International Society of Travel Medicine
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February 2015

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President's Message

David R. Shlim
David R. Shlim

What separates someone who is just starting out in travel medicine from someone who is considered knowledgeable in travel medicine? How do you go from just practicing travel medicine to being consulted as an expert in the field?

Nearly two thousand people have earned the Certificate in Travel HealthTM since it was first offered in 2003. However, the CTH® was conceived as an entry-level exam, not as a board exam. After you take the exam, you need to further understand travel medicine to master the subject.

People who are just entering the field tend to look to textbooks of travel medicine, which are a good start, and soon learn how to use the key references that are used day-to-day, which include subscription services, the CDC Health Information for International Travel, and other material generated in one's own country. However, to go from skilled translator of travel medicine advice for the traveler to someone who truly understands how that information is created is what separates the expert from the average practitioner.

One of the primary activities of travel medicine is to recommend appropriate immunizations for travelers. Knowledge of what is recommended for certain destinations is just the start. How effective is the vaccine? How was that determined—in local people or in travelers? How many studies were done? What kind of vaccine is it? How long does immunity last? How is that measured? The answers to all of these questions are in the book, Vaccines (edited by Plotkin, Orenstein and Offit), which I consider the primary text in the field. At a minimum, every travel medicine practitioner should read the entire chapter on each of the vaccines that we use (or an equivalent text in one's own language, if available).

The decision to recommend malaria prophylaxis may not be a yes or no question. The risk in some parts of the world—West Africa for example—are so high that everyone should take prophylaxis. Other parts of the world have no risk. The difficult areas are locations where risk may exist, but is so low or uncertain that some people would elect to not take prophylaxis, such as many parts of Central America and Southeast Asia. Understanding how malaria risk data is obtained and interpreted—whether through data from local clinics in the destination country, or actual experience of travelers—is a step towards travel medicine expertise.

Travelers' diarrhea is no longer as simple as it once appeared to be. The sudden onset of diarrhea could once be treated with ciprofloxacin for 1-2 days with almost complete assurance that it would work. Now, resistant organisms, the growing understanding of the effects of antibiotics on our bioneme (the ecology of organisms in our intestines and elsewhere), the risk of carrying resistant organisms, and the concerns about persistent diarrhea after travel have all clouded the once simple approach. Coming to understand how this all fits together and what the future may hold is another area that travel medicine practitioners will need to track.

Other mosquito-borne diseases are continuing to plague the world, particularly the rapid and continuing rise of dengue that began a few years ago, and the more recent spread of Chikungunya, which is similar to dengue, but with the risk of persistent arthralgias. Knowledge of these diseases requires an understanding of the vectors, and where they currently exist, and which countries are receptive to further spread.

Uncertainty about rabies prevention is something that plays out on the ISTM listserv more than any other disease. My understanding of rabies was greatly enhanced by what I consider the classic book in the field, The Natural History of Rabies, 2nd edition, edited by George Baer. Unfortunately, this book is out of print and extremely expensive ($300 to $700 on used book websites), but may be available in some university libraries. The book explains all the early studies that confirmed our understanding of rabies.

Finally, it will become clear that one person can't really educate him or herself adequately without relying on other experts. Where can you meet these experts? The single best opportunity is at the Conference of the International Society of Travel Medicine that is held every two years. This year's meeting is in Quebec City, Canada, from 24-28 May, 2015. I can't overstate the value of personally meeting travel medicine practitioners from all over the world, asking them questions about what they do, and starting to explain to newer people what you have now learned. The ISTM is one of the friendliest, most cohesive medical societies in the world, with a gratifyingly rich mix of international members.

This year we have the opportunity to hold our meeting in one of the world's best conference centers in a visually beautiful, fun city with great eating options. This meeting is the one meeting in my life that I get to host as president, and I would really love to see you there, to continue to push our knowledge of travel medicine, and to enhance the friendships that have evolved at this meeting over the past twenty-four years.

We should also acknowledge the good motivation that we need to take care of our traveling patients. We want to prevent suffering as skillfully as we can, and treat suffering when it is already occurring. I had an opportunity to study compassion in a new way when I worked in Nepal and voluntarily offered medical cared for a Tibetan Buddhist monastery. This interest eventually resulted in a book that was published in 2004, entitled Medicine and Compassion. This May, a second edition of the book is being published by Wisdom Publications, in conjunction with Simon and Schuster. For those of you with an interest in investigating the nature of compassion and how one's own capacity for compassion can be increased, I highly recommend this book. Skillful travel medicine, and a compassionate attitude towards applying it: what better way is there to express the purpose of the International Society of Travel Medicine.

David R. Shlim, MD, President


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Editor's Note

Christopher Van Tilburg
Christopher Van Tilburg

The road that connects the border stations near the small town of Futaleufu, Chile, and the only slightly-larger town of Esquil, Argentina, is gravel. You just can't drive fast—in fact, my team walked 0.5 km stretch as we wrapped up a 3-week adventure in Patagonia and began the long journey home. Small outposts on either end of the road were staffed with small, friendly, smiling border personnel. The day was sunny, warm and calm, with towering mountains and crystal-clear rivers surrounding the grassy farmlands. Our bellies were full of breakfast: fresh granola, farm eggs, homemade yoghurt, fresh-baked bread, fruit. Barely a half-day later, I was racing through Buenos Aires transferring airports with a tight connection—no way was I missing my flight. When I told the driver I'd make it worth his while to get me through rush hour traffic, I had no idea he'd be zooming through traffic, on and off the expressway, into back alleys, and through red stop lights. We narrowly avoided collisions every few minutes. And there were no seatbelts.

car

Possibly one of the most rewarding aspects of travel is new experiences. One minute I find myself in a quiet rural contemplative moment on a gravel road border station with friends; the next minute it's an adrenaline-fused, life-threatening inner-city taxi ride. I'm thankful for airport lounges.

Herein is another issue of Travel Medicine News—filled with new experiences. Much change and growth is afoot in the ISTM, and it's all outlined here. The secretariat has a much needed new office and new staff. CISTM14 is right around the corner (reserve your spot for Certificate of Travel Health exam now) and most of the Professional Groups have gatherings and pre-conference workshops. MyISTM.org has some new features: namely the Member Advantage Program and Special Travel Alerts. The Professional Education Committee has a new Webinar Program.

Destination Support Interest Group has been renamed Responsible Travel Interest Group. Student Travel Abroad Group has newly formed. And GeoSentinal is moving forward with a new leadership team.

One final bit of innovation: Travel Medicine News is seeking a non-North American Associate Editor to help with contributions to our quarterly newsletter, published online with the end-of-year issue in Print. Please contact me via MyISTM.org with interest. See you all in Quebec City!

Christopher Van Tilburg, MD, Travel Medicine News Editor


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Secretary-Treasurer's Report

Peter A. Leggat
Peter A. Leggat

ISTM President and Counsellor Elections: Your Vote Requested by 5 March

ISTM has electronic voting for the 2015 Presidential and Executive Board Elections. I encourage all ISTM members to review the candidate information and vote for the various positions available. The balloting system is open for 60 days, and you may cast your vote at any time prior to 6 March 2015.

Before voting, you have the opportunity to:

  • Review the statements provided by each of the candidates on the ballot,
  • Submit any questions you have of a candidate directly to that candidate's email address provided, and
  • Review the election guidelines and current Executive Board Members you can also find on the ballot.

Like a number of other global organizations, the 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 can receive representation.

Emails are being sent to all ISTM Members in good standing directly from the independent balloting company. If you have not yet voted, please watch your email, for reminders to vote are being sent to those who have not recorded their vote. You do not need to vote immediately when you access the actual ballot. You may revisit the ballot as often as you wish. Your actual vote is not recorded until you submit it, but please be sure to submit your vote prior to the 6 March 2015 deadline. If you have not received your email, please contact the ISTM Secretariat at ISTM@ISTM.org .

There are three positions up for election this year and candidates for each of these positions are as follows:

  • Candidates for President-Elect: Eric Caumes, France, and Leo Visser, The Netherlands
  • Candidates for Counsellor 1: Gerard Flaherty, Ireland, and Effrossyni Gkrania-Klotsas, United Kingdom
  • Candidates for Counsellor 2 [Nurse]: Irmgard Bauer, Australia, and Claire Wong, New Zealand

A nominating committee, in accordance with criteria set out in our bylaws, was formed by the ISTM Executive Board and selected these candidates from the nominations received.

Please note that the Board that will be in place in May of 2015 to serve with the successful candidates will be:

Annelies Wilder-Smith, Singapore, President
David Shlim, United States of America, Immediate Past President
Davidson Hamer, United States of America, Counsellor
Marc Mendelson, South Africa, Counsellor

Thank you in advance for participating in this ISTM election.

Québec City CISTM14 and ISTM-CTH®

CTH

Finally, please make sure you have saved the key dates for upcoming CISTM14 in Québec City, Canada, 24-28 May 2015, so you take advantage of the great program being developed, as well as visit (or perhaps revisit) a wonderful location to catch up with friends and colleagues. The ISTM Certificate in Travel HealthTM Exam will also take place there on 24 May 2015. See www.ISTM.org for more information.

Peter A. Leggat, MD, Secretary-Treasurer


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From the Secretariat

Diane Nickolson
Diane Nickolson

These first two months of 2015 has brought a number of exciting changes for us at the Secretariat. We moved our office the first week of January and we are all settling into our new space. It's such a pleasure to be in this new, open office in a building that offers such great amenities. We are still putting pictures on the wall and settling in, but wanted to share a couple of photos with you. Our new location is much more accessible for commuting, with access to major thoroughfares.

 

Click here to view photos

Also in January, Jodi Metzgar moved down to Atlanta from Chicago to accept the position of Managing Director of Projects (just in time to miss the worst of the Chicago winter!). Jodi brings a wealth of knowledge and experience to the ISTM. Jodi and I worked together a number of years ago for another international medical society, and Jodi went on from there to serve as Executive Director of two small national societies in an association management company. It's been such a pleasure and bonus for us to have Jodi with us and able to begin contributing immediately - her first week she took on a number of projects and has been steadily moving them forward and taking on more.

In the first week of this month Amara Ugwu joined the Secretariat as our part-time temporary intern. Amara is taking on the CISTM speaker tracking, correspondence and coordination from Sarah Thomas, and will also support Daveen Capers with the CISTM registration activities. Amara is finishing up work towards her degree and will be with us through the CISTM this May.

As we are in the midst of a very busy time at the Secretariat with the membership renewals, presidential and board elections, preparing for the CISTM14, the course and exam, supporting GeoSentinel 2.0, and establishing new programs like the member-benefit webinars, the foundation and member advantage program -- we can use all of the help we can get.

With the expansion of the Secretariat we've made a few changes to our staffing plan. Jodi's focus will be on GeoSentinel, providing support to the ISTM Groups, the Research Committee, educational programs and projects, and as back-up to me with the Executive Board and CISTM activities. Elena Axelrod will continue in her role managing our financial transactions and GeoSentinel data. Daveen's focus continues to be member and customer service, though she also has taken on a support role in sponsor and exhibitor outreach and service. Sarah's time is largely devoted to the GeoSentinel project, but also helps with member and customer service during these busy times. Sarah is continuing to manage our social media programs until we are fully staffed, and is coordinating the CISTM speaker communications.

We are one person short of being fully staffed. We are searching for a full-time marketing and communications support person, who will work with me on advertising, promotions, marketing, communications, the newsletter, the website, member recruitment, member retention, and social media activities like My ISTM. I'm expecting this new person to be in place soon.

It is an exciting time to be here working with the ISTM. At the direction of the ISTM Board, we have been focused on increasing and offering new member benefits, enhancing our existing programs and supporting the society's contributions to the field of travel medicine.

Diane Nickolson, Executive Director


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Upcoming Meetings

Travel Medicine Review Course: 17-19 April 2015 in Toronto, CA
istmsite.membershipsoftware.org/certificateofknowledgerc

CISTM14: 24-28 May 2015 in Québec City www.istm.org/cistm14


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Society News

ISTM Member Special Travel Alerts

Did you know ISTM members have access to special travel alerts generated only for ISTM members from iJet, Sitata and HealthMap? We are thrilled to report that these three services have been gathering the most compelling alerts on a weekly basis just for the members of ISTM. You can find these alerts and more on the home page of My ISTM at myistm.istm.org/home.


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ISTM Member Advantage Program

Member Advantage Program
Look for this logo to find the
ISTM Member discounts!

What do Air Ambulance Card, Gideon Ebooks, Inca Clinic, Sitata, SteriPen, Shoreland Travax, Travel Care International and Wiley Publishers have in common? In addition to supplying travel medicine practitioners and travellers with important travel support products and programs, they are official ISTM Member Providers. What does this mean to you? As ISTM Members you are eligible to receive exclusive discounts off programs and products offered by these providers. The society is working towards negotiating special discounts with the suppliers you use every day - so that you can save more on these products than what you spend on your annual dues.

The discounts and how to access them are explained in detail on this page of the MY ISTM website. [myistm.istm.org/resourcesandtools/memberadvantageprogram.] Keep this link handy, for we are adding new providers continually - you won't want to miss out on these special savings!


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CISTM14

CISTM14 Update

Delegates have been registering for the CISTM 14 in record rates - we are anticipating one of the highest attended conferences in ISTM history. Many ISTM members are hard at work on the conference to ensure an amazing event with spectacular scientific sessions, social events and more. The CISTM14 information at www.ISTM.org has a wealth of information about the conference, including an update of the scientific sessions confirmed to date. The Scientific Program Committee is constructing the program and we anticipate it will be available in March. Highlights of this special event include:

Social Tours
  • Plenary Scientific Sessions: One scheduled for each day of the conference, the plenary sessions are on some of the most compelling travel medicine topics (presentation titles and speakers information on the website):
  • Our Shrinking World: Health in the 21st Century
  • Travellers' Diarrhea: What's New?
  • Vaccinations: Challenges and Opportunities
  • Malaria in the 21st Century

Pre-CISTM Courses. Scheduled on 24 May right before the Opening Ceremonies, one of these three courses are bound to be of interest to you:

  • Pediatric Travel Medicine: what we know, what we think we know and what we actually end up doing!
  • Expatriates and Lethal Health Threats - Planning, Preparation and Support Learning from Ebola
  • A Focused Review of Some Topics in Travel Health for Pharmacists

Social Tours for Delegates. Consider arriving a bit early to participate in one or more of these special tours only available to CISTM delegates and guests:

  • Whale Watching Cruise Adventure
  • Walking Tour of the Old Québec City
  • Flavor Trail of the Island of Orleans
  • Nature Walk at Canyon Ste. Anne

Sponsored Satellites. The CISTM14 has secured four company-sponsored satellite programs:

  • Monday 25 May Lunch: Exploring new vaccine candidates for travellers' diseases: norovirus sand dengue fever presented by Takeda
  • Monday 25 May Evening: presented by GSK
  • Tuesday 26 May Lunch: “The Changing Landscape of Enteric Diseases: What's Old is New Again” presented by PaxVax
  • Wednesday 27 May Lunch: presented by Novartis

Exhibition. Twenty-five exhibitors have confirmed attendance to date, and we hope there will be more. The exhibition at the CISTM14 promises to be one of the largest gatherings of travel medicine suppliers. There will be ample time to explore the exhibition as it will be open to the delegates during the welcome reception, lunches and tea breaks.


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Standing Committees

Kenneth Dardick
Kenneth Dardick

Exam Application Deadline Date is 8 April 2015

The next CTH® Examination will be offered on Sunday, 24 May 2015 immediately preceding the opening ceremonies of the CISTM14 in Québec City. Detailed information about the CTH® program and the examination are available on the ISTM website at www.ISTM.org.

The ISTM Certificate in Travel HealthTM, developed by an international panel of travel medicine experts representing a variety of professional disciplines, is granted to candidates who pass the examination and recognizes their individual excellence in knowledge in the field of travel medicine associated with pre-travel care and consultation. The Certificate is the first step in the ISTM Travel Medicine Continuous Professional Development Program. The exam focuses specifically on the level of knowledge that is necessary to practice travel medicine and the understanding of specific tropical diseases and treatments is limited to that which should be known to advise travelers (for example, in the diagnosis and treatment of traveler's diarrhea or rabies immunoprophylaxis), including post-travel triage of travelers and post-travel screening. Knowledge of tropical medicine is not required.

ISTM members who have been awarded and maintain the Certificate will be recognized in the ISTM Directory of Travel Medicine Providers and within the Global Travel Clinic Directory on the ISTM website.

Kenneth Dardick, MD, Examination Committee Chair

Professional Education Committee

New ISTM Member Benefit Webinar Program

Sarah Kohl
Sarah Kohl
Lin Chen
Lin Chen
Mary-Louise Scully
Mary-Louise Scully

The Professional Education Committee has a new ISTM member benefit - no fee webinars.  Periodically throughout the year we are now offering interactive online seminars designed to help the practicing clinician stay abreast of critical topics in travel medicine. Experts from around the world deliver engaging and practical programs; and afterwards they answer your questions. You will want to register early as only 300 seats are available free to ISTM Members. If you cannot attend the live webinar, the recordings are made available for a small fee in your member online learning area of the ISTM website. 

On November, 142 people were able to attend Dr. Peter Hackett's presentation "Is Your Traveler Going to High Altitude?"  Moderated by David Shlim, we learned why people suffer from altitude illness, when and how to use medication, and enjoyed a lively question and answer session full of helpful insights and pearls of wisdom. If you missed this engaging and practical webinar you can watch the replay in the online learning area.

Future webinars are in development and possible topics include Travellers' Diarrhea, Malaria, Dengue, and Chikungunya. Watch your email and the ISTM website as information will be posted as soon as available. 

Sarah Kohl, MD, PEC Webinar Co Chair
Lin Chen, MD, PEC Webinar Co Chair
Mary-Louise Scully, MD, Professional Education Committee Chair

 

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Professional Groups

Nursing Professional Group

Carolyn Driver
Carolyn Driver

The NPG steering council is now in full swing with our planning for CISTM Québec, in May. We will be having our traditional nurses welcome meeting at the beginning of the conference. We look forward to meeting our Nurse members and finding out how they would like the Professional Group to represent them within ISTM. We will also be honoring our first recipient of the Distinguished Nurse Leadership award.

We do understand however that not everyone is fortunate enough to be able to travel to Quebec City and so we will also be setting up a survey to get some feedback from you all so look out for the postings about this soon.

In the meantime do explore the My ISTM section of the website and make sure you are registered as a member of the NPG (this is not automatic). We really would like to make full use of the ability to have nurse specific discussions and to support each other via the new “community” section of the website. We now have a CTH® study Group within our community where we hope members will be able to give each other support prior to the CTH® exam in May.

Within the council we will be saying goodbye to some of our members this summer as their terms of office come to an end and so will need to replace them. Opportunities to be part of a truly international committee don't come along every day so please consider serving on the council. We hold conference calls every couple of months and communicate in between by email so being a member is not onerous but we would welcome enthusiastic members with fresh ideas especially from outside North America and the UK. If you would like to know more then you can contact us via our section of the ISTM website and we will be delighted to tell you more.

Carolyn Driver, Nursing Professional Group Chair

Pharmacist Professional Group Activities

Claudine Leuthold
Claudine Leuthold

At the 2015 conference in Quebec, PPG will hold a pre-conference course entitled ‘A Focused Review of Some Topics in Travel Health for Pharmacists' with examples from various countries and focus on the new regulations in Canada which offer pharmacists more opportunities in travel medicine.

We encourage all participants who are interested by this preConference Course to register; Pharmacists are invited to join the PPG Reception which will follow the preconference Course (see Program).

The presentation on vaccines will cover issues such as the immunocompromised traveller, planning regimens and, in particular, when not to give a vaccine.

Advice and recommendations for different categories of travellers can vary greatly. Those issues relating to a wide variety of travel situations will be considered in order to better inform a pharmacy based travel health consultation .One of the most popular activities undertaken during leisure travel is diving . Many travellers will attend a dive school not realising that certain medical conditions or flying within 24 hours of diving can contribute to decompression problems. The pharmacist's extensive knowledge of medication to treat and prevent dive related issues is useful when advising deep see divers.

Other topics that will be addressed include the challenges and opportunities in a community pharmacy based travel clinic, pre-travel risk assessment and the frequently addressed, but very important topic of malaria - in this instance, specifically for travel to Africa.

It is the intention, that at the end of this course, pharmacists, and other healthcare professionals who attend, will be better equipped to deal with a wide range of key areas in travel medicine.

Lee Baker, Co-chair of PPG, will introduce the pre-conference course and the following topics will be presented. The covered topics will be (please see also the program):

  1. Brian Stowe: Steps for success: Incorporating travel clinic services into your pharmacy practice, including an introduction into travel health.
  2. Derek Evans: Consultation styles for pre-travel risk assessment.
  3. Larry Goodyer: Types of travel - from wilderness to business.
  4. Jeff Goad: Vaccines: Required, Recommended and Routine
  5. Derek Evans: Pharmacists insight into safe diving.
  6. Lee Baker: Malaria in Africa - the Good, the Bad and the Ugly.
  7. Brian Stowe: A community pharmacy based travel clinic: Challenges and Opportunities - summing up.

Special Message for PPG's members

Dear Pharmacist Professional Group member,

We would be very grateful if you would consider taking part in a short anonymous survey concerning your involvement in Travel Medicine. The survey examines the activities of community pharmacists regarding the delivery of travel medicine services. In whatever capacity you are working completing the survey will be of benefit to our own research and as information to the ISTM in further engaging pharmacists. Please click on the link below or paste into your browser; it should take no more than 5-10 minutes of your time.

www.surveymonkey.com/r/JZMHGFK

Claudine Leuthold, Pharmacist Professional Group Chair


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Interest Groups

Responsible Travel Interest Group

Sheila Hall
Sheila Hall

After much discussion and debate we have finally emerged with our new title which we hope will reflect our aims and objectives more clearly. (Easier to remember than “Destination Community Support Interest Group”!)

Our ethos remains the same in that we are keen to explore, highlight and discuss issues and topics that are perhaps not in the general remit of Travel Health e.g. cultural awareness, responsible travel, eco travel, sex tourism, volunteer travellers, and the effect of travel and tourism on host countries. If you agree - or disagree - about these issues, then please come and chat to us at the conference in Quebec. We are delighted to have been granted space in the exhibition area where we can meet our group members and hear your views and opinions.

We hope to have some interesting video clips to stimulate discussion - so look forward to seeing you. If you are not able to join us in Quebec, please do sign up to be a group member (free of charge via the ISTM web site) and feel free to contact us by email.

Sheila Hall, Responsible Travel Interest Group Chair

Pediatrics

Mike Starr
Mike Starr

We're looking forward to seeing many of you in Quebec for CISTM14.  We'll be running a Pre-conference Course: Pediatric Travel Medicine: what we know, what we think we know and what we actually end up doing!  We'll cover a range of topics of interest to those who see children in their travel clinics:

  • VFR parents and children
  • How to convince parents to immunise their kids
  • Travellers diarrhoea
  • Making travel safer
  • Children with special needs
  • "Go or not go?" - who's too unstable to travel?

The panel will be John Christenson, Stefan Hagmann, Sarah Kohl, Eyal Leshem, Sheila Mackell and myself.

We'll discuss the evidence, expert opinion, common practice and some controversies.  We'd love to see you there and hear what you have to say too.?

Mike Starr, MD, Pediatrics Interest Group Chair

Psychological Health of Travellers Interest Group

Mike Jones
Mike Jones

The Psychological Health of Travellers Interest Group was formed after CISTM in the Budapest in 2009. Dr Ted Lankester was its first Chair and Dr Tom Valk took over in 2012. My fellow committee members are Dr Tony Abaya, Dr Sung Mo Chung, Dr Ted Lankester, Kathy Smith and Dr Tom Valk and it was my happy privilege to take over as Chair from Dr. Valk after election in September 2014. By way of introduction I worked in Tanzania at a teaching hospital from 1976 to 1982 and helped set up a health care charity, HealthLink360 in 1983 dedicated to providing whole person health care for volunteers working in developing countries.

After finishing as Medical Director in 2006 I continued as an Honorary Consultant. I was also a Consultant in Infectious Diseases in NHS Lothian in Edinburgh until late 2014. In 2007 I joined the newly formed Board of the Faculty of Travel Medicine at the Royal College of Physicians and Surgeons of Glasgow and was delighted to be elected Dean in 2012. Since 2002 I have travelled every year to Charlotte, North Carolina for a Mission agency SIM (Society for International Ministries), which has 1000 personnel scattered across the globe, and have hugely enjoyed being on their International Health Advisory Committee.

We are a group of Travel Medicine Practitioners who know that Travel Medicine is not just about needle jabs and anti-malarials, particularly for longer term travellers, for whom travel is not the passing dream o the tourist, but the reality of adapting to and coping with everyday life in a different culture and location away from home. We are interested in pre-travel selection for longer term expatriates, enhancing resilience, the issues of cultural adaptation, coping strategies for chronic cultural stress, post-traumatic stress disorder and the care of the person returning to their old culture. Several of us know that final return is much tougher than working through initial culture shock.

Those of us who have been conducting candidate medicals for Ebola volunteers, particularly look forward to a really stimulating program at our Ebola-themed Preconference Symposium at CISTM14 in Quebec City on Sunday afternoon 24th May. Dr. Tom Valk was a US Army Psychiatrist and will lead on ‘Advising organizations dealing with a crisis'. Group Captain Andy Green of the Royal Air Force will talk from practical experience organizing the British response to Ebola in Sierra Leone on ‘The human element in planning a crisis response'. Dr Simon Clift is the Director of Health Services at InterHealth in London and will guide our thinking about ‘Preparing the humanitarian volunteer'. Lineke Westerveld-Sassen, from InterHealth in Nairobi, will speak on ‘Caring for the volunteer on-site and on return' and I will close off with some insights into the experience of Ebola survivors.

We look forward to seeing you in Quebec City. Please come to our Interest group meeting and help us expand our horizons.

Mike Jones, MD, Psychological Health of Travellers Interest Group Chair

Student Travel Abroad Interest Group

Sarah Kohl
Sarah Kohl
Gail Rosselot
Gail Rosselot

Announcing New ISTM Special Interest Group: Student Travel Abroad

In response to a request from more than 80 members last summer, ISTM has initiated a new multidisciplinary special interest group that focuses on the student traveler- Student Travel Abroad (STA). This group is now starting to organize, and as we do, we welcome as members every ISTM professional with interest, qualifications or special experience in student health.

Students who travel for education, community service, pleasure or employment are a rapidly expanding population for travel medicine providers. Many institutions of higher learning encourage students to spend at least some of their time studying abroad. Increasingly, younger students are spending summers engaged in international enrichment programs. Older students are returning to school or participating in short-term global learning opportunities. As more students, of every age, travel internationally, this population is of growing interest to the travel medicine community.

The over-riding goals of STA are to meet the clinical and professional needs of its members and advance our understanding of quality travel health services for students. Professional networking will be an important activity for this group.

Additional start-up goals under consideration include:

  • Raising awareness of the unique issues that impact student travelers.
  • Developing evidence based best practices in the care of students during all three phases of travel- before, during, and after travel.
  • Helping develop tools to reduce student travel risk.
  • Promoting educational and research initiatives to improve the health of student travelers.
  • Working closely with other ISTM committees, professional groups and other special interest groups to promote the health of student travelers.

In a recent survey, some new STA members shared their suggestions for future group projects, such as developing a bibliography specific to student travel, exploring the use of social media to counsel this population, evaluating clinic models for maximum efficiency, and documenting current practices in the use of HIV PEP for health science students working abroad. It is evident that pre- and post-travel issues for students are many and varied the world over.

So far 48 members have enrolled in the STA. We invite you to go to www.istm.org and join us. ISTM members can participate in more than one special interest group and a strong, multi-disciplinary STA membership can best help us meet student travel health challenges. As the newest special interest group we welcome your participation, suggestions, and ideas for group activities. We hope to meet many of you at CISTM13 in Quebec City in May.

Sarah Kohl, MD and Gail Rosselot, NP, Student Travel Abroad Interest Group Founders


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Davidson H. Hamer
Davidson H. Hamer

GeoSentinel continues to be a highly vibrant network with 58 sites around the world and more than 230,000 surveillance reports in the database. There have been a substantial amount of chikungunya reports in the last few months and a few Ebola infections in health workers transferred to GeoSentinel sites in Europe. Network members continue to publish including a widely recognized EuroTravNet publication on returning European travellers, led by Prof. Patricia Schlagenhauf, which was published recently in Lancet ID and an analysis of US travellers led by Dr. Stefan Hagmann that was published in Family Practice.

Madrid Meeting December 2014: The two GeoSentinel Working Groups (Diagnostics - Chair: Marc Mendelson; Special Populations - Chair: Elizabeth Barnett) and the Data Task Force - Chair: Karin Leder) together with the GeoSentinel PI: David Hamer and CDC and ISTM representatives met in Madrid in December (12th- 14th) to brainstorm and define specific projects for each group to move forward their respective agendas.

The terms of reference of the working groups were defined, new structures identified and research project suggestions were presented and discussed. Intermediate, short- and long-term goals for the three working groups were agreed upon and some specific projects were identified that could be immediately initiated. This was a very constructive meeting and the discussions and outcomes will be the basis for moving forward with GeoSentinel 2.0.

New Appointment to the GeoSentinel Leadership Team: We are delighted to report that Patricia Schlagenhauf, the Zürich GeoSentinel Site Director, was appointed Chair of a new GeoSentinel Working Group, Surveillance-Tracking-Communication in January 2015. This new Working Group will have global representation and will be constituted by mid February.

Special Populations Working Group Meeting, USA: This is scheduled for February 8-9th in Minneapolis and will focus on “Migrants”.

Publications Committee: As a result of his new position as the Diagnostics Working Group Chair, Marc Mendelson has stepped down as the Data Use and Publications Committee Chair. We greatly appreciate his excellent leadership in this position and the changes that he has implemented in the committee's processes. Andrea Boggild, the Toronto GeoSentinel Site Co-Director, will be the new Chair of the Data Use and Publications Committee. The current members of the committee, Martin Grobusch, Stefan Hagmann, and Poh Lian Lim, will be joined by Philippe Gautret, the Marseille Site Director. Their combined efforts to strengthen the appropriate use of GeoSentinel data and the quality of the network's publications are greatly appreciated.

Davidson H. Hamer, MD, GeoSentinel Principal Investigator


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In the News

Albie de Frey
Albie de Frey
Garth Brink
Garth Brink

Jaundiced about Yellow Fever

In the thirteen months since a six year old boy died unnoticed in the jungles of Guinea in West Africa, another 8 980 people followed him to an untimely death caused by Ebola.i Twenty thousand people had to face up to this terrifying disease. In the same time period, two hundred thousand fell ill from another viral haemorrhagic fever and 30 000 died in Africa and South America. They suffered and died from Yellow Fever.ii

Yellow fever poses a risk to individual travellers to yellow-ever affected areas in Sub-Saharan Africa and South America. It poses a public health risk to countries that do not have local transmission of the virus but in which the vector, Aedes aegypti is present. Yellow fever vaccination is therefore carried out for 3 reasons: to protect populations living in areas subject to endemic and epidemic disease; to protect travellers visiting these areas; and to prevent international spread by minimizing the risk of importation of the virus by viraemic travellers.iii The latter makes yellow fever vaccine the only vaccine in the world regulated by the International Health Regulations (IHR).

The Republic of South Africa harbours A. aegypti but has never been host to endemic yellow fever. In line with the IHR, South Africa Port Health Authorities have always demanded proof of yellow fever vaccination from travellers entering South Africa from yellow fever-affected countries. However,new regulations have changed recommendations.

Following the publication of concerns regarding the safety of yellow fever vaccine and in an attempt to minimise the risk inherent in receiving the vaccine the WHO revised the Yellow Fever maps in 2011 from showing yellow fever “endemic” areas in which “either yellow fever has been reported or the presence of vectors and animal reservoirs creates a potential for risk of infection...” to maps indicating geographical areas for which yellow fever vaccination for travellers were “...recommended..”, “... not recommended...” and “generally not recommended...”. The latter category being new for 2011. After being removed in 2002 for little to no transmission risk, Zambia, along with a number of other African countries, were suddenly back on the map, this time in the latter category, generally not recommended. Tanzania, previously classified as having endemic Yellow Fever was reclassified to the new category as well.

South African travel health practitioners brought the situation to the attention of the South African health ‘authorities' and after several weeks the Department of Health took the stand that if there was ANY risk of unvaccinated travellers to South Africa returning with the virus (from any country...) they must show proof of vaccination.

The status quo, long forgotten by the travelling public and health ‘authorities' alike, is that travellers between South Africa and Zambia had to show proof of yellow fever vaccination.. the decision to remove Zambia, then reclassify it as a country with “generally not recommended” was based on research done in the 1940 and ‘50's...iv not very scientific..

In the last week of January 2015 snippets in the lay press alluded to the fact that the Zambian Government announced that South Africa will no longer demand proof of yellow fever vaccination from travellers from Zambia. The South African Society of Travel Medicine once again found itself scrambling to find out what the actual situation was and was told, along with some officials in the Department of Health, that the requirements had been scrapped during a meeting of the World Health Assembly in Geneva on Friday 30 January 2015, with immediate effect.

The authors are unaware at the time of writing of any official publication on the matter from the WHO and although the 2010 map of yellow fever recommendations for South America had been revised in 2013 - showing the progress in large areas of the continent from “Vaccination generally not recommended” to “Vaccination recommended” ... the map for Africa had NOT been revised in any manner.

We await with great interest a new map showing that Zambia, along with several other countries has NO risk of yellow fever transmission and that the lower third of the Democratic Republic of Congo, the Katanga province, now does carry a recommendation for the administration of yellow fever since the documented outbreak of yellow fever in the Kikondja district in February 2014?v

Public health concerns apart - the WHO and representatives of the South African Department of Health apparently have none, the question remains: If a South African traveller consults a travel health practitioner prior to travel to Zambia and is NOT given a yellow fever vaccine and DOES contract yellow fever in the far west of Zambia, why would a court of law not deem the doctor to be negligent as long as the WHO maps state: “ Yellow fever vaccination is generally not recommended .... However, vaccination might (?!) be considered for a small subset of travellers to these areas who are at increased risk for exposure to YF virus because of prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bites.”vi

A large number of South Africans live and work in Zambia in mining and other industries. All of them fall in the category “prolonged travel” and “inability to avoid mosquito bites”, the latter witnessed by the many malaria cases we see in expats and travellers throughout the year.

Do we now NOT vaccinate these people?

In South America, where health care and medical surveillance is much more sophisticated than in Africa, yellow fever is clearly on the march. The majority of yellow fever deaths occur in Africa and yellow fever coverage in endemic areas is dismal. But with little or no chance of yellow fever returning to the suburbs of Philadelphia and the ports of Europevii this first cousin of Ebola Superstar is unlikely to attract the attention of the media it deserves... and arguably continue its relentless march across our continent.

References
i http://apps.who.int/ebola/en/ebola-situation-report/situation-reports/ebola-situation-report-4-february-2015
ii www.who.int/mediacentre/factsheets/fs100/en/
iii www.who.int/immunization/diseases/yellow_fever/en/
iv Background for the Consultation on Yellow Fever and International Travel, 2010 (update February 2011) Informal Working Group on Geographic Risk of Yellow Fever (WG), a subgroup formed from the World Health Organization (WHO) Consultation on Yellow Fever (YF) and International Travel
v www.who.int/csr/don/2014_04_24_yellowfever/en/
vi http://gamapserver.who.int/mapLibrary/Files/Maps/ITH_YF_vaccination_africa.png?ua=1
vii www.who.int/mediacentre/factsheets/fs100/en/

Dr Albie de Frey
Dr Garth Brink, South African Society of Travel Medicine


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Chat with the Expert

Debra Stoner
Debra Stoner
Kenneth R. Dardick
Kenneth R. Dardick

Kenneth R. Dardick, Examination and Certification Committee Chair

  1. Why did you become involved with the ISTM Certificate of Knowledge exam?
    I have been a travel medicine practitioner since the field became formalized in the late 1980's. Recognizing my own need for additional education I studied at the London School of Hygiene and Tropical Medicine in 1989, earning the Diploma in Tropical Medicine and Hygiene. In 2003 I passed the initial Certificate in Travel HealthTM (CTH®) exam; joined the committee in 2004 and became Chair in 2008.
  2. Why is the ISTM Certificate of Knowledge so important to the mission of the ISTM?
    The CTH® and Continuing Professional Development Program has helped to establish and support the knowledge base we need to practice travel medicine at the highest level.
  3. What one piece of advice would you share with new practitioners with regards to preparing for the CTH® exam?
    Relax. Those who do best have practiced travel medicine; reviewed and studied the Body of Knowledge; understand the basic concepts of our field.
  4. What is one of the most challenging decisions you have made regarding the CTH® examination?
    The examination was originally conceived as a biennial event but high demand required additional exam dates and locations, so the exam is given annually timed to coincide with CISTM. In 2014 the exam was administered twice. Our attendance has remained high, which has confirmed the decision to increase the frequency of exam administration.
  5. What one common mistake do new practitioners make with regards to developing a solid knowledge base in travel medicine?
    The field is constantly changing. New diseases such as MERS-CoV, new challenges of old diseases such as Ebola virus and new concepts such as risk reduction challenge the competent practitioner to constantly acquire new information and adapt old teachings.
  6. How does one build a broad base of travel medicine knowledge?
    Serve the needs of the traveling public by studying the core topics such as infectious diseases, epidemiology, immunology, and preventive medicine at the undergraduate or graduate level. Continue your exposure by working in a travel medicine setting, reading the literature, taking CME courses, and attending professional society meetings. All are excellent ways to develop and perfect a base of knowledge.
  7. What new activity is on the horizon for the ISTM Certificate of Knowledge committee?
    The examination is just one component of the ISTM program in Continuing Professional Development and the first critical step in earning the Certificate in Travel HealthTM. Each 10-year cycle will demand continued active work in the field of travel medicine, meeting attendance, and other professional activities designed to maintain excellence. Some may choose to re-take the exam at the end of the 10-year cycle. All of these activities support the recognition of travel medicine as a critical field in protecting the health of the traveling public and of those who live in destinations we visit.

Debra Stoner, MD, Associate Editor Travel Medicine News


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Travel Talk from the ListServ

Nancy Pietroski
Nancy Pietroski

Antibiotics for TD: Which "Campy" Are You In?

The Topic of note for the list serve this quarter is: What do you prescribe for short-term treatment of traveler's diarrhea? The discussion was fast and intense, like a bout of TD!

Some definitions were offered: Mild to moderate TD was usually caused by ETEC, more common than severe; Severe TD aka dysentery, was accompanied with: stools with blood or mucus, fever, abdominal pain or cramps and often caused by Shigella, Salmonella, Campylobacter

Camp (1)
Always prescribe antibiotics
-Azithromycin 500mg x 1 dose up to 4-5 days
-Cipro 500mg x 1 dose up
up to BID for 3 days

Regarding choice of agent and duration, most everyone who responded favors azithromycin. Cipro has become less effective in many areas and unlike azithromycin, is contraindicated in pregnancy and pediatrics, and has some problematic AEs such as tendon rupture. The longer duration is prescribed for diarrhea with dysentery symptoms

Camp (2)
Never prescribe antibiotics. These providers were concerned about disrupting the normal bowel ecology and putting their patients at risk for resistant bacteria. A recent paper in Clinical Infectious Diseases (Kantele A et al. Antimicrobials Increase Travelers' RIsk of Colonization by Extended-Spectrum Betalactamase-producing Enterobacteriaceae." Clin Infect Dis 2015 Jan 21. pii.ciu957. [EPub ahead of print]) stimulated much discussion; those in favor of its findings wish to stay away from prescribing antibiotics, and those more dubious feel that use of antibiotics by travelers is not sufficient to disrupt the local bacterial population.

Camp (3)
Some only prescribe loperamidebecause they want to stay away from antibiotics. However, concern that loperamide can worsen dysentery, so it sould be avoided with in patients with dysentery

Camp (4)
Some only prescribe ORS or a combination with loperamide, for for mild to moderate TD

Camp (5)
A few prescribe alternative therapy, such as polyphenol-based supplements and micronutrients

It was agreed that mild to moderate TD is self-limiting, but for those travelers who don't want to spend several days out of a short vacation indisposed by diarrhea, business travelers who can't afford this, or travelers in areas where reliable pharmacies or medical care are not found, then antibiotics are prescribed before travel with instructions as to when to take. Common instructions include sudden onset of relatively uncomfortable diarrhea, mild-moderate loose stools or dysentery.

Nancy Pietroski, Pharm D, Associate Editor