Knowledge, Attitudes, and Practices of US Practitioners Who Provide Pre-Travel Advice

Authors


  • A portion of the study results was presented at the 59th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta, GA, in November 2010. Kogelman L, Barnett ED, Yanni E, Winter MR, Chaisson CE, Chen LH, Wilson ME, Karchmer AW, Ooi WW, Gleva E, Brunette G, Hamer DH. Knowledge, attitudes and practices of practitioners who provide pre-travel consultations. Abstract 498.

Abstract

Background

As international travel increases, many health care professionals are being asked to provide pre-travel advice. We designed an anonymous web-based survey to assess the extent to which primary care providers (PCPs) provide travel medicine advice and how their understanding and delivery of itinerary-specific advice and management compare with that of travel medicine specialists.

Methods

We surveyed randomly selected US PCPs registered in the Pri-Med Institute (now pmiCME) database and US travel medicine specialists from the International Society of Travel Medicine (ISTM), American Society of Tropical Medicine and Hygiene (ASTMH), and Centers for Disease Control and Prevention (CDC) yellow fever (YF) vaccine provider mailing lists. SAS software (SAS Institute, Cary, NC, USA) was used for all analyses.

Results

Of 14,932 e-mails sent to valid e-mail addresses, 902 yielded complete or partially completed surveys (6.0% response rate). Eighty percent of respondents personally provided pre-travel advice (95% of travel medicine specialists versus 73% of PCPs). About two thirds of PCPs (68%) providing pre-travel consultations saw <50 travelers per year whereas 30% of travel medicine specialists saw <50 travelers per year. More travel medicine specialists (59%) than PCPs (18%) saw >500 travelers per year. Familiarity with travel-specific vaccines (YF, Japanese encephalitis) and provision of written educational materials increased as volume of travelers increased. Familiarity with antimalarial side effects and malaria resistance patterns, and knowledge scores based on brief pre-travel scenarios were higher in travel medicine specialists, ASTMH or ISTM certificate holders, and respondents who saw more pre-travel patients.

Conclusions

Many PCP survey participants provided pre-travel advice, but most saw few travelers. Volume of travelers and holding an ASTMH or ISTM certificate had the greatest influence on knowledge of travel medicine and provision of appropriate advice and recommendations. Creating easily accessible travel medicine education programs for US providers from a wide range of disciplines is needed to improve the management of travelers.

Outbound travel from the United States increased from 52 million in 1995 to 58.7 million in 2011, with travelers to countries with emerging economies in Africa, the Middle East, and South Asia reaching record high numbers.[1] The United States is also experiencing its largest wave of immigration since the beginning of the 20th century: foreign-born persons accounted for 13% of the total population in 2011.[2, 3] As travel to emerging economies is increasing, travelers, including those with chronic and active medical problems, are undertaking more adventurous itineraries.

Advising travelers about prevention of travel-associated diseases and dangers is no longer a rare focus of health care professionals. Providers from a wide range of disciplines, including nurses and pharmacists, are being called upon to prepare travelers.[4, 5] Unfortunately, many health care professionals may not be trained to meet these needs. Travel medicine is a relatively young interdisciplinary specialty that has grown from an esoteric field to a well-respected discipline with its own professional association, the International Society of Travel Medicine (ISTM), body of knowledge, and practice guidelines.[6, 7] Both ISTM and the American Society of Tropical Medicine and Hygiene (ASTMH) have specialized training courses and qualifying examinations that yield travel and tropical medicine certificates: the ISTM Certificate of Travel Health (CTH®) and ASTMH Certificate of Knowledge in Clinical Tropical Medicine and Traveler's Health (CTropMed®), respectively. One of the main goals of these certification programs is to ensure that health care professionals from multiple disciplines are qualified to provide pre-travel health care.

Most US physicians who provide travel medicine services have training in infectious diseases, internal medicine, or family practice. Nurses also play significant roles, being the sole providers of travel advice 22% of the time.[5] A survey done in March 1994 found that most US physicians who advise travelers saw fewer than 10 travelers per week and 14% saw fewer than two, and few have had formal training in travel medicine.[5] Even those physicians and nurses who regularly provide travel medicine services do not always provide optimal advice. Two studies in the 1990s described variability in the accuracy and completeness of pre-travel health advice provided to travelers about vaccine and malaria prophylaxis by travel medicine specialists, public health clinics, and embassies.[8, 9]

A recent airport-based survey of US travelers to low or low-middle income countries revealed that 46% of these travelers did not seek health information before travel.[10] For those who did, the Internet was the most common source, followed by primary care providers (PCPs); less than a third visited a travel medicine specialist. A previous US airport-based survey of travelers predominantly to Latin America and Asia revealed similar findings; only 36% of travelers sought pre-travel advice, and only 10% were seen by travel medicine specialists.[11]

Although the recent Infectious Disease Society of America guidelines suggest that ideally professionals with expertise in the field, working in specialized travel clinics, should provide pre-travel advice,[7] the reality is that the volume of international travel today is not matched by an adequate number of health care providers who are well trained to do so. We conducted an Internet-based survey of PCPs and travel medicine specialists to assess knowledge, attitudes, and practices (KAP) regarding pre-travel advice in order to ascertain how quality of pre-travel care varies among a range of providers, characteristics associated with provision of appropriate pre-travel advice, and what deficits need to be addressed.

Methods

Participant Selection and Data Management

In December 2009, an invitation to complete an anonymous web-based survey was sent via e-mail to PCPs and travel medicine specialists throughout the United States. Contact information was obtained with permission from the ISTM, ASTMH Clinical Group, the Centers for Disease Control and Prevention's (CDC) list of US yellow fever (YF) vaccine providers, and the Pri-Med Institute, an organization that provides educational services to PCPs across the United States. All travel medicine providers were surveyed; the Pri-Med Institute (now pmiCME) selected PCPs randomly from the 2009 Pri-Med master database of providers who had taken a course in the last year and provided permission to use their contact information for the survey. PCP selection included a mix of physicians [both Doctors of Medicine (MDs) and Doctors of Osteopathy (DOs)], nurse practitioners (NPs), and physician assistants (PAs), including 58% MDs/DOs and 42% NPs/PAs. Pri-Med provided the Boston University School of Public Health Data Coordinating Center (DCC) with a file containing PCPs' e-mail addresses and basic demographic information. The protocol was approved by the Boston University Medical Center (BUMC) Institutional Review Board and CDC Human Subject Advisors, and was designated as exempt. The DCC eliminated duplicate e-mail addresses and was responsible for collection and management of survey data, which were saved onto a secure SQL server, backed up regularly, and managed centrally. Data files were password-protected, and access was restricted to study investigators.

Survey Methods

The same survey was sent to PCPs and travel medicine specialists except that the survey for the latter group requested demographic information. PCP survey responses were stored separately from the demographic information provided by Pri-Med. Follow-up e-mails were sent to providers who did not start the survey at the time of the initial invitation, the first, 7 to 10 days after the initial invitation, and the second and final reminder, a week later to those who had not responded. Follow-up e-mails were sent on different days of the week and at different times of day to maximize response rate.

Participants who completed the survey were given a brochure of travel medicine tips, and one of every 100 respondents had an opportunity to win an Amazon gift certificate.

Questionnaire

Survey questions covered demographic information, practice characteristics, topics discussed during the pre-travel consultation, and travel medicine knowledge, attitudes, and practices (KAP). We assessed travel medicine training by asking if their practice provided YF vaccine, if they held either the ISTM CTH® or the ASTMH CTropMed®, and whether their clinic was listed in the ISTM or ASTMH travel clinic directories (a proxy for membership in these societies).

Respondents were asked about familiarity with safety, indications, and contraindications for routine and travel vaccinations; antimalarials [chloroquine, mefloquine (Lariam®), atovaquone–proguanil (AP, Malarone®), doxycycline, and primaquine]; and management of travelers' diarrhea. Familiarity was assessed on a 4-point Likert scale (very familiar, somewhat familiar, somewhat unfamiliar, and very unfamiliar).

Respondents were asked if they provided written educational materials to travelers on several topics: CDC vaccination information sheets (VISs), vaccine information other than CDC VISs, food and water safety, travelers' diarrhea, malaria, altitude sickness, and destination-specific recommendations.

Three questions were designed to test level of familiarity with chemoprophylaxis options for travelers to areas with and without chloroquine-resistant Plasmodium falciparum malaria and treatment options for travelers to areas with fluoroquinolone-resistant Campylobacter (Box 1). These topics represent basic items in the travel medicine body of knowledge.

Box 1. Knowledge questions

  1. What antimalarials would you consider prescribing for a traveler to a malaria-endemic area of sub-Saharan Africa (eg, Ghana)? Please check all that apply.
    1. Choices were mefloquine, atovaquone/proguanil, doxycycline, chloroquine, primaquine, and other.1
    2. Any answer that included chloroquine was given a knowledge score of 0.
    3. Any of the other choices was given a score of 1.
  2. What antimalarials would you consider prescribing for a traveler to a malaria-endemic part of Central America (eg, rural Nicaragua)? Please check all that apply.
    1. Choices were mefloquine, atovaquone/proguanil, doxycycline, chloroquine, primaquine, and other.2
    2. Any answer that recommended no prophylaxis was given a score of 0.
    3. Any answer that included chloroquine (preferred) as a choice was given a score of 2.
    4. Any answer that did not include chloroquine but included any of the alternative but acceptable options listed above was given a score of 1.
  3. In parts of Southeast Asia, Campylobacter may be resistant to which drugs? Please check all that apply.
    1. Choices were quinolones, macrolides, and resistance is not an issue.
    2. Any answer that did not include quinolones was given a score of 0.
    3. Any answer that did include quinolones was given a score of 1.

1 2

Statistical Analysis

Analysis was restricted to participants who provided pre-travel consultations. Both partial and complete responses were analyzed, and consequently the denominator varies for some responses. We grouped MDs and DOs as “physicians” and NPs, PAs, and registered nurses as “nurses” to analyze questions on familiarity with vaccines and antimalarial resistance, but considered these subgroups separately in the knowledge assessment. We used t-tests to compare continuous outcomes and chi-square tests to compare categorical outcomes. The knowledge score was analyzed as a dichotomous variable (knowledge score <3 or ≥3 points) (Box 1). p Values of <0.05 were considered significant. SAS software (SAS Institute, Cary, NC, USA) was used for all analyses.

Results

Of 14,932 e-mails sent to valid e-mail addresses, 902 (6.0%) yielded complete or partially complete surveys (Figure 1). More than 80% of respondents in both groups completed the survey. Nearly all (95%) of 282 travel medicine specialists and 73% of 620 PCPs provided pre-travel advice. Results for 268 PCPs and 452 travel medicine specialists (720) who stated they provided pre-travel services are presented.

Figure 1.

Survey response profile.

Characteristics of Survey Respondents

More travel medicine specialists than PCPs were older than 50 years old (Table 1). Travel medicine specialists and PCPs did not differ significantly in geographic location, with more than half of them based in the Northeast and West. Travel medicine specialists who had more years of practice [55% had >21 years vs 33% of PCPs (p < 0.0001)] were more likely to hold the ASTMH CTropMed® or ISTM CTH® (p < 0.0001), to have a clinic listing in the ASTMH or ISTM directories (p < 0.0001), and to spend more time per session with patients in pre-travel consultations (excluding time spent in administering vaccinations). Overall, 87% of survey respondents were interested in attending a short course on travel medicine, with significantly more interest from PCPs than travel medicine specialists (94% vs 77%, p < 0.0001).

Table 1. Demographics and practice characteristics of respondents who provide pre-travel consultation
Characteristic (PCP N, travel medicine specialists N, if they differ from the total responders)

PCP

N = 452

Travel medicine

specialists

N = 268

p Value
  1. a

    PCP = Primary care providers; SD = standard deviation; MD = Doctor of Medicine; DO = Doctor of Osteopathy; NP = Nurse Practitioner; PA = Physician Assistant; RN = Registered Nurse; ASTMH = American Society of Tropical Medicine and Hygiene; ISTM = International Society of Travel Medicine; ISTM CTH® = International Society of Travel Medicine Certificate of Travel Health; ASTMH CTropMed® = American Society of Tropical Medicine and Hygiene certificate in travel and tropical medicine.

  2. b

    Denominator for certain variables is lower than the total number of respondents as some did not respond to all questions.

  3. c

    “Other” includes the following: pharmacists and specialists in adult health, allergy immunization, breast health, cardiology, Chinese medicine, college health, dermatology, geriatrics, nephrology, obstetrics/gynecology, preventive medicine, psychiatry, pulmonary medicine, rehabilitation, vascular, and women's health.

  4. d

    The question was phrased as follows: “How much time, on average, do you spend counseling each traveler? This should exclude time spent administering vaccines.”

Maleb (367, 230)38.4%47.8%0.024
Age, mean (years) (SD)49.9 (26.8)52.0 (28.8)0.011
Age, yearsb (362, 229)
<302.2%1.3%0.049
31–4017.4%12.7%
41–5030.4%24.4%
>5050.0%61.6%
Academic degreeb (448, 266)
MD56.3%50.8%<0.0001
DO6.3%2.6%
NP27.0%14.3%
PA10.0%4.1%
RN0.2%26.3%
Geographic location
Northeast38.9%32.1%0.22
Southeast16.4%15.3%
Midwest15.7%17.9%
Southwest7.1%6.7%
West20.8%28.4%
Outside United States0.2%0.0%
Not reported0.9%0.8%
Respondent's medical specialty
Internal medicine32.7%26.5%<0.0001
Family practice39.8%17.9%
Pediatrics9.3%6.0%
Primary care9.5%9.0%
Infectious disease4.7%10.5%
Emergency medicine0.7%2.6%
Travel medicine0.2%8.6%
Otherc6.4%19.0%
Number of years in practice, mean (range)16.6 (0–54)22.0 (0–52)<0.0001
Numbers of years in practiceb (449, 266)
<513.8%7.1%<0.0001
6–1019.2%8.7%
11–2033.9%29.3%
≥2133.2%54.9%
Number of travelers seen per year
<5067.9%29.9%<0.0001
51–10014.4%10.8%
101–2509.3%22.0%
251–5003.1%8.6%
>5005.3%28.7%
Mean time spent counseling patients pre-travel (minutes)d (414, 252)
<1552.2%9.9%<0.0001
16–3040.8%57.1%
31–454.4%24.2%
46–60 or more2.7%8.7%
Clinic listed in ASTMH or ISTM travel clinic directory3.3%74.6%<0.0001
Respondent holds ASTMH CTropMed® certificate1.3%28.4%<0.0001
Respondent holds ISTM CTH®2.9%71.6%<0.0001
Respondent holds ASTMH CTropMed® and/or ISTM CTH® certificate3.3%74.6%<0.0001
Interested in a short course in travel medicineb (445, 267)94.2%77.2%<0.0001

Of 358 PCPs, 69% were aware of travel medicine specialists in their area, and estimated that they referred 22% of their patients to them. The top 10 reasons provided for referrals (multiple responses possible) were lack of travel vaccines in their office (74%), need for YF vaccine (68%), complex itineraries (61%), medical comorbidities (57%), pregnancy (47%), special purpose of travel (39%), children (34%), elderly (32%), lack of insurance (16%), and need for malaria chemoprophylaxis (16%).

Only 291 (44%) of 668 respondents provided YF vaccine on-site and 188 (65%) of 291 YF stamp holders had the stamp listed in their clinic's name. Fewer (17%) had a stamp with their name and medical license although the permit was not in their name.

Familiarity With Travel Medicine Vaccinations

Familiarity with routine vaccinations was similar among providers irrespective of pre-travel volume (data not shown). More travel medicine specialists than PCPs were familiar with three travel vaccines, with differences between the groups being greatest for the Japanese encephalitis (JE, 74% vs 9.8%, p < 0.0001) and YF (94% vs 19%, p < 0.001) vaccines, and, to a lesser extent, for the hepatitis A vaccine (100% vs 78.6%, p < 0.0001) (Table 2). ISTM CTH® and ASTMH CTropMed® holders, both travel medicine specialists and PCPs, were more likely to be familiar with all vaccines than those who did not hold certificates. Comfort level with JE and YF vaccines was greater among travel medicine specialists. Familiarity with all vaccines, especially YF and JE, increased with increasing volume of travelers and years in practice (Table 2).

Table 2. Provider familiarity with hepatitis A, Japanese encephalitis, and yellow fever vaccines
 Hepatitis A vaccine (%)Japanese encephalitis vaccine (%)Yellow fever vaccine (%)
NVery familiarSomewhat familiarSomewhat or very unfamiliarp ValueNVery familiarSomewhat familiarSomewhat or very unfamiliarp ValueNVery familiarSomewhat familiarSomewhat or very unfamiliarp Value
  1. a

    PCP = primary care provider; ISTM CTH® = International Society of Travel Medicine Certificate of Travel Health; ASTMH CTropMed® = American Society of Tropical Medicine and Hygiene certificate in travel and tropical medicine.

  2. b

    Physician = MD (Doctor of Medicine) or DO (Doctor of Osteopathy); Nurse = RN (registered nurse), NP (nurse practitioner), or PA (physician assistant).

PCP42178.618.82.6<0.00014179.819.970.3<0.00141618.526.954.6<0.0001
Travel medicine specialist25599.60.4025473.617.78.725593.74.71.6
PCP certification
PCP with ISTM CTH® or ASTMH CTropMed® certificate1586.713.300.6771533.320.046.60.00681546.720.033.30.0163
PCP without certificate40678.319.02.74029.019.971.140117.527.255.3
Travel medicine specialist certification
Travel medicine specialist with ISTM CTH® or ASTMH CTropMed® certificate20099.50.501.0019979.415.65.0<0.00120097.51.51.0<0.0001
Travel medicine specialist without certificate55100.0005552.725.521.85580.016.43.6
Provider type
Physicianb39889.210.00.80.01939434.019.346.70.92739445.418.336.30.604
Nurseb26882.814.23.026732.619.547.926748.718.732.6
Physician certification
Physician with ISTM CTH® or ASTMH CTropMed® certificate120100.000<0.000111979.014.36.7<0.00112093.30.85.8<0.0001
Physician without certificate27884.514.41.127514.621.564.027424.525.949.6
Nurse certification
Nurse with ISTM CTH® or ASTMH CTropMed® certificate9196.73.30<0.00019171.418.79.9<0.0019194.55.50<0.0001
Nurse without certificate17775.719.84.517612.519.967.617625.025.649.4
Travelers seen per year
<5034381.916.31.80.006734015.618.865.6<0.00133926.322.151.6<0.0001
51–1009484.012.83.29332.328.039.89444.721.334.0
101–25010193.15.91.010048.021.031.010069.017.014.0
251–5003791.98.103756.716.227.03775.78.116.2
>50010196.03.01.010175.310.913.810187.18.94.0
Years in practice
<57577.318.74.00.01257423.020.356.80.00527432.417.650.0<0.001
6–1010480.817.31.910323.322.354.410333.027.239.9
11–2021986.811.02.321831.619.748.721844.017.938.1
>2027491.28.40.427242.317.340.527258.516.225.3

Provision of Written Materials

Travel medicine specialists were more likely than PCPs to provide written educational materials to travelers (91% vs 64%; p < 0.0001). When the data were stratified by whether the provider held the ISTM CTH® and/or ASTMH CTropMed®, provision of handouts was similar for PCP and travel medicine specialist certificate holders (93% vs 97%). Both PCPs and travel medicine specialists who held certificates were more likely than those who did not hold certificates to provide written educational materials (93% vs 63%, p = 0.015 for PCP comparison and 97% vs 76%, p < 0.001 for travel medicine specialist comparison). Longer time in practice and higher volume of travelers seen annually were also associated with providing handouts (p = 0.044 and p < 0.0001, respectively).

Familiarity With Malaria Chemoprophylaxis and Antimalarial Resistance Patterns

Familiarity with side effects and contraindications to mefloquine and AP is presented in Table 3. PCPs were less likely than travel medicine specialists to be familiar with both drugs (PCP vs travel medicine specialist, mefloquine: 22% vs 84%, p < 0.001; AP: 18% vs 77%, p < 0.001). Physicians, nurses, or travel medicine specialists who held certificates were more likely to be familiar with mefloquine and AP than were those who did not. Familiarity with the side effects of and contraindications to malarial medications was greater among practitioners who saw >100 travelers per year and who had been in practice for ≥20 years (Table 3).

Table 3. Provider familiarity with side effects/contraindications to two commonly prescribed malaria chemoprophylactic medications
 Mefloquine side effects/contraindications (%)Atovoquone/proguanil side effects/contraindications (%)
NVery familiarSomewhat familiarSomewhat unfamiliarVery unfamiliarp ValueNVery familiarSomewhat familiarSomewhat unfamiliarVery unfamiliarp Value
  1. a

    PCP = primary care provider; ISTM CTH® = International Society of Travel Medicine Certificate of Travel Health; ASTMH CTropMed® = American Society of Tropical Medicine and Hygiene certificate in travel and tropical medicine.

  2. b

    Physician = MD (Doctor of Medicine) or DO (Doctor of Osteopathy); Nurse = RN (registered nurse), NP (nurse practitioner), or PA (physician assistant).

PCP32521.911.620.912.6<0.000132118.435.825.919.9<0.0001
Travel medicine specialist23683.515.70.40.423677.120.82.10
PCP certification
PCP with ISTM CTH® or ASTMH CTropMed® certificate1353.946.1000.0121353.930.815.400.0055
PCP without certificate31220.544.621.813.130816.936.026.320.8
Travel medicine specialist certification
Travel medicine specialist with ISTM CTH® or ASTMH CTropMed® certificate19187.411.50.50.50.003819181.217.31.600.0091
Travel medicine specialist without certificate4566.733.3004560.035.64.40
Provider type
Physicianb35046.935.711.46.00.071234842.232.814.410.60.154
Nurseb20348.327.114.310.320143.824.418.413.4
Physician certification
Physician with ISTM CTH® or ASTMH CTropMed® certificate11686.212.900.9<0.000111680.219.800<0.0001
Physician without certificate23427.447.017.18.623223.339.221.616.0
Nurse certification
Nurse with ISTM CTH® or ASTMH CTropMed® certificate8483.315.51.20<0.00018477.416.76.00<0.0001
Nurse without certificate11923.535.323.517.711719.729.927.423.1
Travelers seen per year
<5026629.037.620.313.2<0.000126223.333.624.418.7<0.0001
51–1008246.337.812.23.78241.537.89.811.0
101–2508764.429.93.52.38860.225.09.15.7
251–5003164.532.303.23066.726.76.70
>5009581.115.82.11.19576.815.86.31.0
Years in practice
<55836.229.319.015.50.00315832.827.622.417.20.0070
6–107842.337.215.45.17739.031.219.510.4
11–2018842.034.615.48.018535.133.018.413.5
>2023657.229.717.25.923653.826.311.08.9

Travel medicine specialists and PCPs differed significantly in familiarity with areas with mefloquine- or chloroquine-resistant malaria (Table 4). Holding an ISTM CTH® or ASTMH CTropMed® was also associated with greater familiarity with antimalarial resistance patterns. Physicians tended to have greater familiarity than nurses with mefloquine resistance (p = 0.074), and they also had significantly greater familiarity with chloroquine resistance (p = 0.02). Years in practice and annual traveler volume were also associated with greater familiarity with antimalarial resistance patterns.

Table 4. Provider familiarity with resistance to mefloquine or chloroquine in malaria-endemic areas
 Mefloquine-resistant areas (%)Chloroquine-resistant areas (%)
NVery familiarSomewhat familiarSomewhat unfamiliarVery unfamiliarp ValueNVery familiarSomewhat familiarSomewhat unfamiliarVery unfamiliarp Value
  1. a

    PCP = primary care provider; ISTM CTH® = International Society of Travel Medicine Certificate of Travel Health; ASTMH CTropMed® = American Society of Tropical Medicine and Hygiene certificate in travel and tropical medicine.

  2. b

    Physician = MD (Doctor of Medicine) or DO (Doctor of Osteopathy); Nurse = RN (registered nurse), NP (nurse practitioner), or PA (physician assistant).

PCP31812.941.830.514.8<0.000132217.144.427.311.2<0.0001
Travel medicine specialist23576.220.42.11.323683.514.01.31.3
PCP certification
PCP with ISTM CTH® or ASTMH CTropMed® certificate1225.066.78.300.0691338.553.97.700.062
PCP without certificate30612.440.931.415.430916.244.028.211.7
Travel medicine specialist certification
Travel medicine specialist with ISTM CTH® or ASTMH CTropMed® certificate19082.115.32.10.5<0.000119186.411.51.11.10.104
Travel medicine specialist without certificate4551.142.22.24.44571.124.42.22.2
Provider type
Physicianb34839.735.617.57.20.073635043.435.715.45.40.0204
Nurseb19839.427.820.212.620047.524.518.010.0
Physician certification
Physician with ISTM CTH® or ASTMH CTropMed® certificate11582.615.70.90.9<0.000111684.513.801.7<0.0001
Physician without certificate23318.545.525.810.323423.146.623.17.3
Nurse certification
Nurse with ISTM CTH® or ASTMH CTropMed® certificate8472.622.64.80<0.00018481.015.53.60<0.0001
Nurse without certificate11414.931.631.621.911623.331.028.517.2
Travelers seen per year
<5026118.439.126.416.1<0.000126324.039.524.312.2<0.0001
51–1008241.535.417.16.18242.735.415.96.1
101–2508760.927.68.13.58764.426.46.92.3
251–5003063.323.313.303174.219.46.50
>5009371.020.48.609579.014.76.30
Years in practice
<55433.327.825.913.00.0235635.725.028.610.70.0091
6–107735.136.419.59.17835.939.715.49.0
11–2018632.835.023.78.618740.633.718.27.5
>2023548.530.612.38.523654.228.412.35.1

Knowledge of Travel Medicine

Travel medicine specialists and practitioners who held the ISTM CTH® and/or ASTMH CTropMed® were significantly more likely to have a higher knowledge score (p < 0.0001 for both comparisons, Table 5). The trend was toward lower knowledge scores in practitioners aged >50 years. Scores were higher for practitioners who saw larger patient volumes (>100 travelers per year) and for physicians and nurses compared with NPs and PAs. Infectious disease specialists and pediatricians also had higher knowledge scores.

Table 5. Participant characteristics and knowledge scoreb
 NKnowledge score < 3Knowledge score 3+p Value
  1. a

    PCP = primary care provider; SD = standard deviation; Physician = MD or DO (doctor of osteopathy); Nurse = RN (registered nurse), NP (nurse practitioner), or PA (physician assistant); TM = travel medicine; ISTM CTH® = International Society of Travel Medicine Certificate of Travel Health; ASTMH CTropMed® = American Society of Tropical Medicine and Hygiene certificate in travel and tropical medicine.

  2. b

    Total knowledge score ranged from 0 to a maximum of 4. The knowledge score was analyzed as a dichotomous variable (knowledge score <3 or ≥3 points) as described in Box 1.

Provider type
PCP45247.8%52.2%<0.0001
Travel medicine specialist26811.2%88.8%
ISTM CTH® or ASTMH CTropMed® certificate holders2156.0%94.0%<0.0001
Mean age, years (SD)59151.8 (10.2)50.4 (9.8)0.135
Age (years)
<301136.4%63.6%0.067
31–409220.7%79.3%
41–5016619.3%80.7%
>5032228.9%71.1%
How many travelers seen per year?
<5038746.5%53.5%<0.0001
51–1009434.0%66.0%
101–25010118.8%81.2%
251–5003710.8%89.2%
>50110110.9%89.1%
Numbers of years in practice
<5s8139.5%60.5%0.439
6–1010938.5%61.5%
11–2023032.6%67.4%
>2029532.2%67.8%
Respondent's medical specialty
Internal medicine21935.6%64.4%<0.0001
Family practice22833.8%66.2%
Pediatrics5851.7%48.3%
Primary care6734.3%65.7%
Infectious disease348.8%91.2%
Emergency medicine1010.0%90.0%
Travel medicine244.2%95.8%
Other8041.3%58.8%
Respondent's academic degree
MD38730.7%69.3%0.0004
DO3537.1%62.9%
NP15945.9%54.1%
PA5642.9%57.1%
RN7118.3%81.7%
Respondent's geographic location
Northeast25939.4%60.6%0.176
Southeast11533.0%67.0%
Midwest11926.9%73.1%
Southwest5032.0%68.0%
West17032.9%67.1%
Outside US1100.0%0.0%
Not reported616.7%83.3%

Discussion

Our study demonstrates that a substantial proportion of PCPs are providing travel medicine advice in the United States and confirms the value of a travel medicine body of knowledge, practice guidelines, and educational programs in preparing those who give such advice. Greater knowledge of travel medicine topics and providing written educational material were associated with increased volume of travelers and self-identification as a travel medicine specialist. Our findings are consistent with those of other studies comparing travel medicine specialists with other providers. One such study, a retrospective chart review comparing specialized travel health pharmacists with PCPs in Southern California, found that pharmacists who had postdoctoral residency training in travel medicine and who had obtained the ISTM CTH® performed significantly better than PCPs in recommending antibiotics for self-treatment of travelers' diarrhea, antimalarials, and vaccines based on destination, and they more consistently documented relevant data such as purpose of travel.[12] A travel clinic model in Utah using specially trained nurses, standardized patient intake forms, vaccine and prescription protocols, and regular continuing medical education was shown to provide high-quality standardized pre-travel care to international travelers.[13] These studies demonstrate that effective training and certification in travel medicine, along with adjunctive measures such as standardized protocols, can lead to improved quality of pre-travel care by pharmacists and nurses.

Outside the United States, different approaches are used to improve quality of pre-travel care. In the UK in 2005, the National Travel Health Network and Centre (NaTHNaC) introduced a program of registration, training, standards, and audits for YF vaccination centers, run primarily by general practitioners. Evaluation of this program 4 years later revealed that participation in the NaTHNaC program had many positive effects on YF vaccine standards.[14] In the Netherlands, a registry for travel health professionals that offered national guidelines, approval of travel medicine courses, and a telephone consultation service for registered members was established in 2005.[15] This resulted in a large increase in number of providers attending travel medicine courses and registering as travel health professionals. Registered physicians who described themselves as travel medicine specialists were more likely to pose more complex questions when using the telephone consultation service. A study of medical practices providing services for higher education establishments in the UK found that previous travel medicine training was associated with correct vaccination advice but notably not with malaria advice.[16]

Our study documented that PCPs and travel medicine specialists who held the ISTM CTH® or the ASTMH CTropMed® were more likely to be familiar with travel vaccines, antimalarial drugs, and malaria resistance patterns; to provide written educational materials; and to have higher knowledge scores. These certificates are therefore an important parameter for differentiating levels of expertise in the field. Recognizing the importance of maintaining a high level of proficiency in travel medicine, the ISTM began a recertification process for the CTH® in 2011; this process includes a continuing professional development program for travel medicine providers.[17]

Although certification is an important step, travelers and health care professionals also face the challenge of finding a skilled travel medicine provider. Nearly a third of respondents were unaware of travel medicine specialists in their area, indicating either a lack of resources for both providers and patients or insufficient communication channels between PCPs and these specialists. Encouragingly, most respondents indicated interest in travel medicine education opportunities. Currently, ASTMH, ISTM, and various academic centers offer travel medicine review courses, and on-line courses are also available.[18] National registration systems like those used in the UK and the Netherlands represent alternative strategies to improve the quality of pre-travel health care provided by PCPs. Although the best solution might be a mandatory requirement for certification to be qualified as a travel medicine specialist, ongoing training for other health professionals may still be needed to satisfy the demand for travel medicine services in areas where there are no certified travel medicine specialists.

The most significant limitation of this study was the low response rate, which was likely due to the survey length and limited compensation offered. Despite a response rate lower than those of other Internet surveys,[19, 20] we obtained a sample of PCP and travel medicine specialists with a relatively broad distribution of geographic locations, age, years in practice, and provider types. The Northeast and Western United States were overrepresented relative to other parts of the country, although this finding may relate to population densities and relative number of PCPs and travel medicine specialists. PCPs and nurses familiar with travel medicine who provide pre-travel consultations may have been more likely to complete the survey. It was not possible to determine the response rate of specialists whose contact information was obtained from ISTM, ASTMH, and CDC, relative to PCPs although assuming that the proportion of bad addresses was similar in the two groups, about twice as many travel medicine specialists responded as PCPs. Those who know little about travel medicine may have been uninterested in the survey or intimidated by the questions. While PCPs were selected randomly from a nationwide database, we surveyed all travel medicine specialists who could be identified after merging lists of these specialists from different sources. We also relied on the providers to describe their own level of familiarity with vaccines and antimalarials. In so doing, we relied on the recall of providers on many aspects of their practice, which may have resulted in inaccurate estimates of some variables such as their usual patient population characteristics, volume of pre-travel patients seen, and some of their routine practices. It is possible that some providers overstated their abilities. For all these reasons, the survey population and responses may not be fully representative of US health care providers.

The specific knowledge and practice deficits among study participants demonstrate a need for automated decision support systems and/or additional travel medicine education, especially for practitioners who see few travelers. Initial qualification in travel medicine with a re-certification process, augmented by educational programs for those called upon to advise travelers occasionally, and dissemination of information about access to travel medicine specialists may all be necessary steps for protecting the health of travelers in this era of increasing global mobility.

Acknowledgments

We greatly appreciate the willingness of Pri-Med Institute (now pmiCME) to share a portion of their primary care provider database, as well as the American Society of Tropical Medicine and Hygiene Clinical Group, International Society of Travel Medicine, and Theresa Sommers of CDC Travelers' Health for providing e-mail contact information of travel medicine specialists. We thank Chris E. Chaisson and John Lu of the Data Coordinating Center at the Boston University School of Public Health for their kind assistance with the implementation of the survey. We also greatly appreciate Erika Gleva's kind assistance with the development of the brochure on travel medicine tips.

This research was funded by a cooperative agreement (1 U19CI000508-01) between the Centers for Disease Control and Prevention (CDC) and Boston Medical Center.

Disclaimer

The findings and conclusions in this report are those of these authors and do not necessarily represent the views of the CDC.

Declaration of Interests

L. H. C. has received honorarium from Thompson Media LLC (editorial board), research funding from Xcellerex Inc. (YF-Vax seroresponse), and consultant fee (editorial consultant) from Shoreland Inc. E. D. B. has received research funding from Intercell, PaxVax, and Cerexa and has received royalties from a textbook. She serves as a consultant (DMB) for Pfizer. The other authors state they have no conflicts of interest to declare.

Footnotes

  1. 1

    Twenty-five survey respondents answered “Other,” including two who said that they would use primaquine with a G6PD test and one who would use artemether–lumefantrine for standby emergency therapy. The other 22 said that they were unsure or would need to do research before making a recommendation. Total knowledge scores therefore ranged from 0 to a maximum of 4.

  2. 2

    Twenty-three respondents answered “Other.” All indicated that they would need to do research before making a recommendation.

Ancillary