• Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, DuPont HL, Bia FJ, Fischer PR, Ryan ET, Infectious Diseases Society of America. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Dec 15;43(12):1499-539. PubMed

• December 3, 2008, Innohep (tinzaparin): The U.S. Food and Drug Administration (FDA) has requested that the labeling for Innohep be revised to better describe overall study results which suggest that, when compared to unfractionated heparin, Innohep increases the risk of death for elderly patients (i.e., 70 years of age and older) with renal insufficiency. Healthcare professionals should consider the use of alternative treatments to Innohep when treating elderly patients over 70 years of age with renal insufficiency and deep vein thrombosis (DVT), pulmonary embolism (PE), or both.
• July 08, 2008, Fluoroquinolones (ciprofloxacin, norfloxacin, ofloxacin, levofloxacin, moxifloxacin, gemifloxacin): A BOXED WARNING and Medication Guide are to be added to the prescribing information to strengthen existing warnings about the increased risk of developing tendinitis and tendon rupture in patients taking fluoroquinolones for systemic use.
• February 28, 2008, Heparin Sodium Injection: The U.S. Food and Drug Administration (FDA) informed the public that Baxter Healthcare Corporation has voluntarily recalled all of their multi-dose and single-use vials of heparin sodium for injection and their heparin lock flush solutions. Alternate heparin manufacturers are expected to be able to increase heparin production sufficiently to supply the U.S. market. There have been reports of serious adverse events including allergic or hypersensitivity-type reactions, with symptoms of oral swelling, nausea, vomiting, sweating, shortness of breath, and cases of severe hypotension.

• 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 non-infectious travel health risks, and recognition of major syndromes in returned travelers (e.g., fever, diarrhea, and rash) (A-III). All providers should access web, text, and journal based resources. The U.S. Centers for Disease Control and Prevention provides authoritative advice on travel health (www.cdc.gov/travel).

Competency in Travel Medicine

• Appropriate knowledge and aptitude for practicing travel medicine may be demonstrated by achieving a certificate of knowledge in field (see supporting text in the original guideline document). Maintaining competency includes ongoing education and performing pre-travel consultations on a frequent and regular basis. (B III)

Pre-travel Risk Assessment

• The key element of the pre-travel visit is a health risk assessment of the trip (A-II). This balances the health of the traveller: age, underlying health conditions, medications, and immunization history, with the details of the planned trip: season of travel, itinerary, duration, and planned activities.

Spectrum of Travel Medicine Advice

• Topics of health education and advice that should be covered for all travelers are vaccine preventable illness, avoidance of insects, malaria chemoprophylaxis (for itineraries that include a malaria risk), prevention and self-treatment of travelers' diarrhea, responsible personal behavior, sexually transmitted infections and safety, travel medical insurance, and access to medical care during travel (A-II). 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 increase traveler compliance with preventive measures (A-II). The interaction between traveler and health care provider should be collaborative and affords the opportunity to enhance preventive health knowledge.

Records and Procedures

• Permanent records should be maintained for the pre-travel visit: traveler demographics and health history, travel health risk assessment, immunizations, recommendations, and prescriptions given (A-III).
• Standard procedures for immunization should be followed: informed consent, vaccine storage, administration, record-keeping, and reporting of adverse events (A-III).

Immunization

• The pre-travel visit should be used to update vaccines routinely recommended according to U.S. schedules and based on the traveler's age and underlying health status (A-I). These vaccines include tetanus, pertussis, diphtheria, Haemophilus influenzae type b, measles, mumps, rubella, varicella, Streptococcus pneumoniae, and influenza. Vaccines against hepatitis A and B, poliomyelitis, and Neisseria meningitidis may be recommended for travel as well as for routine health care.
• Vaccination against yellow fever is usually indicated for travelers to countries in the endemic zone for yellow fever (areas in Africa and South America where conditions are conducive for yellow fever transmission) (A-III). In addition, under International Health Regulations, some countries that lie in or outside of the endemic zone 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.
• Hepatitis A vaccine should be considered for all travelers (A-III). Booster doses following the primary two-dose series are not currently recommended (A-II).
• Vaccines against Japanese encephalitis, rabies, tick-borne encephalitis and typhoid fever should be administered based on a risk assessment (A-III). 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.

Travelers' Diarrhea

• Travelers' diarrhea is the most common disease of travelers. Management of travelers' diarrhea includes education and advice about prevention: food and liquid hygiene (A-III), and provision for prompt self-treatment in the event of illness (A-I). The elements of self-treatment include hydration, loperamide for control of symptoms if necessary (when there is no fever >38.5 degrees C or gross blood in the stool), and a short course (single dose to three days) of a fluoroquinolone antibiotic (A-I). Antibiotic resistance of enteric pathogens, particularly for Campylobacter, in the destination country needs to be considered. For these destinations, as well as for other travelers, azithromycin may be indicated (B-II). Combination treatment with loperamide and an antibiotic may be considered for travelers with moderately severe diarrhea (B-III). Antibiotic prophylaxis is not recommended for most travelers (A-III).

Malaria

• Malaria is one of the most severe infectious diseases of travelers. Nearly all cases in travelers are preventable. 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 (A-I). When seeking medical care after return from travel, travelers should be instructed to inform their health provider of their travel history.
• Travelers at risk for malaria should practice the following measures to prevent mosquito bites: 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 (A-I). Currently, repellents that contain 20% to 50% DEET are considered to provide sufficient protection (B-II).
• The choice of chemoprophylaxis should be made following a careful assessment of malaria risk during the trip and whether the traveler has contraindications to a particular antimalarial.
• The malaria risk assessment includes the itinerary, the species of malaria at the destination (and whether the most severe form of malaria, Plasmodium falciparum, is present and if 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

• All travelers should be aware of personal safety during travel and exercise responsible behavior (A-III). Road and pedestrian safety, risk of blood borne infections, avoidance of animal bites, awareness of the risk of assault, sexually transmitted infections, and moderation in alcohol use should be discussed.
• Travelers should understand the effects that air, sea, and land travel, sun, altitude, and heat and cold may have upon their health. In order to prevent deep venous thrombosis (DVT) long-haul travelers with journeys of 6 to 8 hours and longer should avoid constrictive clothing around their waist and lower extremities, exercise their calf muscles, and maintain hydration (A-III). Travelers with increased risk factors for DVT may consider wearing below the knee support stockings (B-II) or receiving low molecular weight heparin (B-I).
• Ascent to altitudes above 3,000 m is often associated with various forms of high altitude illness. Staged ascent is an effective way to decrease the risk of altitude illness. Travelers who need to ascend rapidly may take acetazolamide for prevention (B-I).

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 (A-III).

Definitions:

Quality of Evidence

1. Evidence from >1 properly randomized, controlled trial
2. Evidence from >1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from >1 center); from multiple time-series; or from dramatic results of uncontrolled experiments
3. Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Strength of Recommendation

1. Good evidence to support a recommendation for use
2. Moderate evidence to support a recommendation for use
3. Poor evidence to support a recommendation for use
4. Moderate evidence to support a recommendation against use
5. Good evidence to support a recommendation against use

• Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. Attributes of good guidelines include validity, reliability, reproducibility, clinical applicability, clinical flexibility, clarity, multidisciplinary process, review of evidence, and documentation.
• It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
• Because recommendations for the administration of specific vaccines or antimalarials may change from those provided in this document, additional authoritative sources, as outlined in the Appendix of the original guideline document, should be consulted when putting these guidelines into practice. For each vaccine that is licensed in the United States, the Advisory Committee on Immunization Practices (ACIP) (www.cdc.gov/vaccines/recs/acip/default.htm), often in conjunction with other authoritative bodies such as the American Academy of Pediatrics, the American College of Physicians, or the Infectious Diseases Society of America, has developed recommendations that are published by the Centers for Disease Control and Prevention (CDC). These statements and the publication, Health Information for International Travel (known as the Yellow Book), remain the definitive resources for US practitioners. This document will provide guidance on their practical application. Several excellent reviews and new textbooks in travel medicine should also serve as resources. Being able to access and use the many resources available in travel medicine is an important aspect of its practice.
• The application of evidence-based standards to travel medicine is a challenge. The specialty is new and has not had the time required to develop a vast evidence base. Therefore, for many areas, expert opinion defines practice. Where possible, however, the recommendations are graded according to accepted standards.
• The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Department of Health and Human Services.

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

• Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, DuPont HL, Bia FJ, Fischer PR, Ryan ET, Infectious Diseases Society of America. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Dec 15;43(12):1499-539. PubMed

Electronic copies: Available from the Infectious Diseases Society of America (IDSA) Web site.

Print copies: Available from Dr. David R. Hill, National Travel Health Network and Centre, Hospital for Tropical Diseases, Mortimer Market Centre, Capper St., London WC1E 6AU, England (david.hill@uclh.org)

Electronic copies: Available from the Clinical Infectious Diseases Journal Web site.

Print copies: Available from Infectious Diseases Society of America, 1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

A PDA version of the original guideline document is available from www.idsaguidelinesforhandhelds.org.

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