International Society of Travel Medicine
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March 2014

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Travel Medicine News (formerly NewsShare)

Editors Note: We have changed the name of NewsShare to Travel Medicine News to reflect an updated format and increase in travel medicine content, in addition to the society news. CVT.

President's Message

David R. Shlim MD
David R. Shlim

I have to admit that when I talk to doctors, nurses, or pharmacists who are thinking of taking up the practice of travel medicine, I generally tell them that it's not that difficult. There are not that many vaccines and medications that we routinely deal with, and good resources are available to look up malaria and yellow fever risk areas. You can get a lot of help from subscription travel medicine information companies, and if you subscribe to the ISTM listserv, and ProMed you can keep aware of controversies and outbreaks.

At least that's how I felt until I started training my new nurse, Christine, to be able to see travelers on her own. I have a part-time travel medicine practice in which I see all the travelers myself, and my nurse helps with the immunizations and paperwork. However, I'm headed to Asia for six weeks this spring, and I decided that Christine would need to try to keep the practice open to help the adventurous people of Jackson Hole who, having spent the winter skiing, take off for a wide variety of destinations as soon as the ski area closes.

One can take a superficial view of travel medicine (what vaccines or prophylaxis are recommended for a certain destination), or a more nuanced view (what is the real risk, how was that determined, how long are they going, what will they be doing, what are the consequences of getting ill). For most ISTM members, this latter kind of thinking starts to become second nature, but it takes time and experience, and it also takes confronting one's perception of risk—both for the traveler and oneself. The need to consider risk and benefit comes to a head with vaccine recommendations for yellow fever vaccine and Japanese encephalitis vaccine. For example, when do you forego yellow fever vaccine due to your concern about the risks of the vaccine, and then what do you tell your traveler about the risks of the disease?

When I started explaining to Christine about the risk of typhoid fever, the independent risk of paratyphoid fever, the comparison of injectable vaccine to oral vaccine, the countries that have the highest risk, etc., I began to realize how much knowledge might really be necessary. With malaria prophylaxis, there are the relative risks of P falciparum and P vivax, and the problem of looking at maps of places like Indonesia, Myanmar, and Cambodia, where the risk of malaria varies considerably within each country.

The empiric treatment of travelers' diarrhea used to be straightforward, but with increasing incidence of resistant organisms, the right medication for the right place is not easy to determine. Resistance to both ciprofloxacin and azithromycin has been documented in various destinations.

Gradually it reaffirmed for me that there is a wealth of subtle knowledge in travel medicine that can take a lifetime to master. I see this when I meet fellow travel medicine practitioners at the CISTM meetings and regional meetings. Many of you have pursued and mastered this knowledge to a large extent, but you still come to meetings to seek out the details of the areas that you don't know as well, or to see what might have changed. People new to travel medicine come to meetings and are suddenly exposed to details and explanations that they never knew to even ask about. Altogether it makes travel medicine a fascinating field to study and practice, in which there is always more that can be learned.

I think this is why so many people self-identify as travel medicine specialists even when they are board certified in other fields, such as internal medicine, infectious disease, emergency medicine, or gastroenterology. The interest in travel medicine, tropical diseases, global health, vaccinology, and environmental risks provides enough material for a lifetime. When you get to use this knowledge to support the budding sense of adventure in a traveler who is sitting in front of you ready to head out for the first time, it can offer a deep sense of satisfaction.

After more than thirty years of diagnosing, treating, and advising travelers, I haven't grown tired of it. And I sense that ISTM members—really a unique club—share my enthusiasm. That's why it is so great to be a member, to attend conferences, read the journal, and participate in the listserv. It took me a bit by surprise to find out that trying to pass on my knowledge to Christine led to a greater appreciation of what it means to truly be a travel medicine practitioner.

David R. Shlim, MD
ISTM President


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Editor's Note

Christopher Van Tilburg
Christopher Van Tilburg

When things come in threes, I guess I should pay attention.

At my daughter's soccer team's end-of-season award banquet, I dug deep for words to give the teenage girls a lesson beyond soccer. I recalled a news clip from my childhood that I still have: a coach on the cover of Parade Magazine in the late 1970s stood over basketballs labeled: loyalty, courage, energy, leadership and ambition. He was holding the most important: Teamwork.

A few months later, teaching travel and wilderness medicine seminar in Bhutan, I was filling time on an 8-hour, 180-kilometer bus ride on the tortuous East-West Highway. I pulled up Atul Gwande's TED talk on my iPhone and ran it through the bus speakers. Expecting a cutting edge technology or public health lectuer, Gwande instead eloquently spoke of the need for pit crews in medicine today.

A few months later I was asked me to speak on applying our volunteer mountain rescue mantra—self first, team second, and patient third—to my busy, small town Occupational and Travel Medicine practice to foster teamwork. Like many of you, my clinic is fraught with lots of same day appointments, mounds of paperwork, legal statutes, and ever changing recommendations in travel requirements and risks. If I don't have teamwork, my clinic would be nonfunctional.

So, what does this have to do with ISTM? I'm sure other groups of international medical specialists who collaborate via the internet and face-to-face meetings exist: but I suspect few groups have such a direct, immediate, and powerful impact on patient care. Unlike many medical societies, we are both academic researchers and clinicians, who often get a call from a patient "I'm leaving for Africa for two weeks, tomorrow!" We do a great deal of prevention but also evaluate complicated, perplexing during-travel and post-travel problems often remotely. We are a collection of the world's experts in travel medicine, spanning 89 countries. Our enthusiasm for sharing information, fostering collaboration and providing excellent medical care are evident at conferences, on the list serve, in the journal, and in contributions such as the new Post Travel Education Cases, the new Pharm-Net. I am proud to be among great colleagues and on a great team.

Christopher Van Tilburg, MD
ISTM NewsShare Editor


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Secretary-Treasurer's Report

Peter Leggat
Peter A. Leggat

Have you sent your ISTM renewal?

The ISTM Membership year is based on a calendar year and renewals for 2014 were sent late last year to all members. The good news is that we have been able to keep membership subscription cost the same as the previous year. Renewals have been steadily arriving with about 60% of our members already renewing for 2014. Have you sent your ISTM renewal?

At the end of 2013, we had a record 3210 Members from 89 countries. We were also pleased to note that 193 new ISTM Members have already joined this year. It is pleasing to see that pharmacist membership is still increasing and the new membership categories for retired members and for those living in resource-poor countries introduced last year are continuing to attract strong interest. It was good to see that we also have 1040 clinics from 61 countries in the clinic directory already for 2014. Has your clinic been listed?

Keep our Society strong, renew today!

If you haven't yet renewed your ISTM membership, the grace period ends on 31 March. Help keep our Society strong and renew today to ensure that you continue to receive the ISTM Journal, participate in the list serve discussions, and have access to other ISTM member benefits such as the clinic directory. If you did not receive your subscription notice, please contact the ISTM Secretariat on email: ISTM@ISTM.org.

Peter A. Leggat, MD
ISTM Secretary-Treasurer


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News from the Secretariat

Diane Nickolson
Diane L. Nickolson

With close to 1800 Certificates in Travel Health (CTH©) granted the ISTM Certificate of Knowledge program continues to set the international standard for travel medicine practitioners. The scope and complexity of travel medicine continues to challenge the health care professional, with almost a billion travelers crossing international borders annually. The Certificate of Knowledge program recognizes those individuals who have demonstrated their level of expertise in travel medicine by passing the CTH© Examination, and encourages individual and global professional development in the area of travel medicine.

Based on an international survey of experts in the travel medicine field, the Body of Knowledge for the Practice of Travel Medicine has been developed and is regularly updated. Drawn from this material, the CTH© Examination was first administered in 2003, and is now administered annually. This year for the first time the Exam will be offered twice – immediately preceding the Asia Pacific Travel Health Conference on 7 May in Ho Chi Minh City, Vietnam and just prior to the RCISTM6 on 2 August in Jackson Hole, Wyoming, USA. Registration information for either of these two exams can be found here.

Diane L. Nickolson
ISTM Executive Director


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Upcoming Events


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Professional Education Committee (PEC)

Mary-Louise Scully
Mary-Louise Scully

The Professional Education Committee is pleased to announce the addition of “Post-Travel Educational Cases” with the purpose of providing insight on the presentation and treatment of interesting cases of post travel illness. Initial topics now up on the ISTM website include a Dengue Fever case by Philippe Gautret , a Loa Loa case by Michelle Barry, and a myiasis (Botfly) case by Mary-Louise Scully. The cases each include interesting photographs as well. These cases can now be found on the home page under "ISTM Educational Patient Cases" which includes the Pre-Travel Cases (formally called Expert Opinion) and the new Post-Travel cases.

The PEC welcomes other contributions of post-travel cases from all the members. Any submitted case should follow similar format and will be reviewed by the PEC committee. This is a great way for all ISTM members to contribute to the educational aspect of ISTM.

Mary-Louise Scully M.D
Professional Education Chair (PEC)


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Nursing Professional Group (NPG)

NPG elects New Chair-elect:

Gail Rosselot
Gail Rosselot
Carolyn Driver
Carolyn Driver
Jacqueline Mier
Jacqueline Mier

At its November 2013 meeting, the NPG Council unanimously elected Carolyn Driver as Chair-Elect. A specialist in travel health for 14 years, Ms. Driver works as a Health Visitor and Practice Nurse who regularly runs study sessions on all aspects of travel health and immunization, develops educational projects and writes for professional journals. Ms. Driver is a member of the travel health sub group of the U.K. Joint Committee on Vaccination and Immunization and the Board of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow. She is an honorary tutor and examiner on the Glasgow Foundation and Diploma in Travel Medicine course and is a Fellow of the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow.

Nursing Professional Group-Recommendations for CTH® Exam Takers

Preparation for the upcoming Certificate in Travel Health© exam should not be taken lightly. Many travel health nurses currently in the field are involved with the preparation of travelers through risk assessment, education and delivery of vaccines, prophylactics or self-treatment meds. Nurses with this type of experience can do well on portions of the exam that address these pre-travel issues and also with many of questions on tropical diseases. What many nurses are not prepared for are the exam questions on global epidemiology, field treatment, and the post-travel illness. Many of our travelers will seek our advice and we must be able to recognize these issues to give them guidance either before or after their travel. Watch for emails from the NPG to include some preparation tips as well as print and internet resources that nurses may find useful.

Jacqueline Mier, RN, CTH®
NPG Steering Committee

Nursing Continuing Education Credits for ISTM Courses and Conferences

Around the world nursing continuing education (CE) accreditation varies widely. Many countries still do not require nursing CE, however, others do. Some nations offer their own national accreditation while others rely on a variety of accrediting organizations. In the United States both ANCC and AANP accredit nursing education programs and Continuing Medical Education (CME) credits can also be used by some nursing professionals. NPG wants to remind all its members to personally contact their registration boards and employers to confirm that credits offered at any particular educational conference will be accepted. Ultimately it is the responsibility of each professional nurse to know if CE credits will be accepted for their professional licensure, registration, recertification, work advancement, or employer reimbursement.

NPG Membership: Be Sure to Sign Up

Remember to register for membership in the Nurses Professional Group when renewing your 2014 ISTM registration. Every ISTM nursing professional, at any level of educational preparation, is invited to join NPG and help build travel health nursing internationally. There are no additional obligations of NPG membership-financial or otherwise. To learn more about NPG, please go to our webpage at www.istm.org. At that site, we post all Council minutes, articles of interest, as well as our charter and yearly goals.


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Pharmacy Professional Group (PPG)

Larry Goodyer
Larry Goodyer

The PPG has a working database entitled "General Description of countries regulations on bringing medications for personal use across International Borders." There are a few caveats. The list has not been validated to confirm that the information is accurate, there may be missing or incomplete information, not all countries are covered and it is very time dependent as rules change. Hopefully this database, along with several others in the works, will start formation of a larger network of pharmacists around the world to help maintain and validate these databases and warn of developing local issues relating to pharmaceuticals - a sort of "PharmNet."

Larry Goodyer, PhD
Pharmacy Professional Group


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Pediatrics Interest Group

Philip R. Fischer
Philip R. Fischer

Nominations for the Pediatrics Interest Group Steering Council are now being accepted through 21 March 2014. Six places on the Steering Council will be filled during this election process. To qualify, a person should be a current member of ISTM and in the Pediatrics Interest Group, and have a willingness to work with others in sharing ideas and in advancing the field of pediatric travel medicine. Information on the Pediatrics Interest Group, the nomination process, and Nomination Form, can be found here.

Philip R. Fischer, MD
Chair, ISTM Pediatrics Interest Group


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Nancy Pietroski
Nancy Pietroski

In the News: Mass Gatherings

The CDC describes a mass gathering as a group of people at a specific location, for a specific purpose, for a defined period of time. The WHO definition is “an event [where] the number of people attending is sufficient to strain the planning and response resources of the community, state, or nation hosting the event.” Although they can be spontaneous, most mass gatherings are planned, are temporary, and can involve participants from all over the globe. When counseling travelers planning to attend an event, consider (a) purpose (religious vs. rock concert), (b) location (climate, altitude, potential for endemic diseases/outbreaks, sanitation), (c) participants (crowd density, disease transmission, injury risk, drugs/alcohol), and (d) duration (longer = more stress). Evaluations should ideally be done 4-6 weeks before travel.

As with any mass gatherings, the potential for spread of communicable diseases, exacerbation of non-communicable diseases, injuries/accidents and other hazards are amplified during these aggregations. General information and advice on mass gatherings from WHO and CDC can be found at massgatherings@who.int and wwwnc.cdc.gov/travel/yellowbook/2014/chapter-8-advising-travelers-with-specific-needs/travel-to-mass-gatherings.

Two communions of like-minded sports masses are the Winter Olympics in Sochi, Russia (7-23 February; Paralympics 7-16 March) and The FIFA (Fédération Internationale de Football Association) World Cup in Brazil (12 June -13 July). The FIFA World Cup is the largest single-sport event in the world. The 2014 event will be held in 12 cities across Brazil.http://www.fifa.com/worldcup/destination/cities/index.html. The Sports Commission of the La Sociedad Latinoamericana de Medicina del Viajero (SLAMVI, the Latin American Travel Medicine Society) issued a very comprehensive guide for travel health professionals in Spanish: Consejos para Viajeros al Mundial del Futbol Brazil 2014 can be viewed at slamviweb.org. Updates and travel advice are available from the UK government (can sign up for alerts) www.gov.uk/government/news/world-cup-2014.

From the Sochi Olympics, the following are general recommendations that one should advise travelers:

  1. Vaccinations - be current with routine vaccinations (especially flu), hepatitis A
  2. Medical insurance - travelers must have proof of medical insurance to obtain visa
  3. Travel kit – be sure to pack regular medications
  4. Bring Russian phrasebook to communicate any medical issues that may arise during visit (CDC site has common phrases)
  5. Crowd safety - be aware of exits when entering a large arena
  6. Personal safety - wash hands often, pedestrian risks, pickpocketing, safe sex, use alcohol in moderation

CDC Sochi 2014 Winter Olympics and Paralympics site: wwwnc.cdc.gov/travel/notices/watch/sochi-2014-winter-olympics-paralympics

Nancy Pietroski, PharmD
Associate Editor


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Chat with the Expert:

Debra Stoner
Debra Stoner
Christina Greenaway
Christina Greenaway

Dr. Christina Greenaway is the chair of the Migrant and Refugee Health Interest Group (MRHIG). Dr. Debra Stoner caught up with her for some insights into this groups' focus.

  1. Why should travel medicine practitioners join this special interest group?
    Migrants (VFR travelers) have the highest incidence and prevalence of travel related diseases such as malaria, typhoid fever, parasitic diseases, and viral hepatitis. The disparity is due to several factors including lack of preventive intervention prior to travel, increased risk during travel and lack of knowledge of travel practitioners of important health issues of this population.
  2. What one piece of advice would you share with new practitioners with regards to their work with this population?
    The pre and post travel encounter is an opportunity for health promotion for the migrant population. Travel practitioners need to become familiar with the most important health issues of this group and how to best encourage uptake of preventive health measure prior to and after VFR travel.
  3. What is a good method to reach out to this population before they depart?
    This is an area that requires more research and new approaches and is an active focus of the work of the MRHIG.
  4. What new horizon for the MRHIG?
    The main focus of the MRHIG will be to provide education for travel health professional on the most important health issues of immigrants and VFR travelers and how to best utilize the pre and post travel visit as an opportunity for health promotion.

Debra Stoner, MD
Associate Editor


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Nancy Pietroski
Nancy Pietroski

Travel Talk from the ListServ: The Traveler With No Itinerary

The Topic: What advice to render to travelers with no itinerary, like backpackers, and who are abroad for several months.
The Talk: The chat was scholarly, fatherly, and broad reaching.

  1. All immunizations are important including basic such as hepatitis A and B, typhoid, tetanus/TDaP, yellow fever (endemic areas), polio (certain countries), MCV4 (if need booster), JE (Asia), and rabies
  2. Malaria prophylaxis is country dependent, on should carry atovaquone/proguanil or doxycycline (which also works for STDs too)
  3. For traveler's diarrhea, adventurers should carry 2 different medications.
  4. Advise on risky behavior such as motor vehicle accidents (especially pedestrians), STDs, drowning (learn how to swim!), and robbery
  5. Other diseases and drugs should be discussed: antihistamines, ibuprofen, acute mountain sickness and basic wound care.
  6. Discuss the expense: multiple travel clinic visits and vaccines may be needed; young people may want to ask family members to help with cost
  7. Discuss risk/benefit of of self-diagnosis and self-care and recommend loading references on a smartphone such as: Common Symptom Guide, Mayo Clinic, eMedicine, Medline Plus, Where There is No Doctor
  8. Join IAMAT (International Association for Medical Assistance to Travelers; www.iamat.org
  9. Consider travel and medical evacuation insurance
  10. For restocking medications, contact embassy or consulates for local pharmacy provider info
  11. Take first aid course
  12. Do providers give email address to traveler? There was debate because of potential liability or privacy risks? One practice provides an email contact so the traveler can contact them as their plans evolve. Others do not offer clinical advice, instead provides a list of reliable medical resources at destination and stress the need for travelers to obtain local care.

Travel Talk:
Nancy Pietroski, PharmD
Associate Editor