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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 587-590

Role of family physician in healthcare for persons traveling abroad


1 Department of Community Medicine, Menoufia University, Menoufia, Egypt
2 MOHP, Al-Mahla, Gharbia, Egypt

Date of Submission08-Jul-2014
Date of Acceptance07-Sep-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Ibrahim Gabr
MOHP, Al-Mahla, Gharbia 31951
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163923

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  Abstract 

Objectives
The aim of the study was to perform systematic review to summarize the role of family physicians in travel medicine.
Data sources
Medline, articles in Medscape, AAFP, and PubMed were searched. The search was performed on 1 January 2014 and included all articles with no language restriction.
Study selection
The initial search presented 320 articles. The number of studies that met the inclusion criteria was 15. The articles included historical background definition, health services, and role of family physician in travel medicine.
Data extraction
Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest.
Recent findings
The family physician is the one who can best implement the travel medicine services.
Conclusion
Five articles were review articles, and one systematic review summarized the clinical importance of travel medicine. Two studies showed the importance of pretravel assessment. Many studies showed the importance of implementation of travel medicine in primary healthcare services presented by family physicians through a multidisciplinary approach where travel medicine lends itself well to the family physician's broad training, counseling skills, and focus on prevention and continuity of care.

Keywords: post-travel assessment, pretravel assessment, travel medicine


How to cite this article:
Salem MA, Mahrous OA, Gabr I. Role of family physician in healthcare for persons traveling abroad. Menoufia Med J 2015;28:587-90

How to cite this URL:
Salem MA, Mahrous OA, Gabr I. Role of family physician in healthcare for persons traveling abroad. Menoufia Med J [serial online] 2015 [cited 2020 Feb 17];28:587-90. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/587/163923


  Introduction and objectives Top


The increase in travel and travel medicine knowledge over the past 30 years makes pretravel counseling an essential part of comprehensive family medicine. Effective counseling begins with assessment of individual and itinerary-based risks, using a growing body of evidence-based decision-support tools and resources [1] . Counseling recommendations should be tailored to the patient's risk tolerance and experience. An essential component of the pretravel consultation includes reviewing routine and destination-specific immunizations. In addition to implementing behavioral adaptations, travelers can guard against vector-borne disease using N,N-diethyl-meta-toluamide (30%), a safe and effective insect repellent. Patients should also receive malarial chemoprophylaxis when traveling to areas of risk [2] . Proper precautions can reduce the risk for food-borne and water-borne disease. Travelers should take appropriate precautions when traveling to high altitudes. Strategies for minimizing the risk for deep venous thrombosis (DVT) during air travel include keeping mobile and wearing compression stockings. Accident avoidance and coping strategies for health problems that occur while abroad are also important components of the pretravel consultation [3] . The main goal of the study was implementation of safe travel. However, the specific objective of the study was to clarify the commonest traveler's health problems and to clarify the role of family physician in its prevention and control.

Search strategy

Search was performed in several databases. It included Medline, articles in Medscape, AAFP, and PubMed. The search was performed on 1 January 2014 and included all articles published, with no language restriction.

Study selection

All studies were assessed to include in the review by the researchers. They were included if they fulfilled the following:

  1. Historical background of travel medicine.
  2. Definition of travel medicine.
  3. Health services for traveling people.
  4. Diseases related to travel.
  5. Role of family physician in travel medicine.
Articles in non-English language were translated. The article title and abstract were initially screened. Thereafter, the selected articles were read in full and further assessed for eligibility. All references from the eligible articles were reviewed to identify additional studies.

Data extraction

Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. Conclusion and comments were made on each study.


  Results Top


The initial search presented 320 articles. The number of studies that met the inclusion criteria was 15. The articles included historical background definition, health services, and role of family physician in travel medicine.


  Discussion Top


Travel medicine is devoted to the health of travelers who visit foreign countries. It is an interdisciplinary specialty concerned not only with prevention of infectious diseases during travel, but also with the personal safety of travelers and the avoidance of environmental risks [1] . The field has evolved as a distinct discipline over the last two decades. It is represented by an international society - the International Society of Travel Medicine (ISTM) - and by an active clinical group within the American Society of Tropical Medicine and Hygiene (ASTMH) [2] . Those who practice in the field come from a wide range of specialty training experiences; however, it is members of the infectious disease community who have frequently taken the lead in providing the evidence base for practice. Accompanying the growth of travel medicine has been a parallel effort in defining a body of knowledge and standards for its practice. These guidelines set forth the minimum standards for knowledge, experience, and practice in travel medicine and review the major content areas in the field [3] . Travel medicine standards are increasingly based on evidence and are moving away from reliance on the opinion of experts. Where possible, recommendations in this document have been graded using the Infectious Diseases Society of America - United States Public Health Service grading system. As a young discipline, however, expert opinion and experience still dominate many of the topic areas, highlighting the need for continued investigation in the field [4] .

Setting

Primary care physicians and nonspecialists should be able to advice travelers who are in good health and are visiting low-risk destinations with standard planned activities [5] .

Role of family physicians in travel health services

Knowledge base

The knowledge base for the travel medicine provider includes epidemiology, transmission, and prevention of travel-associated infectious diseases; a complete understanding of vaccine indications and procedures; prevention and management of noninfectious travel-associated health risks; and recognition of major syndromes in returned travelers (e.g. fever, diarrhea, and rash). All providers should access Web-based, text-based, and journal-based resources. The US Centers for Disease Control and Prevention (CDC) provides authoritative advice on travel health (http://www.cdc.gov/travel) [6] .

Competency in travel medicine

(a) Appropriate knowledge and attitude for practicing travel medicine may be demonstrated by achieving a certificate of knowledge in the field [7] . (b) Maintaining competency includes ongoing education and performing pretravel consultations on a frequent and regular basis [8] .

Pretravel risk assessment

The key element of the pretravel visit is a health risk assessment of the trip. This balances the health of the traveler (the traveler's age, underlying health conditions, medications, and immunization history) with the details of the planned trip (the season of travel, itinerary, duration, and planned activities) [9] .

Spectrum of travel medicine advice

Topics of health education and advice that should be covered for all travelers include vaccine-preventable illness, avoidance of insects, malaria chemoprophylaxis (for itineraries that include a malaria risk), prevention and self-treatment of traveler's diarrhea, responsible personal behavior, sexually transmitted infections and safety, travel medical insurance, and access to medical care during travel. Other topics should be covered as indicated by the risk assessment. Consistent and clear advice that is provided in both verbal and written form will help to increase traveler compliance with preventive measures [10] . The interaction between traveler and healthcare provider should be collaborative and affords the opportunity to enhance preventive health knowledge [11] .

Records and procedures

(a) Permanent records should be maintained for the pretravel visit, including records of traveler demographic data and health history, travel health risk assessment, and immunizations, recommendations, and prescriptions given. (b) Standard procedures for immunization should be followed, including informed consent, vaccine storage, administration, record keeping, and reporting of adverse events [12] .

Immunization

(a) The pretravel visit should be used to update vaccinations that are routinely recommended on the basis of the traveler's age and underlying health status. These vaccinations include tetanus, pertussis, diphtheria, Haemophilus influenza type b, measles, mumps, rubella, varicella, Streptococcus pneumoniae, and influenza vaccinations. Vaccination against hepatitis A and B, poliomyelitis, and Neisseria meningitidis may be recommended for travel as well as for routine healthcare [13] . (b) Vaccination against yellow fever is usually indicated for travelers to countries in the zone of endemicity for yellow fever (areas in Africa and South America where conditions are conducive to yellow fever transmission). In addition, under International Health Regulations (IHRs), some countries that lie within or outside of the zone of endemicity may require yellow fever vaccination as a condition for entry. Recent recognition of serious adverse events associated with yellow fever vaccination requires that a careful risk-benefit assessment be performed before administration of the vaccine [14] . (c) Hepatitis A vaccination should be considered for young-age travelers. Booster doses following the primary two-dose series are not currently recommended [14] . (d) Vaccination against Japanese encephalitis, rabies, tick-borne encephalitis, and typhoid fever should be administered on the basis of a risk assessment. Quadrivalent (A/C/Y/W-135) meningococcal vaccine should be administered to travelers at risk. It is required by Saudi Arabia for religious pilgrims to Mecca for the Hajj or Umrah [15] .

Traveler's diarrhea

Traveler's diarrhea is the most common disease among travelers. Management of traveler's diarrhea includes education and advice about prevention, food and liquid hygiene, and provision for prompt self-treatment in the event of illness [16] . The elements of self-treatment include hydration; treatment with loperamide for control of symptoms, if necessary [when there is no temperature (38.5°C) or gross blood in the stool]; and a short course (single dose to 3 days of therapy) of a fluoroquinolone antibiotic. Antibiotic resistance of enteric pathogens, particularly Campylobacter spp., in the destination country needs to be considered. For those traveling to these destinations, as well as for other travelers, azithromycin may be indicated (BII). Combination treatment with loperamide and an antibiotic may be considered for travelers with moderately severe diarrhea. Antibiotic prophylaxis is not recommended for most travelers [17] .

Malaria

Malaria is one of the most severe infectious diseases among travelers. Nearly all cases in travelers are preventable. Methods for prevention and best management of malaria include awareness of risk, avoidance of mosquito bites, compliance with chemoprophylaxis, and prompt diagnosis in the event of a febrile illness either during or on return from travel. When seeking medical care after return from travel, travelers should be instructed to inform their health provider of their travel history [18] . Travelers at risk for malaria should practice the following measures to prevent mosquito bites: wearing of protective clothing to cover exposed skin, application of repellents, and sleeping in areas protected by netting (preferably impregnated with a residual insecticide such as permethrin) and screens. Currently, repellents that contain 20-50% N,N-diethyl-meta-toluamide are considered to provide sufficient protection [11] . The choice of chemoprophylaxis should be made following a careful assessment of malaria risk during the trip. In addition, whether the traveler has contraindications to a particular antimalarial should be considered [18] .

The malaria risk assessment includes the itinerary, the species of malaria at the destination (and whether the most severe form of malaria, which is due to Plasmodium falciparum, is present and whether it is resistant to chloroquine or other antimalarials), the season of travel, activities, duration, and access to medical care. Consultation with the latest resource information is necessary.

Personal safety and environmental health

(a) All travelers should be aware of personal safety during travel and exercise responsible behavior. Road and pedestrian safety, risk for blood-borne infections, avoidance of animal bites, and awareness of the risk for assault, sexually transmitted infections, and moderation in alcohol use should be discussed [12] . (b) Travelers should understand the effects that air, sea, and land travel, sun, altitude, and heat and cold may have on their health. To prevent DVT, long-haul travelers with journeys of 6-8 h and longer should avoid constrictive clothing around their waist and lower extremities, exercise their calf muscles, and maintain hydration. Travelers with increased risk factors for DVT may consider wearing below-the-knee support stockings or receiving low-molecular-weight heparin [10] . (c) Ascent to altitudes of 2500-3500 m (8200-11 500 ft) is often associated with various forms of high altitude illness. Staged ascent is an effective way to decrease the risk for altitude illness. Travelers who need to ascend rapidly may take acetazolamide for prevention [1] .

Post-travel care

Health professionals who advise travelers should be able to recognize major syndromes in returned travelers (e.g. fever, diarrhea, respiratory illness, and rash) and either provide care for the traveler or promptly refer them for appropriate evaluation and treatment [14] .


  Conclusion Top


The family physician is the most suitable person who can support provision of health services for people traveling abroad regardless their age, sex, physical, and psychological status. Training the family physician on travel medicine is mandatory. There should be accessibility of information resources about travel medicine, vaccines, and chemoprophylaxis especially for malaria for people traveling abroad.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kish MA. Guide to development of practice guidelines. Clin Infect Dis 2001; 32 :851-854.  Back to cited text no. 1
    
2.
Spira A. Setting the standard. J Travel Med 2003; 10:1-3.  Back to cited text no. 2
    
3.
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4.
World Tourism Organization. Tourism highlights. 2005 ed. Madrid, Spain: World Tourism Organization; 2005.  Back to cited text no. 4
    
5.
Freedman DO, Weld LH, Kozarsky PE. Spectrum of disease and relation to place of exposure among ill returned travelers. New Engl J Med 2006; 354 :119-130.  Back to cited text no. 5
    
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Centers for Disease Control and Prevention. Measles outbreak in a boarding school-Pennsylvania, 2003. Morb Mortal Wkly Rep 2004; 53 :306-309.  Back to cited text no. 6
    
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Centers for Disease Control and Prevention. Epidemiology of measles - United States, 2001-2003. Morb Mortal Wkly Rep 2004; 53 :713-716.  Back to cited text no. 7
    
8.
Kain KC, MacPherson DW, Kelton T, Keystone JS, Mendelson JS, MacLean JD. Malaria deaths in visitors to Canada and in Canadian travellers: a case series. CMAJ 2011; 164 :654-659.  Back to cited text no. 8
    
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Newman RD, Parise ME, Barber AM, Steketee RW. Malaria-related deaths among U.S. travelers 1963-2001. Ann Intern Med 2004; 141 :547-555.  Back to cited text no. 9
    
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Kean BH. The diarrhea of travelers to Mexico: summary of five-year study. Ann Intern Med 2009; 59 :605-614.  Back to cited text no. 10
    
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Gorbach SL, Kean BH, Evans DG, Evans DJ, Bessudo D. Travelers' diarrhea and toxigenic Escherichia coli. New Engl J Med 2012; 292 :933-936.  Back to cited text no. 11
    
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Merson MH, Morris GK, Sack DA. Travelers' diarrhea in Mexico: a prospective study of physicians and family members attending a congress. New Engl J Med 2011; 294 :1299-1304.  Back to cited text no. 12
    
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Sack RB, Froehlich JL, Zulich AW. Prophylactic doxycycline for travelers' diarrhea: results of a prospective double-blind study of Peace Corps volunteers in Morocco. Gastroenterology 2013; 76 :1368-1373.  Back to cited text no. 13
    
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DuPont HL, Reves RR, Galindo E, Sullivan PS, Wood LV, Mendiola JG. Treatment of travelers' diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone. New Engl J Med 2004; 307 :841-844.  Back to cited text no. 14
    
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Ericsson CD, DuPont HL, Mathewson J, West MS, Johnson PC, Bitsura JAM. Treatment of traveler's diarrhea with sulfamethoxazole and trimethoprim and loperamide. JAMA 2011; 263 :257-261.  Back to cited text no. 15
    
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Adachi JA, Ericsson CD, Jiang ZD. Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis 2003; 37 :1165-1171.  Back to cited text no. 16
    
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Steffen R, Sack DA, Riopel L. Therapy of travelers' diarrhea with rifaximin on various continents. Am J Gastroenterol 2003; 98 :1073-1078.  Back to cited text no. 17
    
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Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004; 29:2856-2864.  Back to cited text no. 18
    




 

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