Resistant malaria, the cholera epidemic in South America, traveler’s diarrhea, AIDS and hepatitis A: All were topics at the recent Third Conference on International Travel Medicine.
The widest debate, however, focused on the question of who is to inform prospective travelers, particularly those from developed countries going to the Third World, about how to protect their health.
Participants made progress toward a consensus on the steps needed but remained frustrated on how to deliver the news.
By the end of the conference, a committee had zeroed in on the idea of an information sheet to be distributed by travel agents, but, according to the reports of those who have tried, travel agents do not like talking about disease.
However, the president of the society holding the conference said there was a prospect of a breakthrough in this area.
Some 1,000 medical professionals attended the conference in Paris, which was sponsored by the International Society for Travel Medicine, founded at a similar meeting in Atlanta in 1991.
Research presented to experts from 60 countries, and the experts’ anecdotes, showed that so many people go to the tropics unprepared that the phrase, “slip through the net,” is outlandish; there is virtually no net.
For example, according to Dr. Leonard Marcus, of Newton, Mass., a group of missionaries from Massachusetts preparing to visit Liberia were told recently by their travel agent that a vaccination would be required for yellow fever, which is true, as would one for cholera, which is not.
Malaria was not mentioned. One missionary fell ill and returned with chills and fever, telling her family doctor that she had been in Africa and thought she had malaria. The physician disagreed and treated her with antibiotics for flu, and the patient ended up with pulmonary edema. She was diagnosed correctly elsewhere, was treated and eventually recovered; a second missionary got malaria but was diagnosed correctly. The travel agent made an error, but had the family doctor been asked for pre-travel advice, he might not have been much more help.
Travelers should be aware
Participants agreed that protection against disease requires that it occur to prospective travelers in the first place that inoculations may be needed, that they ask informed people what they should get, be aware of questions about water, food and mosquitoes.
Family doctors took their lumps at the conference, but the increasing availability of constantly revised data bases and the fax information line of the United States Centers for Disease Control and Prevention-404-332-4565-brought agreement that more primary-care doctors and nurses should be equipped to give correct travel advice. However, surveys made by participants showed that wrong information sometimes was dispensed by disorganized travel clinics, so travelers must be sophisticated or persistent.
One obstacle in the flow of information involves inoculations required for entry into a country, and those recommended, which may not be as optional as they sound. The requirements, which are few now and may depend upon which countries a traveler already has visited, are listed in standard references, including annual publications of the World Health Organization and the Centers for Disease Control and Prevention.
Requirements are intended to protect the residents of a country being visited from diseases that may be imported with the traveler.
As Dr. Jonathan Mann, professor of health and human rights at the Harvard School of Public Health, said, epidemics always have been associated with great movements of people, whether in war or in tourism, and it is a government’s instinct to protect its people from “the others.” But steps to safeguard residents do not necessarily protect visitors from diseases they encounter. Many conference participants are associated with travel health clinics, where expertise in tropical medicine and communicable diseases is the stock in trade, and believe they are the best source of counsel.
“We know who we are,” said Dr. Elaine C. Jong, of the University of Washington Medical Center. “How do the travelers find out who we are?”
Rosamond R. Dewart, of the Centers for Disease Control in Atlanta, phrased it differently: “We have the information. What is the delivery vehicle?”
The experts concurred that one simple option-using an airline ticket folder to convey the information-would get data to a traveler too late for many precautions.
Role of travel agents
At one panel, discussion became heated about travel agents, whom the medical people consider ideal deliverers of the message that travelers to certain places should get inoculations and advice.
Two clinic directors in the New York area said they had given brochures to local agencies, but the agencies had asked for a commission on referrals, which physicians do not pay. Jong said she had visited travel agents in the Seattle area with good results; her clinic now sees 30 people a day.
Dr. Tom Madhaven, who runs the Medical Dimensions Specialty Center in Farmington Hills, Mich., took another tack. He said he bought ads in publications intended for ethnic communities in Detroit, saying: “Are you going home? Bring ’em back alive.”
“I got big results,” he said.
Henryk F. Handszuh, coordinator for safety and health of the World Tourism Organization, noted that a 1990 directive of the European Community provides that the buyer of a package tour must be told of “health formalities required for the journey and stay,” first orally, then in writing.
“Formalities” means requirements, it was explained.
So far France, the Netherlands and Germany have enacted legislation to carry out this directive, but a Dutch delegate said travel agents were “in turmoil” about their role. Still, the move creates awareness.
The travel medicine society is as wary as travel agents and tour operators are about having agents and operators cobble together medical advice for their brochures.
Noting that the society had received an inquiry from a major travel organization about a health advice sheet to distribute with brochures or reservation receipts, the society’s president, Dr. Robert Steffen, of the University of Zurich, said a subcommittee had prepared a draft of “minimum standards” of information to be provided by agents and operators. The draft addresses whether any vaccines are required for entry into the specific country; whether any are recommended and whether there is a risk of malaria.
In a high-risk area, Steffen said, the sheet would say that prophylaxis is advised and travelers should see doctors for this. Other precautions would be noted, such as foods to avoid and recommendations against unprotected sex.
Dr. Christopher Neville, of the African Medical and Research Foundation in Nairobi, Kenya, said he feared that taking health responsibility away from travelers may not be a good idea.
Even malaria prophylaxis does not give 100 percent protection, he said: “As they get off the plane, the video should say: `It is possible you will get malaria. Do you know what you will do then?’ “
