Where in the world? Where patients have been affects what they might have
■ With new and old infectious diseases emerging around the globe, public health officials are urging physicians to take a good travel history. Doctors say it's not that simple.
By Victoria Stagg Elliott — Posted June 21, 2004
The patient had a fever and chills and kept coughing. Initially, he was prescribed antibiotics to treat a possible case of pneumonia. A week later, the patient still had symptoms.
It was only when Hilary Gagnon, MD, a staff doctor at Bell Medical Center in Negaunee, Mich., and her colleagues started to ask the patient questions about travel did they realize he had just returned from a long stint in South America.
This example is not an unusual one. Most of the time, the index of suspicion for exotic illnesses is low because the chances of exposure are slim.
"Malaria is very unusual for this area of Michigan," Dr. Gagnon said. "You don't think of malaria first off." But she might be more aware of such possibilities than most because of personal experience. She contracted African tick typhus while a medical volunteer in Africa in the late 1990s.
Still, most physicians will never see a serious travel-related illness such as SARS. Even more common ones such as malaria could be a once-in-a-career event. Many of these ailments also have very nonspecific symptoms, and doctors tend to go for the more likely diagnosis. Sometimes, though, the illness will turn out to be a zebra.
As a result, public health officials increasingly have been exhorting physicians to take a good travel history to note possible contact with novel infectious diseases such as severe acute respiratory syndrome and avian influenza or control old foes such as measles and malaria. "It constantly comes up now," said Phyllis Kozarsky, MD, chief of travelers health at the Centers for Disease Control and Prevention. "We are truly a global village."
Nonetheless, what sounds like a simple request can actually be quite complicated, because most physicians forget to ask and many patients neglect to tell.
"It's something to keep at the back of your mind," Dr. Gagnon said. "But there's so much time pressure, and it's not really the first thing you think about."
Experts warn, however, that although a travel history might be irrelevant for many, it can be critical for a few. Delays in diagnosis for travel-related illnesses are common and can be deadly. If the disease is contagious, the time lapse also can allow it to spread.
"People die of malaria because they were treated for something different," said Stephen Blythe, DO, a family physician based in Melbourne, Fla., who has a special interest in travel medicine. "And we have to be concerned not just with the seriousness of missing the diagnosis for the individual patient, but certainly with things like SARS that are very communicable, it's serious if we don't recognize and send them home for bed rest, and meanwhile they stop by the grocery store and the drug store. That's a scary thing."
Additionally, the time economy of not asking the question might not balance out. For most patients a question about travel can elicit a quick "no," and then the physician can move on to other topics. But in the exceptional case, the details could prove invaluable.
"It only takes a second to ask, 'Have you traveled out of the country?' " said Gregory Juckett, MD, MPH, associate professor of family medicine at West Virginia University and coordinator of the institution's travel clinic. "Not asking that question can cost you, because you can chase your tail trying to work up something when you don't have the proper information."
Where have you been lately?
Very little actually has been written about what "taking a good travel history" means. A good starting point is the following: "Have you traveled within the past six months?" Even such a straightforward query does not always elicit a full answer.
Patients returning to their native country but who are otherwise permanent residents of the United States might not regard that trip as "travel." Some also might not realize that business as well as pleasure travel should be included in their answer.
"People will say no even if they went down to the Caribbean," Dr. Kozarsky said. "They may not consider going to the Dominican Republic as going anywhere because they imagine going somewhere as going to China or Mexico. The other folks who don't consider that they've been anywhere are people visiting friends and family. They don't consider that a new trip. It's going home
Travel medicine experts also say a good travel history involves more than just where a patient has been. It is also entails what they did there, who they did it with and the type of accommodation they had.
"A businessman sitting in an air-conditioned five-star hotel getting fat has one certain risk, but someone who is trekking in Himalaya has others," said Richard V. Lee, MD, professor of medicine and anthropology at the State University of New York at Buffalo's School of Medicine and Biomedical Sciences. He developed dengue fever in Thailand while working in a refugee camp in the 1980s.
Meanwhile, physicians sometimes say they don't ask the question of all their patients because many of them don't go anywhere. Those in the know warn, though, that patients could travel more often than doctors realize. International travel in particular is more common than ever. According to the federal government's Office of Travel and Tourism Industries, 44 million Americans journeyed outside the United States in 1990. Despite a dip after 2001 because of terrorism concerns and the economic downturn, that number jumped to 54 million in 2003. The office predicts the figure to reach 63 million by 2007.
"You can't tell by looking at people or assume that because they're a businessman that they travel, but if they're a housewife or a farmer they don't," said Steven Hanks, MD, an internist and chief medical officer of Finger Lakes Health, Geneva, N.Y. "You just never know. People who don't seem to have means often have significant travel histories. It's worth asking because when it's important, it's real important."
Domestic travel also sometimes plays a role. The headlines were filled in 2002 with tales of bubonic plague in New York City. The afflicted couple were originally from New Mexico, where the disease is endemic although still unusual, but in New York it was unheard of.
Laying the groundwork
The responsibility to talk about travel does not solely rest on the doctor's shoulders.
"Yes, it should be more routine for physicians to ask, but shame on travelers for not mentioning where they've been," said Charles Ericsson, MD, professor of medicine and head of clinical infectious diseases at the University of Texas Medical School at Houston.
CDC materials long have advised that patients and physicians work to incorporate recent travel into the medical history. The agency also revised its travel alert system in May to make it more accessible to the general public.
"Infectious diseases can spread quickly as people travel around the globe," said CDC Director Julie Gerberding, MD, MPH. "This new system allows us to provide travelers with very important real-time information that will be easy for them to apply to protect their health."
It's true that information about outbreaks occurring around the world could be tough for the busy primary care physician to monitor and relevant on rare occasions, Still, experts say that awareness of Ebola outbreaks in the Sudan or avian influenza cases in Egypt might not be necessary. What is? Remembering to ask that first question.
"At least always ask, 'Have you traveled anywhere in last several months?' You're going to catch a lot of things," said Susan McLellan, MD, MPH, associate professor in infectious diseases and tropical medicine at Tulane University in New Orleans. "If you feel you don't really know what to do [for the next step], it's not a bad thing to pick up the phone."
But the best time to deal with travel-related health issues might not be when a sick patient is in the office after a vacation. Rather, it's before -- when patients might approach a physician for vaccinations and other advice in anticipation of the adventure.
"When I prepare people for travel, one of the things I try to set in their minds if that if they return and they happen to be ill, they shouldn't forget to tell the doctor that they've taken the trip," Dr. Ericsson said. "They've got to own up to the fact that they were traveling."