Off-Line Computer Databases

Pretravel databases. These systems usually contain specific information on health risks within a given country, country-specific recommendations for vaccine and chemoprophylaxis for malaria, and “fact sheets” on major diseases with summaries of their epidemiology, clinical presentations, diagnosis, management, and prevention. Most high-quality systems will also contain a feature that provides traveler-specific information that may be printed after the itinerary has been recorded in the system. These printouts generally include immunization and antimalaria recommendations, destination risks, and, in some cases, in-country health care resources. Detailed country-by-country disease maps may also be provided for a number of important tropical infections.

The available electronic databases are mainly personal computer-based and are accessed directly from a personal computer hard disk (CD-ROM), from a local area network, by means of an on-line dial-up modem connection, or increasingly by means of a Web-based browser. Several vendors offer multiple, different access options for the same database software. The database packages listed in table 1 represent the more widely used and available high-quality systems that contain accurate, current, and authoritative information, which is often based on the recommendations of national and/or international bodies.

In general, databases that are located in North America contain recommendations from the Centers for Disease Control and Prevention (CDC) or Health Canada, whereas databases that are located in the United Kingdom (UK) are more likely to contain UK or World Health Organization (WHO) recommendations concerning immunizations and chemoprophylaxis for malaria. As noted in the Travax (Shoreland, Milwaukee) entry in table 1, the cost of each database often depends on the frequency of updates. The 3 UK systems and Travax Encompass (Shoreland) are Internet-based. Demonstration programs are usually available on request. These computer-based databases are most appropriate for users who infrequently do pretravel consultations and/or want itinerary-specific printouts for their patients. In addition, they are useful as an audiovisual tool while advising travelers. Travax Encompass is by far the most comprehensive and well developed of the on-line databases. An example of a provider summary is shown in figure 1.

Posttravel databases. The Global Infectious Disease and Epidemiology Network (GIDEON) [5] is a database containing detailed epidemiological, diagnostic, and therapeutic information (in 4 modules) covering >230 common and exotic infectious diseases as they occur in >200 countries. In the diagnostic module, an algorithm links key clinical features and epidemiological profiles of individual patients to give a ranked differential diagnosis that is very complete although not always appropriately ranked. The epidemiological module enables the user to determine whether a particular disease is found in a specific country and provides lists of infections based on a specific type of exposure (e.g., tick bite, sexual contact, etc.). The therapeutic module provides the pharmacology, drug doses, drug interactions, and international trade names of vaccines and anti-infective agents. The microbiological diagnostic module enables the user to identify a bacterial agent by inputting the growth characteristics of the organism. Quarterly database updates are provided to the user. It is the most comprehensive tropical medicine database available. The GIDEON Web site is www.cyinfo.com.

On-line Information Sources: Internet Sites

Authoritative travel medicine recommendations. The Web sites for authoritative travel medicine recommendations that are listed in table 2 contain guidelines developed by national or other recognized official bodies. These sites are the most comprehensive and include the epidemiology of travel-related diseases, area-specific information, and numerous links to other health sites and resources. The travel health recommendations provided in these sites are primarily on the basis of evidence, although interpretation of information regarding health risks and disease prevention may vary (resulting in differing opinions and recommendations). Although CDC guidelines are the recognized standard for American travelers, it benefits practitioners (and therefore, their patients) to know that travelers from other countries have been given different recommendations. This is particularly the case concerning recommendations for chemoprophylaxis for malaria.

The entire CDC Yellow Book (Health Information for International Travel 1999–2000) may now be downloaded, or the practitioner may link to the Public Health Foundation Web site (www.phf.org) to order the text. Aside from area-specific health information, reference materials may also be viewed, such as the “Blue Sheet,” which lists countries where there are currently diseases that require quarantine, and the “Green Sheet,” which contains the health inspection scores for cruise ships. In addition, there are links to other CDC, non-CDC, medical, and nonmedical sites that are useful for travelers. Travel health recommendations from Health Canada are similar to those from the CDC. However, interesting features of the Canadian Web site include a particularly thorough guide to the prevention and treatment of malaria (with a mefloquine misconception file) and scientifically-based articles detailing otherwise untouched topics, such as retirement abroad and child abduction abroad. A list of travel clinics throughout Canada is provided. The UK Web sites are easily navigable, offer substantial general information, and are suitable for the traveler and the health care provider.

The WHO Yellow Book site contains rather superficial information on most disease topics, and its recommendations occasionally differ from those of North American health advisors. The Fit for Travel site, although authoritative, is geared more for the traveler than the health care provider. A new site for the Roll Back Malaria Program (www.who.int/inf-fs/en/fact203.html) provides color maps for areas of countries where malaria is endemic; these maps come from a variety of sources and are of varying quality and timeliness.

Surveillance and outbreak bulletins. All major disease surveillance bulletins are now available on-line on the day of publication, usually in page description format. This format allows the user to print an exact replica, including color tables, without the inherent delay of postal systems (table 3). The pros and cons of ProMedmail, a very useful resource, are discussed below in the section on listserv discussion groups, but it is included here as the Web version, which many users have found to be more convenient than the e-mail version.

Consumer-oriented sites. A number of Web sites that are useful to the consumer are listed in table 4. Included in these sites are area-specific health information, articles written by travel medicine practitioners that cover travel-related illnesses and health risks, and links to various sites from which consumers may purchase travel-related items. In addition, some sites offer “membership” through which the consumer may obtain (at no cost now) additional information through mechanisms such as “expert panel” queries. Although the medical material offered is often based on authoritative guidelines, it is sometimes difficult to distinguish between recommendations based on a standard of care and those based on editorial opinion. Travelhealth On-Line (Shoreland) and Medicine Planet are the most comprehensive consumer-oriented sites, providing a wide range of detailed information. Both sites offer outbreak news and disease-specific and country-by-country information. The information in Travelhealth On-Line is well-organized and easy to navigate. It includes disease risk maps, a worldwide listing of travel clinics, and US Department of State consular information. Medicine Planet is eye-catching and in a magazine-style format, which includes a medicine translator (which translates generic and brand-name medications from other countries into medication names used in the United States), an “ask an expert” feature, and a listing of travel clinics in the United States. The information from MASTA Australia does not offer the same depth of information as the above 2 sites.

Web sites for travelers with special needs, such as patients with diabetes or those infected with HIV, and some of the more interesting sites that have been found useful for travel medicine practitioners are listed in table 5.

Consumer products. Many travel health-related products (such as permethrin, long-acting diethyltoluamide preparations, bed nets, water purifiers, oral rehydration packets, etc.) are often difficult to find in bricks and mortar retail establishments, especially outside of large urban areas. The major vendors have both print catalogues and sophisticated e-commerce operations, often with links to other commercial Web sites. The vendors that are listed in table 6 have comprehensive lines of travel health products and travel clothing and luggage.

Medical assistance overseas. Approximately 10% of travelers require some sort of medical care while overseas during a 1-month trip, and almost 1 in 1000 requires medical evacuation home or to the nearest sophisticated medical facility [1]. Companies providing overseas medical assistance are listed in table 7. These sites provide information on the services that they provide, the cost, and the ability to enroll on-line into a particular plan. The most frequently used assistance companies provide contact information for English-speaking physicians living and working overseas who are affiliated with a particular network and information on evacuation and insurance (table 7). Other commercial packages may include guarantee of payment of hospital charges and on-line storage of traveler medical information. SOS/AEA is the most comprehensive overseas medical assistance provider; the others listed in table 7 are among the most popular with travelers. It is clear that when patients are ill in some remote location, the Internet soon will enable them to locate a competent health care provider who speaks their language in virtually any city of the world. Credentialing and quality assessment of overseas physician affiliates are difficult, and no industry standard exists.

Professional societies. The Web sites of most travel and tropical medicine societies contain information about their organization, membership benefits, their professional meetings, and links to other sources of information in their respective fields. Both the International Society of Travel Medicine and the American Society of Tropical Medicine and Hygiene provide separate Web sites that contain directories of travel clinics throughout the world that are operated by their members. Neither society endorses individual clinics, nor do they vouch for the competence of the practitioners who provide pretravel advice or posttravel consultation. Many commercial Web sites provide similar information or links to Web sites of society-affiliated travel clinics. Uniform resource locators for professional societies to which those interested in travel medicine might wish to belong are listed in table 8.

Journals with travel medicine content. The only journal that is dedicated to the field of travel medicine is the relatively new and recently indexed Journal of Travel Medicine, the publication of the International Society of Travel Medicine (ISTM). Tropical disease journals, on the other hand, tend to focus on basic aspects of tropical and parasitic diseases from the perspective of the returned traveler, immigrant, or indigenous population living in an area of endemicity. Several narrowly focused journals such as Military Medicine and Aviation, Space and Environmental Medicine occasionally publish articles that are relevant to the travel medicine practitioner. The Journal of Wilderness Medicine focuses on health aspects of outdoor recreation in wilderness areas and adventure travel (e.g., altitude sickness, diving illnesses, etc.). The Web sites of the most important journals within which travel medicine articles will be found and the on-line availability of their articles are listed in table 9.

On-Line Information Sources: Listserv Discussion Groups

The 4 nonautomated listserv discussion groups in table 10 are recommended as invaluable discussion groups for travel medicine providers, although the background and degree of experience of the on-line discussants may vary considerably. Both TravelMed and TropMed are restricted to the members of their respective host organizations, the ISTM and the American Society of Tropical Medicine and Hygiene. TravelMed is probably the most useful for those who focus on the delivery of pretravel health advice (see uniform resource locator for ISTM in table 8). ProMedmail is a global electronic outbreak reporting system where information on emerging infectious diseases is shared and discussed; in 1999, ProMedmail became a program of the International Society of Infectious Diseases. There are currently >20,000 subscribers, and it is open to all. The information that the site disseminates is up-to-date but not verified. Finally, as noted in table 10, several automated listserv discussion groups are available only to access information and not to allow discussion.