early bird registration. No doubt this conference will be a great success.

Last month during the South African Society of Travel Medicine (SASTM) conference in Cape Town, South Africa, we met African delegates from Nigeria, Kenya, Senegal, Angola and Botswana. Although these countries have many other priorities, the first steps are being made to develop travel medicine within these countries. We discussed together with Robert Steffen how ISTM and SASTM could be of assistance to close the gap.

Within the same theme of "Closing the Gap" we are also actively looking to strengthen our relationships with South America with the help of Mary Wilson, and China with the help of Robert Steffen.

We are also looking for a closer relationship with TropNet, a large European network of tropical and travel medicine specialists. In May we had a joint meeting with Geosentinel and TropNet in Porto, Portugal. The first collaborative research projects have been identified and we are looking forward to a fruitful collaboration.

Leo Visser,
ISTM President


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Editor's Note

Christopher Van Tilburg
Christopher Van Tilburg,
Travel Medicine News Editor

Welcome to the latest issue of Travel Medicine News. A member benefit of ISTM is our highly valued and respected Travel Med Forum. We nearly always have excellent dialog and professional courtesy. I do want to take a moment, as I do once a year, to remind everyone of the basics when using the forum.

The Travel Med Forum is discussion of individual clinical cases, patient management issues, guidelines for clinical care, and educational/training opportunities. However, keep in mind this is just a dialogue among colleagues — use caution when basing patient care based on the forum. Always seek a peer-reviewed source.

The best posts keep comments neutral, professional, and short. Keep in mind many professionals from varied backgrounds, cultures, and countries read the forum. Humor does not always translate well. Feel free to take more detailed discussions offline and use the private messaging function. In general, we don't allow any commercial use of the forum — if you're not sure about posting something, just ask. Usually if it's important enough for the forum, we'll find a way to craft a neutral post.

Other tips that will help your post get read:

  • Keep it your query or response to a post short
  • State concisely and clearly the topic of your comments in the subject line. This allows members to respond more appropriately to your posting and makes it easier for members to search the archives by subject.
  • Include only the relevant portions of the original message in your reply. Delete any header information, and put your response before the original posting.
  • Only send a message to the entire list when it contains information that everyone can benefit from. This can done by using the 'reply' or 'reply all' functions.
  • Send messages such as "thanks for the information", "me, too", or any personal messages to individuals - not to the entire list. Do this by using the 'forward' function and typing in or cutting and pasting in the email address of the individual to whom you want to respond.
  • Please search the list archives for recent discussions regarding your posting prior to sending your query. Often a topic has already been discussed. To search the archives you may use the link in the footer of each TravelMed posting or you may access through the website: www.ISTM.org/TravelMed.

If you have any questions: just ask!

Christopher Van Tilburg,
Travel Medicine News Editor


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Secretary-Treasurer's Report

Peter A. Leggat
Peter A. Leggat,
Secretary-Treasurer

The ISTM is governed by seven elected members. These members consist of the President, President-Elect, Immediate Past-President and four counsellors, which together constitute the Executive Board (EB) and have voting rights. The EB meets at least four times per year and as needed, usually by teleconference or other electronic mediums, such as Zoom. The Executive Board together with various Committee and Group chairs and editors represent the leadership of the society and meet from time to time as the Leadership Council. The ISTM Secretary-Treasurer and the Executive Director support these activities, but have no voting rights.

As most members are aware, ISTM has elections for President-Elect and two of the four councellors biannually. I urge leaders amongst our 4000 plus membership to take this opportunity and answer the call for nominations for these positions (closing date is 9 November 2018). Like a number of other global organizations, ISTM Presidency changes continents and there are limitations in the overall number of Board members that can come from these areas as well. This helps to ensure that issues of concern for members in each region are represented. The nominating committee is chaired by the President-Elect and is formed by the ISTM Executive Board in accordance with criteria set out in our bylaws. This committee reviews and selects candidates from the nominations received.

The ISTM depends on high quality and dedication of its leaders, elected leaders in particular, for continued strength. Elections are held every two years prior to the CISTM and the Membership Assembly, where newly elected President-Elect and Board members assume office. As many members are aware, The ISTM President-Elect holds their position for two years before assuming the Presidency for 2 years and then immediate Past-President for 2 years (for a total of six years). Counsellor positions are four year appointments.

In selecting members for the eventual ballot, the Nominations Committee must take into account the Society's bylaws, which set certain constraints in the interests of regional and professional balance. For example, the incoming President, Lin Chen, is from the United States of America, so the next President-Elect will needs to reside in a continent other than North America. Any qualified ISTM member in good standing is eligible to seek office and any ISTM member in good standing without a conflict of interest is eligible for nomination and it is desirable for a candidate to have the following qualifications:

  • Prior service on ISTM committees, professional/interest groups or ISTM-sponsored initiatives
  • Publication of travel medicine-related clinical or research articles in the Journal of Travel Medicine, other journals or books
  • Contributions to the biennial CISTM
  • Leadership experience working with national or international professional societies or groups
  • Professional experience in the field of Travel Medicine

There are many other ways to engage with the Society, including Committees, Interest Groups, Professional Groups and ISTM member activities. Members and officers of the ISTM Board, Committee, or Group or provides a unique insight into our Society and presents an opportunity to help guide the Society into the future. Most importantly, please keep in mind the dates of the 16th Conference of the ISTM (CISTM16) to be held in Washington DC, United States of America, from 5-9 June 2019. It promises to be a fantastic program and a special place to convene in one of the great cities of the world.

I had the pleasure of attending the 3rd Southern Cross Travel Medicine Conference in my home town of Brisbane, Australia, from 7-9 September 2018. It was pleasing to see a strong contingent of Australians and New Zealanders at this conference and keynote speakers included Professor Eric Caumes, France, Past Editor-in-Chief of the Journal of Travel Medicine; Dr Sundeep Dhillon, United Kingdom, who in 1998 became the youngest person to achieve the Seven Summits, a record he held for many years; and Professor Rose McGready, Thailand, Nuffield Department of Medicine, Oxford University. I also had the honour of attending the Inaugural International Conference on Migration Health (ICMH), hosted by the ISTM, which was held in Rome from 1-3 October 2018. The ICMH was a wonderful initiative of the Society and other international groups.

Remember to login to MyISTM from time-to-time and keep your information up to date to check out member-only resources.

Peter A. Leggat,
Secretary-Treasurer


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News from the Secretariat

Diane Nickolson
Diane Nickolson,
ISTM Executive Director

After eight years of keeping our member dues at the same rate while our operating costs and member benefits both saw significant increases, the ISTM Executive Board recently voted in favor of a 20-25 USD annual increase to the cost of ISTM dues. While inflation has been relatively low for the past decade, we all know that costs do not stand still. As of 1 January 2019, the ISTM annual dues will be 200 USD for Doctoral Members and 125 USD for Non-Doctoral Members. The dues will not change for Retiree Members (105 USD), Student and Trainee Members (105 USD), and Associate Members from countries classified as low and low-middle income by the World Bank (40-75 USD).

The Executive Board also approved special discounted 5-year membership dues programs, allowing members to pay in advance for membership at the rates in effective before the increase. Doctors would pay 875 USD and Non-Doctors would pay 525 USD for this 5-year membership. Finally, the Executive Board established a special Retiree Member Dues Option, allowing retirees to pay 1000 USD for a lifetime ISTM membership.

As we ask for your increased level of support we want to remind you of your member benefits. ISTM Members benefit from a network of professionals from around the world with shared interests and with whom they regularly interact for professional support. Members have access to conferences, professional development activities, webinars, courses, interest groups, and online discussions. Members enjoy being part of an organization that is recognized globally as the only society dedicated to the advancement of the specialty of travel medicine. Members can belong to every one of the eight interest groups with membership in the ISTM.

At a time when some question the need for membership in professional associations, it is worth remembering that no other association is working the way the ISTM is, on a global level, for the professional development and interests of its Members in the specialty of travel medicine.

Thank you for being a member of the ISTM.

Diane Nickolson,
ISTM Executive Director

News and Resources

The 2018-2019 ISTM Fellows Class Members are Appointed!
Applications for 2018-2019 Research Awards Now Being Accepted!
CISTM16 Abstract Submission and Registration Now Open
ISTM 2018 Call for Nominations is Now Open!
Journal of Travel Medicine Article Database now Available!
May Issue of Travel Medicine News now Available!
Migration Health Conference Speaker Presentations Now Available
Online Program on "Fever in the Returning Traveller" Now Available Free for ISTM Members!
Registration for the 5 June 2019 CTH® Examination is Now Open!


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Meetings/Conferences

  • International Meeting on Emerging Diseases and Surveillance (IMED 2019)
    Vienna, Australia
    9-12 November 2019
    imed.isid.org
  • ISTM North American Review Course
    Atlanta, Georgia, United States of America
    April 2019
    www.ISTM.org
  • European Society of Clinical Microbiology (ECCMID 2019)
    Amsterdam, The Netherlands
    13-16 April 2019
    www.eccmid.org
  • American College of Occupational and Environmental Medicine (AOHC 2019)
    Aneheim, California
    April- May 1 2019
    www.acoem.org
  • 16th Conference of the ISTM (CISTM16)
    Washington DC, United States of America
    5-9 June 2019
    www.ISTM.org/cistm16

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Professional Groups

Nurses

Heather Connor
Heather Connor,
Nursing Professional Group Chair

October in Canada is a breathtaking time of year as the greenery of summer slowly gives way to vibrant reds, yellows and oranges. It is also our time for Thanksgiving, a national holiday to celebrate the end of the harvest season.

Although I initially took on the position of NPG Chair with some trepidation — unsure of what I might be getting myself into — I am thankful for Sue Ann McDevitt, United States of America, who has agreed to stay on for the next year so we can continue learning from her expertise. I'm also thankful and happy to announce that we've gained three new members on our Steering Committee: Lisa Scotland joins us from New Zealand, while Catherine Keil and Danielle Peel join us from Australia. Last but not least, Caroline Nash, Australia has been selected as our new Chair Elect. We have an exceptional team, and I'm very much looking forward to being a part of it.

This year the Nursing Professional Group has decided to highlight the contributions of nurses who are involved in travel health research. In November, an article on the work of Jutarmas Olanwijitwong in Thailand will be featured on the NPG webpage. The NPG Steering Committee has also begun a joint research project with Pharmacist Professional Group to develop a database of national and regional public health risks related to travel.

Looking ahead to the upcoming CISTM, the committee is excited to announce that we submitted and were selected to present two workshops at CISTM16 in Washington, DC "The Imperfect Travel Health Consultation" will be a session in the scientific program and "Destination Southeast Asia: An overview with case studies" will be presented as a pre-conference workshop. Please watch our webpage over the following months for updates on these and other exciting NPG initiatives. I look forward to seeing you all in Washington, DC!

Heather Connor,
Nursing Professional Group Chair

Pharmacists

The Current State of Play - Pharmacists as Travel Health Advisors in Australia

Pharmacists in Australia have only recently been allowed to vaccinate, have no prescribing rights and can only supply a limited range of medications without prescription and so, when compared to other countries, many pharmacists in Australia may consider their impact in the area of travel health to be minimal. However, pharmacists still play an important role, as over two-thirds of pharmacists report that they do advise travellers, and although few perform comprehensive pre-travel risk assessments, many offer advice on a range of important issues, especially to younger or lower risk travellers who may not see the importance of visiting a travel health professional before their journey. Other travel health professionals also recognize the important role that pharmacists play in identifying and referring higher risk travellers or those who require travel vaccines or medicines not currently available without prescription. There is a great deal of interest among the pharmacy profession and the professional representative bodies. However, the inability to vaccinate has always been viewed by many in the profession as a barrier to more pharmacists offering comprehensive travel health services, even though simple advisory services have been shown to be profitable. However, although regulations differ, in most states, pharmacists are now able to administer a limited range of vaccines (influenza, MMR and triple antigen) to adults and it is hoped that the range of vaccines will soon be expanded. However, this will require active lobbying and regulation change in each of the individual Australian states and territories and although the professional bodies seem keen to pursue these changes the busy legislative workload of some state parliaments may slow down the process. However, the profession is still keen to continue pushing for change.

Pharmacist Professional Group News

The Pharmacist Professional Group (PPG) continues to grow and develop. Three members of the PPG Steering Council recently presented posters at the International Pharmaceutical Federation (FIP) World Congress in Glasgow, Scotland (2-6 September 2018). Karl Hess presented information on the activities of the PPG as well as a needs assessment survey of its members. This survey will help to inform the PPG Steering Council of those activities and areas that membership finds of value that will help them to meet the needs of membership. These findings will also be released shortly and actioned in due course. Derek Evans, United Kingdom and Larry Goodyer, England also presented information about PPG's database of information for travellers carrying and obtaining medicines overseas.

View the ISTM PPG Database on International Regulations on Importation of Medicines for Personal Use here.

Recognizing the importance of networking with other pharmacy professional bodies to promote the benefits of greater pharmacist involvement in travel health, Derek Evans and Karl Hess also met with FIP leadership. A meeting between the FIP CEO, President, President-Elect, and staff with Derek and Karl was organized to discuss possible collaborations between FIP and the PPG in order to better meet the needs and aims of both organizations as well as the interests of its members. The FIP World Congress is one of the largest global pharmacy conferences in the world, so this was an ideal opportunity to promote the PPG and the work of travel health pharmacists to a global audience.

Finally, it is excellent to report that the work of the Chair-Elect of the PPG Steering Council, Derek Evans, has recently been awarded the designation of Fellow of the Royal Pharmaceutical Society and a Memebr of the Faculty of Travel Medicine at the Royal College of Physicians and Surgeons (Glasgow). This is the first time that a pharmacist in the United Kingdom has received the designation because of their work in the area of travel medicine, which demonstrates both Derek's hard work and commitment to travel health and the current level of importance placed on travel medicine by the United Kingdom pharmacy profession.

Ian Heslop, Karl Hess
PPG Steering Council Members


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Interest Groups

Military Travel

Military Travel Logo

Olivier Aoun
Olivier Aoun,
Military Travel Interest
Group Chair

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 a military symposium with original topics was approved for the next CISTM that will be held in Washington 5-9 June 2019. Moreover, a military pre-course was recently submitted for the same conference. We are currently working on the merchandising and promotion of the group as well as the organisation of a social program during CISTM16.

Help us in promoting our group!

Military Travel Interest Group Council

  • Olivier Aoun, France, Chair
  • Holly Doyne, United States of America, Co-chair
  • Mildred Casey-Campbell, Canada, Secretary/Treasurer
  • Peter Leggat, Australia, Scientific Coordinator
  • Sean Smith, United States of America, Local Organizer

Olivier Aoun,
Military Travel Interest Group Chair

Pediatrics

Stefan Hagmann
Stefan Hagmann,
Pediatrics
Interest Group Chair

"Advance the science of pediatric travel medicine and provide professional education about pediatric travellers" is a key point of the Pediatric Interest Group Charter.

In 2018 the Pediatric Interest Group Council decided to seek the membership's input about pediatric travel medicine-relevant topics where respondents perceived relevant practice and knowledge gaps, and more so about the preferred method of education. Our newest member to the council, Shirley Molitor-Kirsch from Children's Mercy Hospital in Kansas City, Missouri, United States of America, took the lead to develop an online survey to gather information to evaluate the educational needs of travel medicine professionals who provide care for children with the aim of guiding future educational offerings and resources. The survey was eventually distributed to the membership through the Listserv in the month of June. We would like to thank all those who took the time out of their busy schedules to read through the survey and submit their responses. The information will indeed be critical to develop educational sessions and programs at future meetings, and as a guide to think about important topics for review publications. Rest assured that the data is currently being analyzed and will be presented to the ISTM membership at the upcoming CISTM16 in Washington, DC in June of 2019. Stay tuned.

Stefan Hagmann,
Pediatrics Interest Group Chair

Digital Communications Committee

Sarah Kohl
Sarah Kohl,
Digital Communications
Committee Chair

Enhancing communication amongst our members and between our organization and the global community remains the focus of the DCC. We aim to increase the use of digital communication tools such as the internet, mobile apps, and social media to increase our networks and easily transmit information to and from each other. Our current project is learning what our ISTM members want in a website and whether adding a mobile app makes sense at this point in time. We have completed an online survey and are finishing up interviews with individual members to corroborate the findings of the survey. We thank you for your participation in the online survey and the interviews. We'll be happy to share the results once they are analyzed, formatted and reviewed by the Executive Board.

Sarah Kohl,
Digital Communications Committee Chair

Responsible Travel

Jim Bond,
Jim Bond,
Responsible Travel
Interest Group Chair

Ethics and practicalities of current schistosomiasis (bilharzia) prevention advice for travellers — a personal view

Don't go in the water!

(But if you can't help yourself, seek expert help on your return.)

This seems to be the mantra trotted out to most United Kingdom travellers to Africa, particularly if visiting Lakes Malawi and Victoria. At first glance, this sounds pretty sensible, but:

a) is it practical or helpful to a traveller visiting a paradise beach?

b) is it ethical? (and is it evidence-based?)

a) Practicalities:

As a child growing up in Zambia, I naturally learned about the risks of bilharzia (as it is more commonly called in Africa) — at school, from Orbit (a 'magazine for young Zambians') and from my mother. It was instilled in me from an early age how to make a rapid risk assessment of a stream or river for: a) bilharzia (speed of flow, reeds for snails, proximity to a village...), and b) crocodiles, hippos etc., before crossing a stream or going for a dip with friends in a tempting pool.

The above advice has apparently served me well as I went on to explore a wide range of waterways in my native Africa and Madagascar on canoe expeditions from the age of 19 - and I am still doing so at 55. I have bathed or swum in the infamous Lake Malawi (a.k.a. Lago Niassa and Lake Nyasa) at least 200 times, next to many different communities in which I know there is bilharzia present because our team has been treating it, yet I have never tested positive, despite always testing myself on my return.

How have I done it? Am I just lucky? A case series of one is hardly significant after all.

Well, it turns out, the evidence presented by experts in South Africa, including Chris Appleton, Professor of Parasitology and Freshwater Malacology at the University of KwaZulu-Natal, supports the value of informed prevention advice, i.e. to choose:

  • where to swim (more than 200 metres from a village bathing spot and reeds, preferably in deep water...)
    and
  • when to swim (in the cool of the morning when all the previous day's midday release of cercariae have died or sunk to the bottom, each having used up the limited glycogen stores in its tail).

Informed prevention advice clearly can and does work, according to his research.

b) What about the ethics of current prevention advice?

Let us consider this applying the Four Principles (+ Scope) model of medical ethical reasoning, i.e. 1) Autonomy, 2) Beneficence, 3) Non-maleficence and 4) Justice to the question:

1. Respect for Autonomy:

  • Are we really empowering our travellers with the above message to make informed decisions about whether, where and when to bathe/take a swim in the tropics?
  • Are we enabling them to understand the natural ecology and life cycle of the parasite, which includes humans as an essential host?

By explaining just a bit more, we may even ensure that travellers don't take inappropriate local advice, e.g. acquiring some praziquantel (PZQ) in-country and taking a dose immediately after exposure, since because PZQ is only effective against adult flukes, this does not render them safe from developing bilharzia and so may lead to a false sense of security.

2. Beneficence:

  • Who, if anyone, benefits from someone not going for a swim on a beautiful lake in Africa (except perhaps a foreign-owned hotel with a chlorinated swimming pool)? Does a traveller really benefit from sitting on the shore, feeling hot, sweaty, grubby?
  • Does this sort of frightening, blanket negative advice encourage international visitors - and the much needed tourist dollars they can bring to the local economy?
  • How many people do actually seek 'expert help' on their return? (And how informed are the General Practitioners they see on how to investigate, diagnose, or manage bilharzia?)

3. Non-maleficence ('Do no harm'):

  • What are the possible negative effects on local people?

As an African myself, who has spent time evaluating schistosomiasis control efforts in communities along the shore of Lago Niassa, I am perhaps more aware than most about the offence caused by Western tourists appearing to be too precious to go for a swim in the lake.

In traditional, Nyanja (literally: 'People of the Lake') culture, it is actually considered very rude for a traveller to enter someone's home or to share a meal if they have not washed (and been seen to wash) properly beforehand. Very little goes unnoticed in an African village, where foreigners are concerned.

Despite the close ties and numerous twinning arrangements between Malawi and Scotland, cross-cultural advice is still woefully inadequate.

4. Justice:

Local people usually have no choice but to source their drinking water, wash themselves, their clothes and pots in that water. Their livelihood often depends on the fish served on the tourist's plate, which was caught in that water.

Local people have to live with that risk every day. Their children's health, physical development and educational potential are all likely to be stunted by the burden of chronic bilharzia. If they get to their teenage years, their adolescent daughters are at significant risk of female genitourinary schistosomiasis (FGS), which renders them at increased risk of HIV infection, due to e.g. lesions on the cervix.

However, local people do not have access to affordable schistosomal serology tests or rapid diagnostic kits (yet), like the tourists who are visiting.

Effective informed schistosomiasis prevention advice:

In our travel clinic, we not only try to educate and empower travellers to Africa about the actual risks of bilharzia and how to minimise them (read more online), but also try to raise some awareness about the potential cultural implications of their actions and behaviour. It is someone else's home territory they have the privilege to be visiting, after all, and they should conduct themselves with understanding and respect.

We advise every traveller to have a post-travel serology test 12 weeks after last exposure, if they find they have gone in the water. The test is relatively cheap in the UK, and if negative should lead to peace of mind for the traveller. If positive, we can treat it promptly and so help to prevent the long-term sequelae of chronic schistosomiasis. Either way, it also provides a useful, clinical baseline for any future trips and exposures.

Finally, we also provide the opportunity for patients to 'give something back' via our adopted charity, the Schistosomiasis Control Initiative (SCI), with whom I have worked in the past:

A 5-tablet dose of praziquantel is prohibitively expensive in the UK £157.50 to the National Health Service (NHS) in a hospital, (£500 on a community prescription), mainly because it is not licensed here as a human drug. In the Developing World, with differential pricing, it is 40 US cents. Hence, in a 'typically African solution', we have come up with an arrangement whereby SCI donate some of their stock of tablets to us, and we simply ask patients for a £25 donation to SCI per positive case treated, which goes directly to treat up to 75 people, and in turn helps to reduce the burden of disease in Africa and Yemen, where the disease is also endemic.

This arrangement also saves the NHS money, (not only in screening and PZQ treatment costs, but it also saving having to deal with sequelae years later), which again can only be a Good Thing.

Dr Jim Bond currently works as an independent Consultant in Travel Medicine in Edinburgh, Scotland. His long-term career passions include community-led rabies and bilharzia elimination work in Africa and Madagascar, both of which he sees as eminently achievable, given the right approach and local involvement. He is Acting Chair of the ISTM Responsible Travel Group.

Jim Bond,
Responsible Travel Interest Group Chair

Travel for Work

Albie de Frey
Albie de Frey,
Travel for Work
Interest Group Chair

The Travel for Work Interest Group was formed following the regional travel medicine conference in Port Elizabeth, South Africa in September 2016. We have managed to get some structure going in spite of the fact that we have never had the opportunity to meet face to face. The Council members are:

Chair: Albie de Frey, South Africa
Chair-Elect: Michael Holzer, United States of America
Carolyn Driver, United Kingdom
Dipti Patel, United Kingdom
Douglas Randell, Australia
Herbert Schilthuis, The Netherlands

Carolyn Driver retired during the year — we are grateful for her contribution to getting the group off the ground.

The Travel for Work Interest Group aims to establish best practice guidelines and recommendations to assist employers and organizations to keep employees and members safe, healthy and productive while traveling abroad and upon their return.

The goal of this group is not to establish work place occupational health specific guidelines, requirements or standards, as these already exist within a country or industry.

Instead we have set out to, through inter-collegial consultation within the ISTM forum, provide international best practice guidelines for sending employees abroad, focusing on destination specific disease risk mitigation, access to adequate medical care and safety issues.

At the recent Pan African Travel Medicine Conference in Cape Town, a session on Travel for Work clearly identified the need to establish international best practice Fit for Work Abroad guidelines that can serve as a reference for multinational companies. Guidelines exist in the mining, public transport and construction and oil and gas industry but those mainly pertain directly to the work place rather than the working and living environment abroad, very often in places with extremely limited medical care in place. The TFW Interest Group aims to change this with the ISTM Conference in Washington in 2019 serving as a launch date.

If you are interested in joining this group, sign into your MyISTM account and join or you may contact the ISTM Secretariat (ISTM@ISTM.org).

Albie de Frey,
Travel for Work Interest Group Chair


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CTH

ISTM Certificate in Travel HealthTM Examination

Wednesday, 5 June 2019
Washington, DC,
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 HealthTM 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.

For more information about the Exam please consult the ISTM website.


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Jet Lag

Sarah McGuinness
Sarah McGuinness
Sarah Kohl
Sarah Kohl

Jet lag, that scourge of international travel, adversely affects the physical and cognitive function of travellers. Insomnia, daytime sleepiness, reduced concentration and gastrointestinal upset are frequent symptoms. A common adage is that it takes 1 day for every time zone crossed for the human body to adapt. That may be a bit simplistic since most people find eastbound travel more difficult than westbound travel. Nonetheless, it often takes several days to adapt to a new time zone.

Commercial products that employ light therapy to minimise jet lag are widely promoted to travellers, such as a sleep mask that flashes light onto sleeping travellers' eyes or ear buds that shine light into the ear canals. Although it is well established that light, including pulsed light, has profound effects on circadian rhythms, the evidence to support the use of such devices is limited. What if there was a simple way to use our phones, tablets or computers to help us adjust our internal clocks? After all, our phones travel with us and know our location. We examined multiple apps and websites that aim to do just that. Our review of the top three apps are given below.

ChronoShift App


(3 stars)
(chronoshiftapp.com)
Free

This app is designed to allow you to adjust to your new time zone, starting 3 days in advance of travel. This is truly impractical since most travellers only begin adaptation to their new time zone upon departure. Once your travel plans are entered into the app your individualized recommendations are presented in an easy-to-read interface. Recommendations include advice about when to sleep, when to wake up, and when to seek or avoid light in the three days leading up to your departure.

With permission, the app will send push notifications to your phone, making compliance with the recommendations a bit easier. Chronoshift does not include recommendations about the use of melatonin, caffeine, or naps. Likewise it does not have recommendations for or against adjusting meal times. The app is missing some destinations, such as Chennai, which means some users will have to find an alternative city in same time zone to get appropriate advice. This can and should be easily corrected.

Overall, it's a sturdy, pared-down app giving standard advice. The biggest drawback is the impracticality of starting 3 days in advance of travel; this simply isn't possible for the majority of travellers.

StopJetLag


(1 1/2 stars)
(stopjetlag.com)
Paid-$45 USD

The app works in concert with their website, but this fact is not intuitively obvious when you open the app. Your jet lag remedy is delivered to you either by email or through the app. Your plan is available in three (3) formats: daily agenda, weekly calendar, or app interface. Their emphasis is on 'natural solutions' to jet lag including exposure to sunlight, timing of meals and caffeine, and melatonin supplementation. There is a large emphasis on what type of food you eat, which is not supported in the literature.

The app interface is colorful and full of icons. Actually it's too full, it's dizzying. It appears dated and does not have intuitive navigation. The app initially seems more concerned about getting access to your email than providing plans to prevent jet lag. The advice is sound, with the exception of advice about what to eat at each meal.

Time Shifter


(4 stars)
(timeshifter.com)
In-App purchases - $10 USD/trip or $25 USD/yr

This easy-to-use app is based upon current research on jet lag. Upon launching the app it asks whether you are interested in using melatonin and your chronotype (early bird vs night owl). Once your personal data (including age and gender) is entered along with your trip details the app provides a list of do's and don'ts based upon the time of day (sleep, caffeine, light). Surprisingly, it doesn't provide advice about power napping or when to eat — both of which are established strategies in the management of jet lag.

The suggestions made are based upon screening questions such as chronotype and when you want to start adapting to your internal clock to your destination (before or after departure). You can toggle your answers in your profile to tailor recommendations for each of your individual trips.

TimeShifter and StopJetLag have similar recommendations about when to sleep, wake, eat and drink caffeine that are in line with current research. Curiously, neither of the apps discuss avoiding alcohol until adapted to local time which is important due to its effect late in the sleep cycle. Alcohol avoidance is an important piece of jet lag advice.

The first app (Chronoshift) is designed to help the traveller adjust their circadian clock to their destination time zone in the days preceding the trip. However, for most travellers, it is impractical to start adjusting sleep and wake times 3 days prior to travel, which limits the usefulness of this app.

The use of an app or website to minimize jet lag is not currently supported by scientific evidence. Advice given in the office is likely to be more detailed and helpful. For those travellers who want reminders, TimeShifter can be used as an adjunct to in-person counseling.


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TravelTalk

Talking Tough About Typhoid

Nancy Pietroski
Nancy Pietroski,
Travel Medicine News
Associate Editor

An interesting discussion appeared several months ago on the TravelMed Forum: a 61yo male was diagnosed with typhoid fever after a trip to western Africa in 2015-2016. He was noted to have been successfully treated. The diagnosis and treatment were documented in the electronic health record. He is now planning a cruise to Central America. The questions posed were: 1) Would you vaccinate for typhoid for this upcoming trip? 2) How long does natural immunity last for typhoid fever?

One responder cautioned that unless the diagnosis was made by culture in a reputable hospital, and the symptoms were classic for typhoid fever, the diagnosis should not be thought to be credible. Practitioners may have patients that have been declared to have had the disease and were treated, but may not have in fact had the disease at all. The advice was to immunize for the trip.

Another responder supplied data from the literature that showed that immunity after natural infection lasts less than a year, if exposure to Salmonella Typhi does not occur again (i.e., the person lives in a typhoid endemic area): www.ncbi.nlm.nih.gov/pmc/articles/PMC269142.

There is an ongoing outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan that began in Hyderabad in November 2016. During 2018, cases have been reported in the United Kingdom and in the United States of America among travellers returning from Pakistan.

As a reference for readers, the following information was posted on the U.S. Centers for Disease Control and Prevention (CDC) website in June 2018. Please visit this site or see other country health notices for complete information: wwwnc.cdc.gov/travel/notices/alert/xdr-typhoid-fever-pakistan.

"This strain of Salmonella Typhi is resistant to most antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone) used to treat typhoid fever. The Pakistan outbreak strain remains susceptible to azithromycin and carbapenems. Azithromycin is effective for uncomplicated (diarrhea or bacteremia without secondary complications) typhoid fever; carbapenems should be used for patients with suspected severe or complicated typhoid fever. Be aware that most (90%) Salmonella Typhi isolates from patients coming from South Asia have decreased susceptibility or resistance to fluoroquinolones, including ciprofloxacin; therefore, fluoroquinolones should not be used as empiric treatment for suspected typhoid fever in patients who have travelled to this area.

Travel medicine providers should advise that all travellers to Pakistan are at risk of getting XDR typhoid fever. Those who are visiting friends or relatives are at higher risk than tourists and business travellers. All travellers (even short-term travellers) to South Asia, including Pakistan, should get vaccinated against typhoid fever and should carefully follow safe food and water guidelines.

In returning travellers, obtain a complete travel history (asking about travel to South Asia, including Pakistan) from patients with suspected typhoid fever. Collect stool and blood cultures from patients with suspected typhoid fever and request antimicrobial susceptibility testing on isolates. Report all cases of confirmed typhoid fever to the appropriate local or state health departments."

Nancy Pietroski,
Travel Medicine News Associate Editor


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Review Course

The ISTM held its annual North American Travel Medicine Review and Update Course in Atlanta, Georgia 13-14 April 2018 at the Georgia Tech Global Learning Center. There were over 180 registered attendees from countries all over the world. The attendees included physicians, nurses, nurse practitioners, Physician Assistants and pharmacists. There were some administrative staff members as well.

The organizers, Nancy Piper Jenks, Sheila Mackell and Mary-Louise Scully created a diverse and interesting program. As always, our expert faculty is key to this meeting and bring invaluable insight and a wealth of experience. This year's speakers were Elizabeth Barnett, Lin Chen, David Hamer, Jay Keystone, Sheila Mackell, Anne McCarthy, and Mary-Louise Scully.

Topics presented included:

  • adventure travel
  • bites and envenomation
  • food and water exposures
  • ill returning travellers
  • traveller's diarrhea prophylaxis and treatment of malaria
  • special needs travellers
  • routine and travel vaccines
  • vector-borne diseases

Other topics focused on the care of special groups such as:

  • pregnant women
  • pediatric travellers
  • migrants VFR travellers
  • diabetics
  • immunocompromised travellers

There were lively discussions around ISTM case studies presented, highlighting new developments in the field.

The 2019 course is being planned for April. Watch the website for details.


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Challenging Cases: Voice Your Opinion

Mary-Louise Scully
Mary-Louise Scully
Nancy Piper Jenks
Nancy Piper Jenks

Welcome back to Challenging Cases - Voice your Opinion to see how your colleague responded to the case of schistosomiasis testing in a returning traveller. Then scroll down to read and weigh in on the next challenging case for Travel Medicine News.

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?

Catherine Streeton, Melbourne, Australia

We are not sure as to whether any of his travelling companions have been diagnosed with schistosomiasis, but irrespective of this, as the student reports having swum in potentially infected waters I would recommend testing for schistosomiasis. Both S. mansoni and S. haematobium are distributed throughout Africa, therefore, a patient with a history of freshwater exposures in these areas should have both stool and urine samples examined for eggs. However, you need to delay the urine and stool screen until at least 2-3 months from his last point of exposure to the infected water (or you may receive falsely negative test results). Serology is more sensitive for diagnosis, and can be positive earlier. Late seroconversions may also occur, so if an initial serology test is negative, depending on the epidemiological risk, another later serology should be done. Serology is positive for life, so it is not helpful in endemic populations, but useful in a first time traveller to an at risk area.

After an appropriate time interval, the laboratory tests I would order are 1) a schistosomiasis serology, 2) mid-day terminal urine analyses collected on 3 different days for S. hematobium eggs, and 3) stool samples collected on 3 different days for S. mansoni eggs. Stool or urine samples are examined microscopically for schistosoma eggs, and as they are shed intermittently, and in low amounts in light-intensity infections, may not be detected with a single urine/stool sample.

I would not treat him today empirically with praziquantel since praziquantel is only effective against the adult worm. Therefore, I would wait until 3 months after the last exposure and treat at that stage if the laboratory tests are supportive of the diagnosis.

Now, here's your next challenging case:

A 45-year-old male presents for a routine physical. He is originally from Honduras but immigrated to Canada when he was 25 years old. He is healthy, has no history of asthma or allergies. He has had no recent international travel except to Europe.

His physical exam is normal but his routine labs show a total WBC of 8.0 (Ref 4-10.0 10*3/uL) and a 9 % eosinophilia (Ref 0.0 - 5.0 %), and an absolute eosinophil count of 0.72 ( Ref 0.0- 0.40 10*3/uL).

EKG and all other labs (liver, kidney and urinalysis) are normal. You order stool for ova and parasite x 3 and all 3 return negative.

At this point, would you just reassure the patient or would you proceed with further testing, and if so what laboratory tests would you order and why?

Send all responses to maryscully.ms@gmail.com. Responses should be relatively brief, 300 words or less.

PLEASE DO NOT RESPOND ON THE Travel Med Forum.


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Journal of Travel Medicine

Journal of Travel Medicine

On 1 July, I had the privilege and honor of taking over the role as Editor-in-Chief of the Journal of Travel Medicine.

Annelies Wilder-Smith
Annelies Wilder-Smith,
Editor in Chief,
Journal of Travel Medicine

As I am still on a steep learning curve, I would like to thank Eric Caumes, the publisher (Oxford University Press), the ISTM secretariat and the editorial board for all their help to smoothen the transition. It has been a joy to liaise with the existing editorial board and set up an expanded board with Advisors, Associate Editors, Section Editors and Clinical Pearl Editors.

I am proud to say that the number of submissions is higher than ever. Our publication time has achieved a new record. With the new Advanced Publishing, we have brought down our publishing time from 6 weeks to 3 days. We understand the value of speed in publishing.

We have instituted a new category called "Clinical Pearls". Clinical pearls include unusual, or educational clinical case presentations, diagnostic conundrums or clinical management dilemmas in a traveller or migrant, often related to tropical medicine. However, interesting pre-travel case scenarios and non-communicable diseases will also be considered. The highlight of the clinical pearl is the photograph or video! Why not check out the video of our first clinical pearl: Something is emerging from the eyelid! 10.1093/jtm/tay066

Lastly, the new themed issue:

Under the dynamic leadership of Francesco Castelli, Italy and Christina Greenaway, Canada, we are currently putting together a theme issue on Migration Health which should be ready by early 2019. Until then, do have a look at our Advanced Published Articles and our theme collections here: https://academic.oup.com/jtm

I am looking forward to making the Journal better with all of you,

Deputy Editor
Eli Schwartz, Israel

Associate Editors
Kristina Angelo, United States of America
Andrea Boggild, Canada
Federico Gobbi, Italy
Eyal Leshem, Israel
Mark Riddle, United States of America

Section Editors
Basic Science in Travel Medicine, Kevin Kain, Canada
Emerging Infectious Diseases, David Freedman, United States of America
Extreme Travel, Jenny Visser, New Zealand
Global Health and Travel, Michele Barry, United States of America
Laboratory Medicine, Martin Haditsch, Austria
Malaria, Blaise Genton, Switzerland
Migration, Christina Greenaway, Canada
Non-Communicable Diseases, Gerard Flaherty, Ireland
Pharmacy, Larry Goodyer, United Kingdom
Sentinel Surveillance in Travellers, David Hamer, United States of America
Skin Diseases and STI, Eric Caumes, France
Special Populations, Elizabeth Barnett, United States of America
Travel Medicine Education, Mary Louise Scully, United States of America
Travellers Diarrhoea, Charles Ericsson, United States of America
Tropical Medicine, Michael Libman, Canada
Vaccines, Robert Steffen, Switzerland

Editors for "Clinical Pearls"
Sapha Barkati, Canada
Emmanuel Bottieau, Belgium
Christina Coyle, United States of America
Jose Munoz, Spain
Joachim Richter, Germany
Cornelia Staehelin, Switzerland
Perry van Genderen, The Netherlands

Editorial Board Members
Masatoki Adachi, Japan
Paul M. Arguin, United States of America
Buddha Basnyat, Nepal
Ronald H. Behrens, United Kingdom
Emmanuel Bottieau, Belgium
Mads Buhl, Denmark
Francesco Castelli, Italy
Santanu Chatterjee, India
Lin H. Chen, United States of America
Bradley A. Connor, United States of America
Tyler Evans, United States of America
Vanessa Field, United Kingdom
Stefan Hagmann, United States of America
Anita Heywood, Australia
George Kassianos, United Kingdom
Herwig Kollaritsch, Austria
Susan Kuhn, Canada
Thomas Küpper, Germany
Tamar Lachish, Israel
Nicky Longley, United Kingdom
Anne McCarthy, Canada
Marc Mendelson, South Africa
Andreas Neumayr, Switzerland
Hans D. Nothdurft, Germany
Salim Parker, South Africa
Androula Pavli, Greece
Watcharapong Piyaphanee, Thailand
Harunor Rashid, Australia
Lars Rombo, Sweden
Marc Shaw, New Zealand
Tadishi Shinozuka, Japan
Mike Starr, Australia
Phi Truong, Vietnam
Haibo Wang, China
Adrienne Willcox, United Kingdom
Saber Yezli, Saudi Arabia
Lorenzo Zammarchi, Italy
Rudolf Zimmer, Canada
Thomas Zoller, Germany

Annelies Wilder-Smith
Editor in Chief, Journal of Travel Medicine

JTM Jighlights
Advanced publishing has reduced the publishing time from 6 weeks to 3 days
New: Clinical Pearls
Upcoming: Theme Issue on Migration Health


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Group photo GeoSentinel Annual Meeting, May 2018, Porto, Portugal

Davidson Hamer
David Hamer,
Principal Investigator

Vanessa Field
Vanessa Field,
Chair,
Tracking and Communications
Working Group


Phillippe Gautret
Phillippe Gautret,
Chair,
Special Projects
Working Group


Kevin Kain
Kevin Kain,
Chair,
Enhanced Clinical Surveillance
Working Group


Phyllis E. Kozarsky
Phyllis E. Kozarsky,
Special Advisor
on behalf of the CDC


Karin Leder
Karin Leder,
Chair,
Data Collection
Working Group

The GeoSentinel project, which will continue to be led by David Hamer as Principal Investigator (PI) and advised by Phillis Kozarsky, Special Advisor on behalf of the CDC, has gone through Co-Investigator changes this past year. We would like to introduce you to the (mostly) new GeoSentinel Co-Investigators. At the beginning of 2018 we received many Co-Investigator applications. After a long, thoughtful process, the PI, a special ad hoc advisory team, and the ISTM Executive Board (EB) chose the following people to help lead GeoSentinel for the next four years.

Data Collection Working Group - Chair, Karin Leder, Australia

Karin is continuing her work with the Data Collection Working Group to improve the overall quality of data collection from all sites along with their work on drafting a new integrated data collection form. This new form will streamline the data collection process and help GeoSentinel collect more precise data on certain special populations including migrants, VFRs, and expatriates.

Enhanced Clinical Surveillance Working Group - Chair, Kevin Kain, Canada

Kevin is a new addition to the GeoSentinel Leadership team and we are looking forward to seeing the impact his energy and great research ideas will have on this Working Group. The multi-site study of the medium to long-term impact of chikungunya, dengue, falciparum malaria and Zika (CHIDEZIMA) will continue and the SEVTRAV project that looks at severe febrile illness in travellers will be initiated in the near future. Other new, exciting projects are being considered along with the possibility of outside funding, including an evaluation of neurocognitive impairment following severe malaria and other serious infections in travellers, and an evaluation of new fever triage tools and other point-of-care tests relevant to travel, tropical, and migration medicine.

Special Populations Working Group - Chair, Philippe Gautret, France

Philippe, another new addition to the Leadership Team, has been working on the Special Populations Working Group for some time, so he has intimate knowledge of the ongoing work of the group. He plans to work closely with the Data Collection Working Group to develop forms for prospective studies on topics such as Chagas disease, schistosomiasis, strongyloidiasis, VFR travellers, students, and older travellers.

Tracking and Communications Working Group - Chair, Vanessa Field, U.K.

Vanessa is the third new addition to the Leadership Team. With the help of the Tracking and Communications Working Group, she will continue to track illness in travellers through the daily review of data entries and quarterly regional trend assessments, and produce alerts and rapid reports for internal and external publication. The revival of the quarterly E-bulletins, and revision of the GeoSentinel web pages on the ISTM website, will help keep sites and affiliated members up to date with all the network's news. Vanessa will continue to work on strengthening existing external partnerships and look for opportunities to form new collaborations which further GeoSentinel's aims.

We would like to recognize the three former Working Group Chairs for their great contributions to GeoSentinel over the last four years: Elizabeth Barnett (Special Populations), Marc Mendelson (Enhanced Clinical Surveillance) and Patricia Schlagenhauf (Tracking and Communications).

2018 Meeting

The GeoSentinel annual meeting took place 15-17 May 2018 in a lovely beach hotel south of Porto, Portugal. Many sites presented interesting and informative cases, and there were some excellent talks such as that by Mary Wilson' on "Urbanization, Slums, and Vector-borne Infections". On 17 May, GeoSentinel held a joint meeting with TropNet at the Porto Hospital Center, Porto. This was the first joint meeting of these two groups. It allowed several projects of mutual interest to be discussed, and the potential for collaboration to be explored.

There will be a mid-year GeoSentinel meeting for those site directors attending the ASTMH Annual Meeting in New Orleans, LA, USA on 29 October 2018.