The Body of Knowledge for the Practice of Travel Medicine

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Introduction

The field of travel medicine has grown dramatically as greater numbers of people travel to exotic and remote destinations. Over 700 million travellers cross international borders annually. However, studies suggest that only a very small percent seek pre-travel health advice, and typically from practitioners who are ill equipped to provide current and accurate information. Travel medicine has become increasingly complex due to dynamic changes in global infectious disease epidemiology, changing patterns of drug resistance, and a rise in the number of travellers with chronic health conditions.

Why do we need a Body of Knowledge?

This Body of Knowledge was created to guide the professional development of individuals practicing travel medicine and to shape curricula and training programs in travel medicine. It is also expected to serve as a vehicle for establishing the content validity of a credentialing process.

What is a Body of Knowledge?

It is the scope and extent of knowledge required for professionals working in the field of travel medicine. Major content areas include the global epidemiology of health risks to the traveler, vaccinology, malaria prevention, and pre-travel counseling designed to maintain the health of the traveling public.

How was the Body of Knowledge developed?

In September 1999, the ISTM Executive Board established a group of travel medicine experts from its membership to define the scope of knowledge in the field of travel medicine worldwide. The final draft of their report was converted to survey format and mailed 110 ISTM members worldwide, who were representative of the diversity within the profession. The respondents provided further input into the relative importance of each of the content areas. The results were published in the Journal of Travel Medicine and served as the foundation for topics covered in educational courses and for the ISTM Certificate of Knowledge exam content. In 2006 the ISTM membership was asked to review the items in the Body of Knowledge and some additions were made. The current Body of Knowledge is presented below.

1. EPIDEMIOLOGY
1. Basic concepts (e.g. morbidity, mortality, incidence, prevalence)
2. Geographic specificity/global distribution of diseases and potential health hazards
2. IMMUNOLOGY/VACCINOLOGY
1. Basic concepts and principles (e.g., live vs. inactivated vaccine, measurement of immune response)
2. Handling, storage, and disposal of vaccines and related supplies

Types of Vaccines/Immunizations

Indications/contraindications, routes of administration, dosing regimens duration of protection, immunogenicity, efficacy, potential adverse reactions and medical management of adverse reactions associated with the following vaccinations/combination vaccinations:

3. Bacille Calmette-Guerin
4. Cholera
5. Diphtheria
6. Encephalitis, Japanese
7. Encephalitis, tick-borne
8. Haemophilus influenzae type B
9. Hepatitis A
10. Hepatitis B
11. Hepatitis A and B combined
12. Immune globulin
13. Influenza
14. Measles
15. Meningococcal
16. Mumps
17. Pertussis (DTaP)
18. Plague
19. Pneumococcal
20. Poliomyelitis
21. Rabies
22. Rubella
23. Tetanus
24. Typhoid
25. Varicella
26. Yellow Fever
3. PRETRAVEL CONSULTATION/MANAGEMENT

Patient Evaluation

1. Relevant medical history (e.g. previous vaccinations, allergies, chronic illness)
2. Evaluation of travel itineraries/risk assessment (e.g. pre-existing activities, travel to rural vs. urban areas)
3. Assessment of fitness/contraindications to travel (e.g. pre-existing illness, fitness to fly)

Special Populations

Unique management issues pertaining to the following populations:

4. Athletes
5. Corporate travellers
6. Disaster/relief workers
7. Elderly travellers
8. Infants and children
9. Immigrants/expatriates
10. International adoptees
11. Missionaries/volunteers
12. Pregnant travellers
13. Students
14. travellers with chronic diseases (diabetes, chronic obstructive pulmonary disease, cardiovascular disease)
15. travellers with disabilities
16. travellers who are immunocompromised, including HIV and AIDS
17. VFR's (those visiting friends and relatives in their countries of origin)

Special Itineraries

Unique management issues associated with the following activities/itineraries:

18. Cruise ship travel
19. Diving
20. Extended stay travel
21. Extreme/wilderness/remote regions travel
22. Last minute travel
23. Mass gatherings (e.g. the Hajj)
24. High altitude travel
25. Travel to areas experiencing disease outbreaks
26. Air travel

Prevention and Self Treatment

27. Travel health kits
28. Chemoprophylaxis
    1. Malaria
    2. Travellers' diarrhea
    3. Filariasis
    4. Altitude illness
29. Self treatment (e.g. diarrhea, malaria)
1. Malaria
2. Diarrhea
30. Personal protective measures (e.g. restriction of outdoor activity at dawn and dusk and barrier protection [e.g., bed nets, insect repellents])

Precautions (and reasons for precautions) regarding:

31. Food consumption
32. Water consumption and purification
33. Contact with fresh and salt water
34. Walking barefoot
35. Animal contact (including birds)
36. Close interpersonal contact (e.g. sexually transmitted diseases)
37. Safety and security
4. DISEASES CONTRACTED DURING TRAVEL

Geographic risk, prevention, transmission, possible symptoms and appropriate referral/triage of:

Diseases Associated with Vectors

1. African Tick Bite Fever
2. Dengue
3. Encephalitis, Japanese
4. Encephalitis, tick-borne
5. Filariasis (e.g. Loa loa, bancroftian, onchocerciasis)
6. Hemorrhagic fevers
7. Leishmaniasis
8. Lyme
9. Malaria
10. Plague
11. Rift Valley Fever
12. Trypanosomiasis, African
13. Trypanosomiasis, American
14. Typhus Fever
15. West Nile
16. Yellow fever
17. Other (Emerging Infections)

Diseases Associated with Person-to-Person Contact

18. Diphtheria
19. Hepatitis B
20. Hepatitis C
21. Influenza
22. Measles
23. Meningococcal disease
24. Mumps
25. Pertussis
26. Pneumococcal disease
27. Rubella
28. Sexually transmitted diseases
29. Tuberculosis
30. Varicella
31. Other

Diseases Associated with Ingestion of Food and Water

32. Amebiasis
33. Cholera
34. Cryptosporidiosis
35. Cyclosporiasis
36. Giardiasis
37. Hepatitis A
38. Hepatitis E
39. Poilomyelitis
40. Seafood poisoning/toxins
41. Transmissable spongiform encephalopathy
42. travellers' diarrhea
43. Typhoid fever
44. Other

Diseases Associated with Bites and Stings

45. Envenomation (e.g. jelly fish, sea urchin, scorpion, snake, spiders)
46. Herpes B virus
47. Rabies

Diseases Associated with Water/Environmental Contact

48. Cutaneous larva migrans
49. Legionella
50. Schistosomiasis
51. Tetanus
5. OTHER CONDITIONS ASSOCIATED WITH TRAVEL

Conditions Occurring During or Immediately Following Travel

Symptoms, prevention, and treatment of:

1. Motion sickness
2. Barotrauma
3. Thrombosis/embolism
4. Jet lag

Conditions Associated with Environmental Factors

Symptoms, prevention and treatment of:

5. Sunburn, heat exhaustion and sun stroke
6. Frostbite and hypothermia
7. Respiratory distress/failure (associated with humidity, pollution, etc)
8. Altitude sickness

Threats to Personal Security

Precautions regarding:

9. Accidents (e.g. motor vehicle, drowning)
10. Other transportation
11. Violence-related injuries

Psychocultural Issues

Unique management issues associated with:

12. Culture shock/adaptation (e.g., travellers, refugees)
13. Repatriation
6. POST-TRAVEL MANAGEMENT
1. Screening/assessment of returned travellers
2. Emergencies and triage
3. Conditions requiring referral to a specialist

Diagnostic and management implications of the following symptoms:

4. Diarrhea
5. Eosinophilia
6. Fever
7. Nausea and/or vomiting
8. Respiratory illness
9. Skin problems
10. Other
7. GENERAL TRAVEL MEDICINE ISSUES

Medical Care Abroad

1. Procedures and considerations regarding locating medical care and recommendations regarding access of medications in resource-poor areas
2. Blood transfusion guidelines for international travellers
3. Limitations of standard medical coverage during international travel and alternative medical insurance for international travellers
4. Aeromedical evacuation

Travel Clinic Management

5. Equipment
6. Supplies and disposables
7. Resources for laboratory testing
8. Documentation and record keeping (e.g. vaccination certificate requirements, reporting of adverse events)
9. Infection control procedures
10. Management of medical emergencies

Travel Medicine Information/Resources

11. International health recommendations/advisories (e.g. World Health Organization and national public health organizations)
12. International Health Regulations
13. National/regional recommendations, including national/regional differences
14. Information for travellers

Conclusion

The field of travel medicine encompasses a wide variety of disciplines including epidemiology, infectious disease, public health, tropical medicine, immigrant and refugee health, and occupational medicine. As a unique and growing specialty, it has become necessary to establish standards of practice in the field. These standards have been established to identify the scope of competencies expected of travel medicine practitioners, guide their professional training and development, and ensure an acceptable level of patient care.

This Body of Knowledge serves as the basis for the Certificate of Knowledge examination that is available through the ISTM for all travel health professionals. This exam is currently administered prior to the biennial ISTM conferences. Consideration is being given to administration of the exam in conjunction with other meetings and at other venues. Practitioners who successfully complete this examination will be awarded a Certificate in Travel Health (CTH®) by the ISTM. Information about the Certificate of Knowledge examination is available at www.istm.org.