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D E D I C AT I O N
This edition of Travel Medicine is lovingly dedicated to our colleague,
our mentor, our friend, Dr. Jay Keystone. One could easily enumerate
a list of superlatives for Jay by just reeling off items from his lengthy
curriculum vitae – his manuscripts, academic appointments, the many
awards he has received, and the immense contributions he has made
to travel and tropical medicine in his decades of service. Perhaps the
most distinguished of his honors was his induction into the Order of
Canada in May, 2016. The Order recognizes individuals who have
exhibited lifelong exemplary achievement, service, and have made major
contributions to Canada; Queen Elizabeth II is the Sovereign of the
Order. This was truly well deserved.
So, if it were the editors’ decision to dedicate this text to Jay just on
the basis of his awards and honors, it would be enough.
But many of us who use this text know Jay as a one of the fathers
of the practice of clinical tropical medicine and travelers’ health. Jay
received his MSc from the London School of Tropical Medicine in 1974
and since then he has cared for countless patients around the world
and excelled in judgment and clinical management.
ii
Many of us are students of Jay. Jay received the Ben Kean Medal
from the American Society of Tropical Medicine and Hygiene (ASTMH)
recognizing his teaching skills. His teaching style connects with students
at all levels. Over the decades, he has been on the roster of invited
speakers for countless educational conferences that we attend and we
are always delighted to see Jay at the podium. His lectures are informative,
up to date, and enormously entertaining. In fact, he is one of few who
make us all laugh – at ourselves and at the human condition – no
matter our background or beliefs.
Some of us know Jay as an early pioneer in travel medicine. He was
chosen to speak about malaria at the 1988 travel medicine conference
in Zurich, and was one of the founding members of the International
Society of Travel Medicine (ISTM). A former president of the Society,
Jay sought greater membership from underrepresented countries, and
participated in the development of the Certificate in Travel Health
examination. During his tenure as ISTM President he created a “Coalition
for Healthy Travel” encouraging pharmaceutical industry partners to
forgo their own corporate interests and contribute to general education
in travel medicine and travelers’ heath. He was the GeoSentinel site
director for the Toronto clinic, which was the first GeoSentinel site
recruited outside the United States.
And finally, some of us are fortunate enough to know Jay as one of
the most caring persons we have ever known. Jay is one of those rare
individuals who is always his authentic self. He is equally willing to give
his time to advise junior students as senior colleagues. For some of us,
his support helped us forge our own careers in travel medicine. As a
physician, he is compassionate, understanding the importance of holding
the hand of a frightened patient or family member. He will stop at
nothing to help his patients, and is incredibly generous with his time
in consultations. As a friend, he is always available to lend an ear. He
is quick to offer his opinion when asked (and sometimes even when
not!). Bright, energetic, fun-loving, realistic, and kindhearted, he embodies
those qualities we admire. A loving father of five and grandfather of
five, he has found his soulmate, Margaret Mascarenhas, and they cherish
the moments they spend together. However, Jay still manages to take
time for his patients and for all of us who seek his counsel and rely on
his wisdom.
We thank you, Jay, with all our hearts.
Your Editorial Team – Phyllis Kozarsky, Bradley Connor, Hans
Nothdurft, Karin Leder, and Marc Mendelson
Travel
Medicine
Fourth Edition

Jay S. Keystone CM MD MSc(CTM) FRCPC Hans D. Nothdurft MD

Professor of Medicine, University of Toronto Professor
Tropical Disease Unit Department of Infectious Diseases and Tropical
Toronto General Hospital Medicine
Toronto, ON, Canada Head, University Travel Clinic
University of Munich
Phyllis E. Kozarsky MD Munich, Germany
Professor Emerita
Department of Medicine Marc Mendelson MD PhD
Division of Infectious Diseases Division of Infectious Diseases and HIV Medicine
Emory University University of Cape Town
Groote Schuur Hospital Observatory
Bradley A. Connor MD Cape Town, South Africa
Clinical Professor of Medicine
Weill Cornell Medical College Karin Leder MD MPH PhD
The New York Center for Travel and Tropical Head, Infectious Disease Epidemiology Unit
Medicine School of Epidemiology and Preventive Medicine
New York, NY, USA Monash University
Melbourne, VIC, Australia

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© 2019, Elsevier Inc. All rights reserved.
First edition 2004
Second edition 2008
Third edition 2013
Fourth edition 2019

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Chapter 14: “Malaria: Epidemiology and Risk to the Traveler” by David Lalloo and Alan J. Magill (†) is in
Public Domain.
Chapter 20: “Clinical Presentation and Management of Travelers’ Diarrhea” by Mark S. Riddle is in Public
Domain.
Chapter 21: “Persistent Gastrointestinal Symptoms in the Ill-Returning Traveler” by Mark S. Riddle is in Public
Domain.
Chapter 58: “Eosinophilia” by Amy D. Klion is in Public Domain.

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“When you travel, remember that a foreign country is not designed
to make you comfortable. It is designed to make its own people
comfortable.” Clifton Fadiman
Clifton Fadiman pointed out correctly that travel is not without its
challenges. Whether one travels first class or in no class at all, there
remain a variety of health issues that may be beyond our control. For
example, when it comes to adhering to food and beverage precautions,
one can do everything right and become ill, or everything wrong and
remain well. Sometimes luck and our body’s immune system are what
keep us healthy.
As the scientific base of travel medicine continues to grow, so does
the need for synthesizing this material into a formal text. Yes, readers
may go online now and research every travel health topic separately to
find the most recently published articles, but these may not give the
reader sufficient history, perspective, or the various opinions that make
up all the features of the topic or this text.
Our aim then has not only been to provide a review of important
areas, but to update the previous edition and to include new items that
comprise travel health. New information covering immunizations,
prophylactic medications, and guidance are all included.
As well, this fourth edition has an expanded editorial team, including
representation from other parts of the world: Dr. Marc Mendelson from
South Africa and Dr. Karin Leder from Australia. The importance of
having a truly global team looking at the text cannot be overstated. We
realize that to cover worldwide health issues, we needed to think more
globally about inclusion.
On the other hand, there are some things that a text cannot do. We
urge all those who need information on a current or new health problem
P R E FA C E
in a particular country to investigate more widely using WHO or national
websites. Certainly, one of the many things we have learned about
medicine, and travel medicine in particular, is that health recommenda-
tions can change overnight with the emergence or reemergence of disease.
The field’s mandate continues to be the maintenance of health of
international travelers. In 1988, the first international meeting of travel
medicine experts took place in Switzerland and from that initiative
came the International Society of Travel Medicine, now with 3500
members from 94 countries. Since then the world of travel medicine
has changed significantly, as is highlighted by changes in our text with
each edition. Now the fourth edition includes chapters covering ecotour-
ism, VIP travel, and pretravel considerations in the prevention of
non-vaccine preventable infections such as Zika, chikungunya, and
MERS viruses. Also, we have provided travel medicine consultants with
an approach to the illnesses they might encounter in ill-returned travelers,
both the investigations and the management issues. Our outstanding
authors are subject matter experts who have comprehensive and
authoritative knowledge in their respective fields, individuals who have
been selected from a number of countries. We believe that by incorporat-
ing both a practical and evidence-based approach, our authors and
editors have made this book an essential resource for all travel medicine
practitioners.
We hope you enjoy this edition. We believe that all of our authors
and editors love to travel, knowing it enhances their careers and lives.
Despite travel’s many challenges, one must also consider the alternative
and why it is so important to travel, stated so succinctly here:
“If you think adventure is dangerous, try routine, it’s lethal.”
Anonymous
v
LIST OF CONTRIBUTORS
Vernon Ansdell MD FRCP DTM&H
Associate Clinical Professor
University of Hawaii Department of
Tropical Medicine
Medical Microbiology and Pharmacology
Honolulu, HI, USA
Olivier Aoun MD MSc
Lieutenant Colonel, French Military Health
Service
Chief physician of the 46th Medical Unit
5th Armed Forces Medical Center
Strasbourg, Alsace, France
Howard Backer MD MPH FACEP FAWM
Director
California Emergency Medical Services
Authority
California State Government
Sacramento, CA, USA
Michael Bagshaw MB MRCS FFOM
DAvMed
Professor of Aviation Medicine; Army
Civilian Consultant Adviser in Aviation
Medicine
Centre of Human & Aerospace Physiological
Sciences
King’s College London
London, UK
J. Kevin Baird PhD FASTMH
Eijkman-Oxford Clinical Research Unit
Eijkman Institute of Molecular Biology
Jakarta, Indonesia
Centre for Tropical Medicine & Global
Health
Nuffield Department of Medicine
University of Oxford
Oxford, UK
Roger A. Band MD FACEP
Senior Advisor, Medical, Shoreland-Travax
Vice Chair, Strategic Out of Hospital
Initiatives
Director Quality Assurance, Peer Review
and Process Improvement
Medical Director Jefferson Enterprise
Urgent Care
Department of Emergency Medicine
Thomas Jefferson University
Philadelphia, PA, USA
Elizabeth D. Barnett MD
Professor of Pediatrics
Section of Pediatric Infectious Diseases
Boston Medical Center
Boston, MA, USA
vi
Trish Batchelor MD FRACGP MPH
DipCH PG Dip Occ Env Med
Principal Medical Adviser
Australian Department of Foreign Affairs
and Trade
Canberra, ACT, Australia
Ronald H. Behrens MD FRCP
Director of Department of Travel Medicine,
Hospital for Tropical Diseases
Research Degree Director, Faculty of
Infectious and Tropical Diseases, London
School of Hygiene and Tropical
Medicine
London, UK
Jiří Beran MD
Professor of Medicine
Department for Tropical, Travel Medicine
and Immunization,
Institute for Postgraduate Medical
Education
Prague, Czech Republic
Vaccination and Travel Medicine Centre
Hradec Králové, Czech Republic
Sarah Borwein MD
Managing Partner and Physician
Central Health Medical Practice and
TravelSafe
Hongkong, SAR China
William B. Bunn MD JD MPH
Advisor / Consultant
Former VP of Health, Safety, Security &
Productivity
Navistar International Corporation
Lisle, IL, USA
Professor
Medical University of South Carolina
Charleston, SC, USA
Gerd D. Burchard MD PhD
Professor
Department Tropical Medicine / Infectious
Diseases
University Medical Center Hamburg
Hamburg, Germany
Michael V. Callahan MD DTM&H MSPH
Director, Clinical Translation
Vaccine and Immunotherapy Center
Division of Infectious Diseases
Massachusetts General Hospital
Harvard Medical School
Boston, MA, USA
Suzanne C. Cannegieter MD PhD
Professor in Clinical Epidemiology
Department of Clinical Epidemiology and
Department of Internal Medicine,
Thrombosis and Haemostasis
Leiden University Medical Center
Leiden, the Netherlands
Eric Caumes MD
Professor
Head of Department
Service des Maladies Infectieuses et
Tropicales
Groupe Hospitalier Pitié-Salpêtrière
Paris, France
Lin H. Chen MD FACP FASTMH FISTM
Director, Travel Medicine Center, Mount
Auburn Hospital
Associate Professor, Harvard Medical School
Division of Infectious Diseases and Travel
Medicine
Mount Auburn Hospital
Cambridge, MA, USA
Joannes Clerinx MD
Senior Consultant, Department of Clinical
Sciences
Institute of Tropical Medicine
Antwerp, Belgium
Bradley A. Connor MD
Clinical Professor of Medicine
Weill Cornell Medical College
The New York Center for Travel and
Tropical Medicine
New York, NY, USA
Jakob P. Cramer MD PhD
Infectious Diseases
Travel Medicine
Tropical Medicine Specialist
Hamburg, Germany
Thomas E. Dietz MD
Providence Hood River Memorial Hospital,
Emergency Department
Portland, OR, USA
Herbert L. DuPont MD
Mary W. Kelsey Chair in Medical Sciences,
University of Texas McGovern Medical
School, Professor of Infectious Diseases,
University of Texas School of Public
Health, Clinical Professor, Baylor College
of Medicine, President and CEO, Kelsey
Research Foundation
Houston, TX, USA
 LIST OF CONTRIBUTORS vii

Yoram Epstein PhD Philippe Gautret MD PhD DTM&H Stephen W. Hargarten MD MPH
Head, Environmental Physiology Branch Senior Clinician, Travel and Tropical Professor and Chair of Emergency Medicine
Heller Institute of Medical Research Medicine Associate Dean for Global Health
Sheba Medical Center Head of Out-Patients Department, Comprehensive Injury Center Director
Tel Hashomer, Israel Infectious Diseases and Travel Clinic Medical College of Wisconsin
Aix Marseille Univ, IRD, AP-HM, SSA, Milwaukee, WI, USA
Charles D. Ericsson MD VITROME, IHU-Méditerranée Infection,
Dr. and Mrs. Carl V. Vartian Professor of Marseille, France Christoph Hatz MD DTM&H
Infectious Diseases Principal Investigator, EuroTravNet Emeritus Professor of Tropical and Travel
McGovern Medical School Medicine
Houston, TX, USA Jason Gibbs Swiss Tropical and Public Health Institute,
Pharmacist Basel, Switzerland
Philip R. Fischer MD Nomad Travel Clinics Emeritus Professor of Epidemiology and
Professor of Pediatrics UK Prevention of Communicable Diseases
Mayo Clinic Epidemiology, Biostatistics and Prevention
Rochester, MN, USA Jeff Goad PharmD MPH FISTM Institute,
Professor and Chair University of Zürich, Switzerland
Gerard T. Flaherty MB BSc MSc MD Department of Pharmacy Practice
FRCPI FFTM RCPS (Glasg) FISTM Chapman University School of Pharmacy Deborah M. Hawker PhD DClinPsy
Professor of Medical Education; Adjunct Irvine, CA, USA CPsychol AFBPsS
Professor of Travel Medicine and Clinical Psychologist
International Health Larry Goodyer MPharm MRPharmS Nottingham, UK
School of Medicine, National University of Phd FFTMRCPS(Glasg) FRGS FISTM
Ireland Galway Professor of Pharmacy Practice Patrick Hickey MD FAAP FIDSA
Galway, Ireland Leicester School of Pharmacy Lieutenant Colonel, Medical Corps, US
De Montfort University, Army
Mark S. Fradin MD Leicester, UK Deputy Principal, PEPFAR-DOD
Adjunct Clinical Associate Professor of Consultant Travel Health Specialist Nomad Military HIV Research Program
Dermatology Stores and Clinics, UK Walter Reed Army Institute of Research
Department of Dermatology Silver Spring, MD, USA
University of North Carolina at Chapel Hill Christina Greenaway MD FRCPC MSc Associate Professor
Chapel Hill, NC, USA Associate Professor Division of Tropical Public Health
Division of Infectious Diseases Department of Preventive Medicine and
Tifany Frazer MPH Jewish General Hospital Biostatistics
Office of Global Health Manager Centre for Clinical Epidemiology of the Uniformed Services University
Medical College of Wisconsin Lady Davis Institute for Medical Bethesda, MD, USA
Milwaukee, WI, USA Research
McGill University Carter D. Hill MD FACEP
David O. Freedman MD Montreal, QC, Canada Evergreen Emergency Services, Inc.
Professor Emeritus of Infectious Diseases Evergreen Healthcare
University of Alabama at Birmingham Sandra Grieve RGN Kirkland, WA, USA
Medical Director, Shoreland Travex Independent Travel Health Specialist Nurse
Birmingham, AL, USA Independent Practitioner David R. Hill MD DTM&H FRCP FFTM
Warwickshire, UK (RCPS Glasg) FASTMH
Joanna Gaines PhD MPH CHES Professor of Medical Sciences
Senior Epidemiologist Martin P. Grobusch Director of Global Public Health
Travelers’ Health Branch, Division of Global Center of Tropical Medicine and Travel Frank H. Netter MD School of Medicine
Migration and Quarantine Medicine Quinnipiac University
Centers for Disease Control and Prevention Department of Infectious Diseases, Division Hamden, CT, USA
Atlanta, GA, USA of Internal Medicine
Academic Medical Center, University of Euna Hwang MD FRCSC
Kenneth Gamble MD FFTM RCPS Amsterdam Clinical Lecturer
(Glasg) Amsterdam, the Netherlands Section of Otolaryngology-Head and Neck
President Surgery
Missionary Health Institute and Peter H. Hackett MD Department of Surgery,
International Medical Services Director, Institute for Altitude Medicine University of Calgary
Toronto, ON, Canada Ridgway, CO, USA Calgary, AB, Canada

Davidson Hamer MD Petra A. Illig MD

Professor of Global Health and Medicine Senior Medical Examiner
Boston University Schools of Public Health Aviation Medical Services of Alaska
and Medicine Anchorage, AK, USA
Boston, MA, USA
viii LIST OF CONTRIBUTORS

Clarion E. Johnson MD David G. Lalloo MB BS MD FRCP Alberto Matteelli MD

Advisor / Consultant Dean of Clinical Sciences and International Associate Professor
Former Global Medical Director Public Health Clinic of Infectious and Tropical Diseases
ExxonMobil Corporation Liverpool School of Tropical Medicine University of Brescia and Brescia Spedali
Houston, TX, USA Liverpool, UK Civili General Hospital
WHO Collaborating Centre for TB/HIV
Jay S. Keystone CM MD MSc(CTM) William L. Lang MD MHA and TB Elimination
FRCPC Vice President, International Medicine Brescia, Italy
Professor of Medicine, University of Inova Health System
Toronto Fairfax, VA, USA Anne McCarthy MD BMedSc MSc
Tropical Disease Unit FRCPC DTM&H
Toronto General Hospital Beth Lange MB ChB Director, Tropical Medicine & International
Toronto, ON, Canada Otolaryngologist Health Clinic, Division of Infectious
Alberta Health Care Services Diseases
Amy D. Klion MD Calgary, AB, Canada Professor of Medicine, University of Ottawa,
Senior Clinical Investigator Faculty of Medicine
Head, Human Eosinophil Section Karin Leder MD MPH PhD UGME Lead for Global Health, Faculty of
Laboratory of Parasitic Diseases Head, Infectious Disease Epidemiology Unit Medicine University of Ottawa
National Institute of Allergy and Infectious School of Epidemiology and Preventive Department of Infectious Disease, The
Diseases Medicine Ottawa Hospital
National Institutes of Health Monash University Ottawa, ON, Canada
Bethesda, MD, USA Melbourne, VIC, Australia
Sarah L. McGuinness MBBS FRACP
Herwig Kollaritsch MD DTM C. Virginia Lee MD MPH MA MPH DTM&H BMedSc
Institute of Specific Prophylaxis and Senior Medical Officer Infectious Diseases Physician
Tropical Medicine Travelers’ Health Branch, Division of Global Department of Infectious Diseases,
Center for Pathophysiology, Infectiology Migration and Quarantine The Alfred Hospital
and Immunology Centers for Disease Control and Prevention School of Public Health and Preventive
Medical University of Vienna Atlanta, GA, USA Medicine,
Vienna, Austria Monash University
Michael Libman MD Melbourne, VIC, Australia
Camille Nelson Kotton MD FIDSA FAST Professor of Medicine
Clinical Director, Transplant and Director, J. D. MacLean Centre for Tropical D. Bruce McIndoe MS
Immunocompromised Host Infectious Diseases President and Founder
Diseases McGill University WorldAware, Inc.
Infectious Diseases Division, Massachusetts Montreal, QC, Canada Annapolis, MD, USA
General Hospital
Associate Professor, Harvard Medical School Sheila M. Mackell MD Susan L F McLellan MD MPH FIDSA
Boston, MA, USA Pediatrics and Travel Medicine FASTMH
Mountain View Pediatrics Professor, Infectious Diseases Division
Phyllis E. Kozarsky MD Flagstaff, AZ, USA Medical Director, Biocontainment
Professor Emerita Treatment Unit
Department of Medicine Alan J. Magill† Director of Biosafety for Research-related
Division of Infectious Diseases Colonel US Army Infectious Pathogens
Emory University Emeritus, Walter Reed Army University of Texas Medical Branch
Institute of Research 301 University Blvd.
Susan M. Kuhn MD MSc DTM&H Associate Professor of Preventive Galveston, TX, USA
FRCPC Medicine and Biometrics
Associate Professor Associate Professor of Medicine W.A.J. (Jack) Meintjes MBChB DOM
Departments of Pediatrics and Medicine Uniformed Services University of the Health FCPHM(SA) Occ Med MMed (Occ Med)
University of Calgary Sciences Occupational Medicine Specialist and
Alberta Children’s Hospital Bethesda, MD, USA Senior Lecturer
Calgary, AB, Canada Division of Health Systems and Public
Poppy Markwell MD MPH MSPH Health, Department of Global Health
Tamar Lachish MD Senior Infectious Disease Fellow Faculty of Medicine and Health Sciences,
Infectious Diseases Unit Tulane University School of Medicine Stellenbosch University
Shaare-Zedek Medical Center New Orleans, LA, USA Cape Town, South Africa
Jerusalem, Israel

†
Deceased.
 LIST OF CONTRIBUTORS ix

Marc Mendelson MD PhD Eskild Petersen MD DMSc DTM&H Patricia Schlagenhauf PhD FFTM RCPS
Division of Infectious Diseases and HIV MBA FESCMID (Glasgow) FISTM
Medicine Professor, Senior Consultant Professor and Senior Scientist
University of Cape Town Department of Infectious Diseases University of Zürich Centre for Travel
Groote Schuur Hospital Observatory The Royal Hospital Medicine
Cape Town, South Africa Muscat WHO Collaborating Centre for Travellers’
Sultanate of Oman Health
Maria Denise Mileno MD Epidemiology, Biostatistics and Prevention
Associate Professor of Medicine Mark S. Riddle MD MPH&TM DrPH Institute
Division of Infectious Diseases Chair and Professor Zürich, Switzerland
Alpert Medical School of Brown Department of Preventive Medicine and
University Biostatistics Eli Schwartz MD DTM&H
Consultant and former Director, F. Edward Hebert School of Medicine— Professor of Medicine
Brown Medicine Travel Clinic, East “America’s Medical School” Center for Geographic Medicine and
Providence RI Uniformed Services University Tropical Diseases
The Miriam Hospital Bethesda, MD, USA Chaim Sheba Medical Center, Tel Hashomer
Providence, RI, USA Sackler School of Medicine
Frits R. Rosendaal MD PhD Tel Aviv University
Laurie C. Miller MD Professor in Clinical Epidemiology Tel Aviv, Israel
Professor of Pediatrics, Tufts University Department of Clinical Epidemiology
School of Medicine Leiden University Medical Center David R. Shlim MD
Adjunct Professor, Friedman School of Leiden, the Netherlands Medical Director
Nutrition Science & Policy Jackson Hole Travel and Tropical Medicine
Adjunct Professor, Eliot-Pearson Gail Rosselot NP MS MPH COHN-S/R Jackson Hole, Wyoming
Department of Child Study & Human FRCPS (Glas) FAANP FISTM The New York Center for Travel and
Development Certificate in Travel Health® Tropical Medicine
Tufts University President, Travel Well of Westchester, Inc. New York, NY, USA
Boston, MA, USA Director, The Westchester Courses
President, American Travel Health Nurses Frédéric Sorge MD
Daniel S. Moran PhD Briarcliff Manor Consultation Adoption, Enfant Migrant
Head, Health Promotion Department New York, NY, USA Département de Pédiatrie
School of Public Health Hôpital Necker Enfants Malades
Ariel University Edward T. Ryan MD Paris, France
Ariel, Israel Director, Global Infectious Diseases,
Massachusetts General Hospital Mike Starr MBBS FRACP
Michael P. Muehlenbein PhD MsPH Professor of Medicine, Harvard Medical Pediatrician, Infectious Diseases Physician,
MPhil School Consultant in Emergency Medicine
Professor and Chair Professor of Immunology and Infectious Honorary Clinical Associate Professor,
Department of Anthropology Diseases, Harvard T.H. Chan School of University of Melbourne
Baylor University Public Health The Royal Children’s Hospital
Waco, TX, USA Boston, MA, USA Melbourne, VIC, Australia

Erni J. Nelwan MD PhD Nuccia Saleri MD PhD Robert Steffen MD

Division of Tropical Infectious Diseases Tropical Medicine Specialist Emeritus Professor
Faculty of Medicine Universitas Indonesia TB and TB/HIV Technical Advisor University of Zurich
Jakarta, Indonesia Independent Consultant Epidemiology, Biostatistics and Prevention
Pondicherry, India Institute
Silvia Odolini MD WHO Collaborating Centre for Travellers’
Clinic of Infectious and Tropical Diseases John W. Sanders MD Health
University of Brescia and Brescia Spedali Professor of Medicine Zurich, Switzerland
Civili General Hospital Chief, Section on Infectious Diseases Adjunct Professor
WHO Collaborating Centre for TB/HIV Wake Forest School of Medicine Division of Epidemiology, Human Genetics
and TB Elimination Winston-Salem, NC, USA & Environmental Sciences
Brescia, Italy University of Texas School of Public Health
Houston, TX, USA
Philippe Parola MD PhD
Professor, Infectious Diseases Kathryn N. Suh MD FRCPC MSc
Head of Department, Acute Infectious Division of Infectious Diseases
Diseases The Ottawa Hospital
Aix Marseille Univ, IRD, AP-HM, SSA, Associate Professor of Medicine
VITROME, IHU-Méditerranée Infection, University of Ottawa
Marseille, France Ottawa, ON, Canada
x LIST OF CONTRIBUTORS
Andrea Summer MD
Professor of Pediatrics
Medical University of South Carolina
Charleston, SC, USA
David N. Taylor MD
Chief Medical Officer
Vaxart, Inc.
South San Francisco, CA, USA
W. Robert Taylor
Mahidol Oxford Tropical Medicine Research
Unit
Bangkok 10400, Thailand
Division of Tropical and Humanitarian
Medicine
University Hospitals of Geneva
Geneva, Switzerland
Shiri Tenenboim MD MSc(MIH)
DTM&H
Medical Doctor
Chaim Sheba Medical Center, Tel Hashomer
Sackler School of Medicine
Tel Aviv University
Tel Aviv, Israel
Joseph Torresi MBBS BMedSci FRACP
PhD
Department of Microbiology and
Immunology
The Peter Doherty Institute for Infection
and Immunity
The University of Melbourne
Melbourne, VIC, Australia
Richard J. Tubb MD
Senior Advisor, Medical, Shoreland-Travax
Brigadier General, USAF (ret)
White House Physician Emeritus
Washington, DC, USA
Thomas H. Valk MD MPH Annelies Wilder-Smith MD PhD MIH
President FAMS FACTM
VEI, Incorporated Professor of Infectious Diseases
Marshall, VA, USA Director, Global Health and Vaccinology
Programme
Jenny Visser MbChB MTravMed Lee Kong Chian School of Medicine
Senior Lecturer Novena Campus
Department of Primary Health Care and Singapore
General Practice
University of Otago Mary Elizabeth Wilson MD FACP FIDSA
Wellington, New Zealand FASTMH FISTM
Clinical Professor of Epidemiology and
Leo G. Visser MD PhD Biostatistics
Professor of Infectious Disease School of Medicine
Head of Department of Infectious Diseases University of California San Francisco
Leiden University Medical Center San Francisco, CA, USA
Leiden, the Netherlands and
Adjunct Professor
Edward Wasser MD Department of Global Health and
The Toronto East General Hospital, Population
Sunnybrook Health Sciences Centre, Harvard T.H. Chan School of Public Health
Examiner, Medical Council of Canada Boston, MA, USA
Peer Assessor and Investigator, College of
Physicians and Surgeons of Ontario Henry M. Wu MD DTM&H
Toronto, ON, Canada Assistant Professor of Medicine
Division of Infectious Diseases
Eric L. Weiss MD DTM&H Emory University School of Medicine
Associate Clinical Professor Atlanta, GA, USA
Department of Emergency Medicine
Stanford University School of Medicine
Stanford, CA, USA
Ursula Wiedermann MD PhD
Professor of Vaccinology
Head of Institute of Specific Prophylaxis
and Tropical Medicine,
Medical University of Vienna
Vienna, Austria
 AC K N OW L E D G M E N T S

The editors of Travel Medicine would like to thank our Elsevier publishing We would also like to thank our families, and particularly our partners,
staff for encouraging us to embark on a 4th edition of the Textbook, for their patience and understanding during the long process of writing
and for being enthusiastic about moving forward with the addition of and editing.
our new editors.

xiii

Introduction to Travel Medicine
Each year the World Tourism Organization (WTO) publishes its statistics
revealing staggering numbers of people crisscrossing the globe; indeed,
over the last decade there have been double-digit increases in travel.
International tourist arrivals reported by the WTO in 2016 grew to
1235 million, 46 million greater than in 2015. Preliminary data show
the Asia-Pacific region leading the way with 8% growth, the Americas
(primarily South and Central America) with 4% growth, and Europe
with 2% growth, primarily in the north. Existing data from Africa show
a healthy increase in travel to the sub-Saharan region—8% as well. The
Middle East has seen a decrease in about 4%. Despite this continued
growth and despite 2017 having been designated by the United Nations
as the “International Year of Sustainable Tourism for Development,”
challenges continue. Not only were there protests at a recent meeting of
the WTO regarding the problem of overtourism and the need for more
responsible travel (http://media.unwto.org/press-release/2017-11-08),
but also the challenges of safety and security have been reawakened
recently with episodes of terror and violence.
Although considerations about health maintenance during travel
have probably always been present, as explorers founded new regions,
armies overtook others, and nomads wandered with their flocks, travel
medicine’s scientific birth can probably be measured in just decades
since the first international conference on travel medicine in Zurich in
1988, and the beginning of the International Society of Travel Medicine
(ISTM) in 1991.
Much has changed in the last several decades. Conferences and
literature still feature the forever lasting topic of malaria chemopro-
phylaxis punctuated by debates about self-treatment. However, if we
quickly scan the most recent news that encompasses our field and engages
our constituency, articles in the last several months have included those
highlighting tuberculosis in asylum seekers, ceftriaxone-resistant gonor-
rhea imported into Canada, Zika once again in Miami, and details
about the use of CRISPR (gene editing tool) as a diagnostic tool for
infectious diseases and the potential use of such new genomics for
point-of-care-diagnosis. As well, Brazil is now facing a serious yellow
fever outbreak that is challenging public health in that country as well
as elsewhere as importations into other countries has occurred. At the
same time, the UK Daily Mail featured interactive maps from International
SOS highlighting the world’s most dangerous and safest countries by
type of risk, labeling Finland, Norway, and Iceland as safest.
Global mobility is now taken for granted, not something unique to
any one group, any one company, or any one humanitarian effort,
conflict, or migration pattern. Travel health has become the sum of all
health maintenance considerations, both physical and emotional, as
travelers embark on journeys from days to years for every different
reason. In addition, we are now beginning to better understand the
concept of One Health, that is, the importance of the interaction and
intersection between human and animal health, and how this impacts
the spread of emerging and reemerging diseases.
1
Phyllis E. Kozarsky and Jay S. Keystone
With the fourth edition of the textbook Travel Medicine, the editors
needed to be cognizant of the growth of the body of knowledge
(www.istm.org) in the field, while respecting the need to focus content
on what is most important for the provider to understand practicing
pretravel health. In addition, we have tried to include information
concerning the more common issues facing travelers at their desti-
nations as well as on return, being sure to capture the most recent
developments.
Because travel is no longer just associated with tourism, but often
incorporates work, volunteerism, medical care, migration, etc., new
content has also been added to assist the provider in caring for specific
populations engaging in different types of travel. For example, chapters
have been added on ecotourism, military travel, and the VIP traveler.
In addition, we have added a section on the pretravel consultation to
assist practitioners advising their clients on the prevention of vectorborne
diseases such as chikungunya, dengue, and Zika viruses.
Keeping up to date in the field of travel medicine is not easy. It
requires a review of travel medicine, infectious disease, tropical medicine,
and general medical journals as well as national government and
international recommendations. Annual updates and international
conferences in these fields may help. This textbook has been designed
to bring it all to you, the most recent advances in the field as well as
practical information on the management of pretravel and posttravel-
related issues. For example, since the third edition, new vaccines and
regimens have been developed to prevent both routine and travel-related
infections such as the high dose and adjuvated influenza and herpes
zoster vaccines as well as a new oral vaccine from bovine colostrum
for the prevention of Enterotoxigenic Escherichia coli, the most frequent
cause of travelers’ diarrhea. For the last-minute traveler, both rabies
and Japanese encephalitis vaccines now include 1-week accelerated
regimens. Newly proposed single-dose antibiotic regimens for self-
treatment of travelers’ diarrhea may help to reduce the development
of drug-resistant enteric flora that make up our microbiome. In fact,
the challenge of increasing antimicrobial resistance has crept into the
field, impacting not only the provider but potentially the traveler, and
perhaps even the traveler’s contacts on return. This important issue
must be addressed not only within the context of travelers’ diarrhea,
where new guidelines have been published by the ISTM,1 but also with
the use of any antimicrobial agent.
The World Health Organization (www.who.int) and the ISTM
(www.istm.org) remain major resources for the provider, as well as
various country-specific guidelines for healthy travel. As well, there are
many groups and agencies that provide national recommendations and
guidance. A goal for those who choose to practice travel medicine should
be to join the ISTM and to sit for the ISTM examination that awards
the Certificate in Travel Health (CTH), an international standard of
care for the practice of travel medicine. As guidance for healthy travel
changes, disease outbreaks occur, and science advances, remaining up
1
2 SECTION 1 Practice of Travel Medicine
to date is critical as it is for any specialty. Although awareness of travel
health and the possibility of the global spread of infectious diseases
appeared to peak with the Ebola outbreak in West Africa from
2013 to 2016, we are aware of no recent data to support an increasing
use of travel health clinics or providers; and with concerns such as
vaccine shortages (e.g., yellow fever, hepatitis A), the incidence of even
preventable travel-related illnesses will likely not decrease.
Primary providers remain the best to ask the questions whether a
person plans travel or has returned from travel. After “thinking travel,”
the provider must then determine whether he or she is capable of caring
for the person or whether it is best to refer to someone with more
expertise. We hope the material in this text will provide basic information
for those who are new to the field, and updates for the veterans. We
trust that those providers who choose to care for travelers can count
this newest edition as a reliable and “go-to” reference.
REFERENCE
1. Riddle M, et al. Guidelines for the prevention and treatment of travelers’
diarrhea: a graded expert panel report. J Travel Med 2017;24(1):S63–80.

Epidemiology: Morbidity and Mortality
in Travelers
KEY POINTS
• Travel health risks are dependent on the itinerary, duration and
season of travel, purpose of travel, lifestyle, and host
characteristics.
• Motor vehicle injuries and drownings are the major causes of
preventable deaths in travelers, while malaria remains the most
frequent cause of infectious disease deaths.
• Complications of cardiovascular conditions are a major cause of
death in travelers, particularly when senior citizens spend the
winter in southern destinations.
INTRODUCTION
Compared to staying at home, mortality and morbidity are increased
in those who travel, especially when their destination is a developing
country. Travel health risks vary greatly according to:
Where
• industrialized versus destination in a lower income country
• city or highly developed resort versus off-the-tourist-trail locale
When
• season of travel (e.g., rainy versus dry, extremes of temperature)
How long
• duration of stay abroad
For what purpose
• tourism versus business versus rural work versus visiting friends or
relatives (VFR)
• other (military, airline crew layover, adoption, medical procedures
abroad, etc.)
Style
• hygiene standard expected: high (e.g., multistar hotels) versus low
(e.g., low-budget backpackers)
• special activities (high-altitude trekking, diving, hunting, camping,
etc.)
Host characteristics
• healthy versus preexisting condition, nonimmune versus semi-
immune
• age (e.g., infants, senior travelers)
This chapter will concentrate on the available epidemiologic data
associated with travel health risks in general (Tables 2.1 and 2.2); it will
only to a limited extent describe the epidemiology of individual diseases
at the destinations (Table 2.3). Such data are often unsatisfactory because
they are incomplete, old, or were generated in studies that may have
been biased.1 Lastly, visitors often experience far less exposure to
pathogens than the native population (e.g., with respect to hepatitis B,
2
Sandra Grieve and Robert Steffen
• Travelers’ diarrhea (TD) remains the most frequent illness among
travelers; the risk of TD can be divided into three risk categories
based on destination.
• Casual sex without the regular use of condom protection
continues to be common practice by travelers.
typhoid). Thus, seroepidemiologic data from destination countries are
usually of little relevance when assessing the risk in travelers. Among
the infectious health risks, only those about which travel-related data
have been published will be mentioned. The reader should consult
current websites and tropical medicine textbooks for information about
less common travel-related infections, such as trypanosomiasis.
CORNERSTONES OF TRAVEL
HEALTH EPIDEMIOLOGY
Health problems in travelers are frequent. Three of four Swiss or Finnish
travelers to developing countries had some health impairment, defined
as having taken any therapeutic medication, or having reported being
ill.2,3 At first glance, this proportion is alarming, but 50% of short-term
travelers who crossed the North Atlantic had health impairments, often
constipation.2,3 Acute gastroenteritis, respiratory tract infections, and
ear infections were the most frequent.4
A larger follow-up study showed that only a few of these self-reported
health problems were severe. Less than 10% of travelers to developing
countries consulted a doctor either abroad or after returning home, or
were confined to bed due to travel-related illness or an accident; <1%
were hospitalized, usually only for a few days.2,3 However, it remains
disturbing that >14% of such travelers are incapacitated. The most
tragic consequence of travel is death abroad, which occurs in approxi-
mately 1/100,000. Sudden cardiac death, defined as an “unexpected,
nontraumatic death that occurs within 24h of the onset of symptoms,”
has been shown to account for up to 52% of deaths during downhill
skiing and 30% of mountain hiking fatalities5 (Fig. 2.1).
A study based on medical insurance claims among World Bank staff
and consultants demonstrated that business travel may also pose health
risks beyond exposure to infectious diseases, and that medical claims
are increasing with the increasing frequency of travel.6 Such data illustrate
how noninfectious problems also play a significant role.
3
 CHAPTER 2 Epidemiology: Morbidity and Mortality in Travelers 3.e1

Abstract Keywords
In spite of natural disasters and turmoil in many countries, the number Epidemiology
of people travelling abroad continues to increase. Reasons for travel Morbidity
vary with no barrier to age, health status, and proposed activities. Mortality
Compared to staying at home, the potential for morbidity and mortality Prevention
increases with travel, especially when people visit exotic or remote Risk
destinations in lower income countries. Because disease surveillance Travel
may be inadequate at some destinations, predicting the level of individual Travelers’ health
risk can be difficult and those offering travel health advice will remain
uncertain about the risk behaviors of their clients. There are also limited
data on people hospitalized abroad with most cases identified by anecdotal
reporting on return home.
 4

TABLE 2.1 Characteristics of Studies Including the Number of International Travelers Acquiring a Travel-Related Illness,
January 1, 1976–December 31, 2016 (n = 9)
Median Travelers Ill
Median Top 5 Travel During or
Study Study Age in Destination Duration, Total After
(Publication Data Participant Years Sex Destination(s) Region Countries Days Travelers Travel, n
Year) Year(s) Nationality (Range) (%F) Travel Reasons (%) (%) (%) (Range) (n) (%)
Chen et al. 2009–2011 United Statesa 47 (19–83) 59 Tourism/vacation (67) N/A India (12) 12 (3–65) 628 400 (64)
(2016) Business (18) South Africa (5)
Volunteer/missionary/aid (15) Tanzania (5)
Visiting friends and relatives (14) Kenya (4)
Educational/research (4) Haiti (4)
Medical/dental care (<1)
Other (2)
Vilkman et al. December Finland 35 (27–54) 62 Vacation (84) Southeast Asia (23) India (14) 16 460 363 (79)
(2016) 2008– Business (8) East Africa (21) Thailand (13) (IQR:
February Other/multiple (8) West Africa, Middle Africa (19) The Gambia 13–27)c
SECTION 1 Practice of Travel Medicine

2010 Southern Asia (15) (11)

Latin America/Caribbean (9) Tanzania (10)
Southern Africa (6) Kenya (9)
Europe/North America (3)
Stoney et al. 2011 United Statesb 52 (18–88) 59 Tourism (71) N/A Mexico N/Ab 841 48 (6)
(2016) Visiting friends and relatives (18) Canada
Business (8) Dominican
Otherd (3) Republic
The Bahamas
Italy
Balaban et al. September United States 41 (25–63) 62 Epidemiology/technical assistance (66) Africa (50) N/A 18 (4–99) 122 33 (27)
(2014) 2009– Teaching/trainings (42) Asia (23)
September Attending professional meetings (37) Mexico/Central America (8)
2010 Working in a laboratory (12)
Working in a health care facility (12)
Dia et al. January– France 43.3 (19–79) 52 Tourism (77) Africa (100) Senegal 8 (3–92) 358 313 (87)
(2010) December Visiting friends and relatives(12)
2003 Business (7)
Missionary (3)
Study (1)
Rack et al. July Germany 40.3 ± 13.5 51.7 Tourism (100) Asia (57) N/A 23.9 ± 10.3 658 282 (43)
(2006) 2003– Africa (30)
June 2004 South America (13)
 Hill (2000) June United States 44.1 ± 17.5 56 Vacation (74) Indian subcontinent (21) Kenya 19 784 501 (64)
1989–May Study or teaching (15) Central/East Africa (20) India
1991 Missionary or service (6) South America (16) Nepal
Business (6) Southeast Asia (14) Thailand
West Africa (10) Tanzania
Central America/Mexico (10)
North Africa (6)
East Asia (6)
Caribbean (5)
Southern Africa (5)
Middle East (3)
Steffen et al. July German- 39.9 ± 14.2 47 Tourism (93) East Africa (33) N/A 18 ± 11 7886 1209 (15)
(1987) 1981– speaking Business (1) Sri Lanka/Maldives (26)
June 1984 Switzerland Various (6) West Africa (19)
South America (9)
Far East (east of Burma) (7)
Asia, various regions (4) Greece, Spain 15 ± 6 2296 178 (8)
Various/other regions (2)
CONTROL:
Greek / Canary Islands
Steffen et al. Dec 1975– German- 40.6 (mean) 41 N/A East Africa (25) N/A 21 (mean) 10,555 7906 (75)
(1978/1985) Mar 1977 speaking West Africa (5)
Switzerland Thailand (17)
Sri Lanka/Maldives (13)
Various Far East (24)
Brazil (12)
Various South America (2)
CONTROL: United States, 18 (mean) 1379 643 (47)
North America Canada
a
Among these travelers, 18% were born outside the United States.
b
Among these travelers, 26% were born outside the United States.
c
n = 458 (2 missing).
d
Other includes volunteers/missionaries, health/medical treatment, research/study, or “other not mentioned.”
IQR, Interquartile range; N/A, not available.
CHAPTER 2 Epidemiology: Morbidity and Mortality in Travelers
5
6 SECTION 1 Practice of Travel Medicine

TABLE 2.2 Study Characteristics Used to Determine the Best Estimate of the Number of
International Travelers With a Travel-Related Illness (n = 9)
Data Collection
Study Data Source Enrollment Instrument(s) Timeframe(s)
Chen et al. Boston-Area Travel Medicine Recruited at pretravel Extraction from medical record At pretravel visit
Network (BATMN) consultation Weekly diary During travel
Posttravel survey 2–4 weeks posttravel
Vilkman et al. Travel Clinic of Aava Recruited at pretravel Pretravel questionnaire At pretravel visit
Medical Center consultation Follow-up questionnaire 3 weeks after pretravel visit
Stoney et al. New Jersey Behavioral Risk Random-digit dialing NJBRFS Travel Health Module Travel in the previous 12 months
Factor Survey (NJBRFS)
Balaban et al. Large American public health Recruited at pretravel Pretravel survey At pretravel visit
agency consultation Posttravel survey (web-based) N/A
Dia et al. Marseille Travel Medicine Recruited at pretravel Pretravel questionnaire At pretravel visit
Centre consultation Posttravel questionnaire Within a week of return
Rack et al. Berlin Institute of Tropical Recruited at pretravel Extraction from medical record At pretravel visit
Medicine consultation Posttravel questionnaire N/A
Hill University of Connecticut Recruited at pretravel Brief questionnaire (with possible Within 2 weeks after travel
Health Center consultation telephone interview) 2 months after travel
Standardized questionnaire
(phone-based)
Steffen et al. Zurich University Zurich airport Pretravel questionnaire Just prior to boarding a flight
Travel Clinic Retrospective questionnaire 7 months after departure
Steffen et al. Returning flights to On board airplane Questionnaire Flight back to Switzerland
Switzerland by cabin crew

N/A, Not available.

MORTALITY
At first glance, data on the primary cause of deaths abroad appear
contradictory. While some studies claim that accidents are the
leading cause of death, others demonstrate the predominance of
cardiovascular events.7
These differences are due primarily to the varied examined popula-
tions and destinations as well as to the fact that some see accidents as
preventable and cardiovascular events as nonpreventable travel-related
deaths. Southern Europe, Florida, Thailand, and parts of the Caribbean
are favorite destinations for senior travelers, in whom elevated mortality
rates due to a variety of natural causes are to be expected, whereas in
developing destinations the risk of fatal accidents is clearly higher. In
the 13 years between 1999 and 2011, there were 104 recorded deaths
in the GeoSentinel global network, which captures trends in travel-related
morbidity; included in these data are those seen at the GeoSentinel
clinics who cross an international border, be they tourists, business
people, or migrants. Malaria is prominent, along with sepsis, pulmonary
syndromes including pneumonia and tuberculosis, and acute encephalitis.
Underlying illnesses may also play a significant role, such as cardiovascular
disease, AIDS, diabetes mellitus, and cancers (Pauline Han, personal
communication, September 2011), as well as cofactors such as substance
abuse. One of the limitations of GeoSentinel data is that the providers
are generally experts in tropical and travel medicine practicing in tertiary
care centers, and thus would not typically be in a position to see patients
following trauma or for other ailments unrelated to infectious diseases;
thus infectious diseases are overrepresented.
Accidents
Deaths abroad due to injuries are two to three times higher in travelers
age 15–44 years than in the same age group in industrialized countries.
Fatal accidents are primarily due to motor vehicle injury. There are
fewer than 20 deaths per 100,000 motor vehicles per annum reported
in most Western European countries, compared to 15 in the United
States, 20–71 in Eastern Europe, 9–67 in Asia, and 20–118 in Africa.8
Motorbikes are frequently implicated (partly because in many countries
there is no obligation to wear a helmet), and alcohol often plays a role.
Tourists are reported to be several times more likely than local drivers
to be involved in accidents.9
Drowning is also a major cause of death and accounts for 16% of
all deaths (due to injuries) among US travelers. Reasons include alcohol
intoxication, the presence of unrecognized currents or undertow, and
being swept out to sea.
Kidnapping and homicides have been increasing, but these are usually
limited to employees of international and nongovernmental organizations.
Fatal assaults on tourists and terrorism may occur anywhere, not only
in developing countries.
Animals are a relatively uncommon cause of death among travelers.
There are now some 50 annual confirmed shark attacks worldwide and
the number is rising, possibly due to neoprene wetsuits, which allow
the wearer to stay longer in colder water where the risk is greater.10
Among safari tourists in South Africa, three tourists were killed by
wild mammals in a 10-year period, two by lions after the individuals
left their vehicle to approach them. The number of fatal snakebites is
estimated to be 40,000 worldwide (mainly in Nigeria and India), but
few victims are travelers.
A broad variety of toxins may also be a risk to travelers. Ciguatoxin
leading to ciguatera syndrome after the consumption of tropical reef
fish is a major risk: The case fatality is 0.1%–12%. “Body-packing” of
heroin, cocaine, and other illicit drugs in the gastrointestinal tract or
in the vagina may result in the death of travelers when the condoms
or other packages break. Fatal toxic reactions and life-threatening
neurologic symptoms after the inappropriate and frequent application
of highly concentrated N,N-diethyl-m-toluamide (DEET, now called
 CHAPTER 2 Epidemiology: Morbidity and Mortality in Travelers 7

TABLE 2.3 Illnesses Acquired by International Travelers in the Included Studies (n = 9)

No. (%) of Travelers Who Hospitalizations
Study (No. Ill) Top 5 Illnesses (%) Sought Medical Care n (%)
Chen et al. Diarrhea (52) 73 (18) 4 (<1)a
(n = 400) Headache (26)
Fatigue (25)
Cough (24)
Runny/stuffy nose (24)
Vilkman et al. Travelers’ diarrheac N/A 3 (1)
(n = 363)b Skin problem
Fever
Vomiting
Respiratory tract infection
Stoney et al. N/A N/A N/A
(n = 48)
Balaban et al. Diarrhea (21) 6 (19) 1 (3)
(n = 33) Sore throat (11)
Nausea/vomiting (9)
Congestion/runny nose (8)
Coughing (7)
Dia et al. Arthropod bite (62) 33 (11) 1 (<1)
(n = 313) Diarrhea (46)
Sunburn (36)
Vomiting (9)
Cough (8)
Rack et al. Gastrointestinal (81) 44 (16) 1 (<1)
(n = 282) Respiratory (32)
Fever (15)
Dermatologic (10)
Hill Diarrhea (46) 59 (8) 2 (3)d
(n = 501) Respiratory tract symptoms (26)
Skin problem (8)
High-altitude sickness (6)
Motion sickness (5)
Steffen et al. Severe diarrhea (56) 659 (8) 43 (1)
(n = 1209) Vomiting or abdominal cramps (26)
Common cold (14)
High fever over several days (13)
Dermatosis (8)
C: Greek/Canary Severe diarrhea (43) 61 (3) 1 (.04)
Islands Vomiting or abdominal cramps (28)
(n = 178) Common cold (13)
Steffen et al. Diarrhea (34) N/A (4.3 by M.D., plus 1.0 by N/A (0.7, some just outpatients)
(n = 7906) Constipation (14) nurse)
Respiratory infections (12)
Insomnia (11)
Headache (8)
C: N. America Constipation (20) N/A (0.9 by M.D., plus 0.2 by N/A (0.2, some just outpatients)
(n = 643) Respiratory infection (8) nurse)
Headache (8)
a
One traveler with heart disease and a pulmonary embolism; two others with unspecified chronic medical conditions; one unknown.
b
Based upon data available for 459 of the 460 ill travelers in this study.
c
Denominator could not be determined from the article.
d
One traveler with malaria and the other with angina.
C, Control group; N/A, not available.
8 SECTION 1 Practice of Travel Medicine
Accidents: Drowning,
mountain 18.3%
Traffic accidents
28.1%
Suicide, homicide
3.2%
Unknown illness
Cardiovascular
18.4%
27.4%
Infection 1.4%
FIG. 2.1 Fatalities among French abroad 2000–2004. (With permis-
sion from Jeannel D, Allain-Loos S, Bonmarin I, et al. Bull Epidemiol
Hebd 2006;23–24:166–8.)
N,N-diethyl-3-methylbenzamide) in small children have rarely been
observed. Lead-glazed ceramics purchased abroad may result in lead
poisoning and could remain undetected for a long period of time.
Infectious Diseases
Malaria is the most frequent cause of infectious death among travelers.
Between 1989 and 1995, 373 fatalities due to malaria were reported in
nine European countries, with 25 deaths in the United States.11,12 Most
reported malaria cases in Europe were travel related, the overall confirmed
case rate in 2014 was 1.24 cases per 100,000 population, which is the
highest rate observed during the period 2010–2014.12 This was almost
exclusively due to Plasmodium falciparum, the case fatality rate ranging
from 0% to 3.6%, depending on the country. The most recent US
surveillance data show that there were 1724 cases of imported malaria
reported to the Centers for Disease Control and Prevention (CDC) in
2014, numbers indicative of a steady trend upward since 1973. The
largest percent were in the VFR population (67%). The number of
military cases climbed twofold from 2013 to 2014. Of all cases reported
in the United States in 2014, 17% were severe and 1.7% died.
Among deaths due to infectious diseases, HIV previously held a
prominent place, although it did not appear in the statistics as it is a
late consequence of infection abroad and may not be recognized as
having been acquired during travel. With modern treatment options
and postexposure prophylaxis, mortality associated with HIV infection
abroad has decreased. HIV patients have a higher risk of complications
of other infections while traveling, which ultimately may be fatal.13
There is a multitude of other infections that may result in the death
of a traveler. There are anecdotal reports about fatal influenza, mainly
among older adults participating in cruises. Rabies, if untreated, has a
case fatality rate of almost 100%. Overall, however, fatal infections in
the traveler can, for the most part, be effectively prevented. Two cases
of West Nile virus (WNV) were reported in Dutch travelers returning
from Israel14 and one Canadian traveler died of WNV infection after
a visit to the state New York.
Other Illness and Mortality
Senior travelers in particular may experience a new illness or complica-
tions of a preexisting condition such as cardiovascular problems.15
Evidence has also been generated to support the fact that pulmonary
embolism associated with deep vein thrombosis occurs after long-distance
air travel, and many of these cases are fatal. Severe symptomatic
pulmonary embolism in the period immediately after travel is extremely
rare after flights of <8 hours. In flights >12 hours the rate is five per
million. Risk factors for this have been clearly identified.16
Aeromedical Evacuation
Accounts on repatriation are instructive, as they are a mirror of serious
health problems, many of which are not reported otherwise. Some 50%
of aeromedical evacuations are due to accidents, often involving the head
and spine, and 50% are due to illness. In the latter group, cardiovascular
or cerebrovascular and gastrointestinal problems are the most frequent
causes. Psychiatric problems continue to be a cause for evacuation, but
their numbers may have decreased. It may be that psychiatric conditions
are less likely to be reported as the reason for evacuation or it may be that
worldwide communication has improved to the extent that emotional
support and assistance from home is more easily accessed.17
MORBIDITY
As mentioned, illness during and following travel is common. Many
articles have been written citing a variety of percentages of travelers
becoming ill; most recently a review of these data estimated that between
43% and 79% of travelers who visited developing nations become ill,
most frequently with diarrhea.1
Men and women present with different profiles of travel-related
morbidity. Women are proportionately more likely than men to present
with urinary tract infection.17
Travelers’ Diarrhea
Classic travelers’ diarrhea (TD) is defined as three or more unformed
stools per 24 hours, with at least one accompanying symptom, such as
fecal urgency, abdominal cramps, nausea, vomiting, or fever. Also milder
forms of TD may result in incapacitation.18
TD is usually caused by fecal contamination of food and beverages.
The pathogens responsible for TD are described elsewhere in this volume
(see Chapters 18 and 20).
There are three levels of risk for TD (Fig. 2.2): (1) Low incidence
rates (up to 8%) are seen in travelers from industrialized countries who
stay for 2 weeks in Canada, the United States, most parts of Europe, or
Australia and New Zealand; (2) intermediate incidence rates (8%–20%)
are experienced by travelers to most destinations in the Caribbean, some
southern and eastern European countries, Japan, and South Africa;
and (3) higher incidence rates (20%–66%) of TD are seen in journeys
to developing countries during the first 2 weeks of stay.19 TD is still
the most frequent illness among travelers from high to lower income
countries, whereas those who live in areas of high endemicity have a
lower risk as a result of acquired immunity. Groups at particularly
high risk of illness include infants, young adults, and persons with
impaired gastric acid barrier; some have a genetic predisposition.
TD often has a particularly severe and long-lasting course in small
children. If women more often present themselves with acute diarrhea,
that may be associated with differences in perception.20
Over the first decade of the 21st century the rates of TD have
decreased, mainly in emerging economy countries.21 The symptoms of
TD in tourists frequently start early during the stay abroad, though
second episodes may occur. Untreated, the mean duration of TD is 4
days (median 2 days), and in 1% the symptoms may persist over 1
month. About one in five patients show signs of mucosal invasive or
inflammatory disease with fever and/or blood in the stools. In 2.4%–17%
of TD patients (and also few without TD symptoms), they will experience
a postinfectious irritable bowel syndrome, rarely arthritis, or other
sequelae may develop. There is also concern about the importation of
multidrug-resistant enterobacteriaceae.22
 CHAPTER 2 Epidemiology: Morbidity and Mortality in Travelers
Risk:
Low <8%
Intermediate 8%–20%
High 20%–50%
No recent data
FIG. 2.2 Incidence rates of travelers’ diarrhea 2006–2008 (n = 2800). (With permission from Pitzurra
R. BMC Infect Dis 2010;10:231 and smaller recent studies.)
Malaria
Some 10,000 imported malaria infections are recorded annually by
travelers and immigrants to nonendemic countries, but the real number
might be six times higher.23 Most reported malaria cases in Europe were
travel related; the overall confirmed case rate in 2014 was 1.24 cases
per 100,000 population, which is the highest rate observed during the
period 2010–2014.24
According to the annually published World Malaria Reports there
has been a dramatic decline in the global malaria burden with 88% of
global cases originating in the World Health Organization (WHO)
African region.25 The risk of infection among tourists has decreased.26
Nevertheless some countries experience an increase of imported cases
associated with VFRs and immigrants.27 The risk of malaria transmission
also remains high in other parts of tropical Africa, in Papua New Guinea,
and on neighboring islands.28
The proportion of P. falciparum infection varies. Depending on the
precise destination, patients treated abroad are typically not included
in reporting data. If they failed to use appropriate prophylactic medica-
tion, malaria would be a frequent diagnosis among travelers to tropical
Africa. Using existing surveillance data and the numbers of travelers
to the respective destinations, the relative risk of malaria in travelers
visiting such countries can be estimated. Such data will only indicate
a risk per country, not a precise destination.
The annual entomologic inoculation rate clearly demonstrates broad
differences within a country. This is illustrated in Kenya, with rates
from 0 to 416 (at the coast locally exceeding 200), or within a city and
its suburbs, such as Kinshasa, 3–612 (equivalent to two infective bites
each night).26,29
9
Risk of infection is influenced not only by destination but also by:
• number of vectors
• Anopheles species (infected vector density)
• population density (infected population density)
• infrastructure condition (housing, water management, mosquito
control)
• resistance to insecticides
• seasonality, particularly rainfall
• duration of exposure (the cumulative risk of contracting malaria is
proportional to the length of stay in the transmission area)
• compliance (personal protection measures, chemoprophylaxis)
• style of travel (camping versus staying in air-conditioned or well-
screened urban hotel)
• host factors (such as semi-immunity, pregnancy)
These variables illustrate that it is impossible to predict the risk of
malaria transmission by more than a rough order of magnitude in any
specific traveler. The travel health advisor and even the traveler will
often ignore at least some of these parameters. Finally, old data may
have become obsolete in view of global warming: In Nairobi, for example,
in an area previously free of transmission at an elevation of 1700 m,
an increasing risk of malaria is reported. Nevertheless, one can at least
estimate whether a traveler will be at high or low risk.
A more detailed account of malaria epidemiology, with maps, is
found in Chapter 14, where the adverse events due to prophylactic
medication against malaria are discussed.
Vaccine-Preventable Infections
Updated morbidity and mortality data (Fig. 2.3) have recently been
generated for vaccine-preventable diseases. It is uncertain as to what
10 SECTION 1 Practice of Travel Medicine
Estimated incidence per month of vaccine preventable diseases in lower-income countries
among nonimmune Western travelers with most recent references 2017
Influenza Belderok 2013, Ratnam 2013
Animal bite — rabies risk Gautret 2012
Latent TB infection Brown 2016
Typhoid (South Asia) Greenaway 2014
Measles or Pertussis Dahl 2017
Hepatitis A Nielsen 2012, Dahl 2017
Tick borne encephalitis (rural Baltics) Steffen 2016
Hepatitis B Sonder 2009, Nielsen 2012, Johnson 2013, Dahl 2017
Typhoid (Africa, South America) Greenaway 2014
Active TB (PCV) Brown 2016
Typhoid (Caribbean, Central America) Greenaway 2014
Japanese encephalitis (Pavli 2015)
Rabies (Carrera 2013)
Meningococcal dis., poliomyelitis, cholera, yellow fever—(nonimmune, exposed?)
FIG. 2.3 Vaccine preventable diseases.
degree an observed decrease in the risk of hepatitis A is due to improved
hygiene conditions at the destinations or to greater immunization rates.21
Travel-related vaccine-preventable diseases are often divided into those
that are required, routine, and recommended (see also Chapters 9, 10,
11, 12, and 13). Below is a list of those as well as some of the recent
epidemiology relating to the illnesses in travelers.
Required Immunizations. Yellow fever occurs only in subSaharan
Africa, South America, and Trinidad. Usually a few hundred cases are
reported to WHO annually, but it is estimated that >100,000 cases
occur. Yellow fever has never been transmitted in Asia, although the
vectors, Aedes (now Stegomyia) and Haemagogus, have been observed
there.28 Yellow fever is extremely rare in travelers, but nevertheless cases
in unvaccinated travelers have increasingly been reported in the last
few years despite the fact that these travelers should have been immu-
nized.28 In 2016, several cases were imported to China, some of them
fatal.30 Even though there is no risk at the destination, sometimes
countries will require a yellow fever vaccine certificate, because the
traveler has just transited a yellow fever zone (even when staying in the
aircraft).31 Travel health advisors and travelers alike need to remain
vigilant about checking on regulations through the WHO website or
national guidelines that are updated frequently. Even so, countries have
the capacity to alter their policies as they deem necessary.32
Until the early 2000s, meningococcal disease was frequently observed
during or after the hajj or umrah pilgrimage to Mecca (200/100,000), but
this problem has been resolved by public health measures issued by the
Saudi authorities. The disease is rare even in travelers staying in countries
where the infection is highly endemic (0.04/100,000). The case fatality
rate among travelers slightly exceeds 20%. Rarely, Neisseria meningitidis
may be transmitted during air travel of at least 8-hour duration.33
100%
10% = 1/10
1% = 1/100
0.1% = 1/1,000
0.01% = 1/10,000
0.001% = 1/100,000
0.0001% = 1/million
<1/10 million
Proof of polio vaccine for certain populations has also been recently
required by the Saudi government for pilgrims to the hajj. Polio
immunization is also required for travelers leaving polio-infected
countries, such as Pakistan, after a stay exceeding 4 weeks.34
Routine Immunizations. To the authors’ knowledge, a single case of
tetanus was reported in a traveler several decades ago, but such cases
may be hidden in national surveillance data.
As demonstrated by a large epidemic in the former Soviet Union
during 1990–1997, diphtheria may flare up under specific circumstances.35
This epidemic resulted in dozens of importations to Western Europe
and North America; some travelers died while still in Russia. Far less
serious forms of cutaneous diphtheria are occasionally imported, mainly
from developing countries.
Poliomyelitis has continued to be a problem in the past few years,
mainly in Afghanistan, Pakistan, and Nigeria, from where some cases
were exported by travelers.36 In typical travelers, poliomyelitis has in
the past decade been observed in a single VFR student returning from
Pakistan to Australia.37 Thus WHO has developed an interactive map
with the countries or areas for which it recommends polio immunization
or boosting (http://apps.who.int/ithmap/).
Anecdotal reports exist on pertussis, Haemophilus influenzae B,
measles, mumps, and rubella in travelers. European infectious disease
surveillance data are available.38 In view of suboptimal compliance with
measles vaccination, European, African, and Asian travelers are respon-
sible for outbreaks mainly on the American continent where vaccine
uptake is far superior.39,40
Recent reports showed a sharp rise in the number of measles cases
reported in European Union/European Economic Area (EU/EEA)
countries, five times more than the annual average for the preceding
 CHAPTER 2 Epidemiology: Morbidity and Mortality in Travelers
5 years. These cases may be linked to travel to and from Europe, where
unimmunized or nonimmune travelers have come into contact with
the disease or transported it.41
Pertussis is a reemerging disease in many areas and immunity has
waned. New vaccine availability in some areas allows boosting of adults
to tetanus, diphtheria, and pertussis in a single injection. Hepatitis B,
now a routine immunization in most industrialized countries, was
mainly a problem for expatriates living close to the local population
and for travelers with bloodborne or sexual exposures. The estimated
incidence in travelers from Amsterdam to HBV-endemic countries is
4.5/100,000 travelers.42 While minute quantities of the virus are sufficient
for transmission and the exact mode of transmission may remain
undetected in many individuals, clear risk factors (casual unprotected
sex, nosocomial transmission, etc.) have often been suspected. Behavioral
surveys have shown that 10%–15% of travelers voluntarily or involuntarily
expose themselves to blood and body fluids while abroad in high-risk
countries. Besides the risk factors mentioned, such persons have also
visited dental hygienists, had acupuncture, cosmetic surgery, tattooing,
ear piercing, or scarification. Travel specifically for surgical procedures
abroad (medical tourism) is increasing and is highlighting the emergence
of a new antibiotic resistance mechanism and associated consequences
for creating global public health problems.43
Recommended Immunizations. The most frequent vaccine-
preventable infection in nonimmune travelers to developing countries
is influenza. Various outbreaks on cruise ships have been described (the
usual risk groups are at risk of complications). Hepatitis A is now third,
with a current average incidence rate of 30/100,000 per month. It is
also the case that “luxury” tourists staying at multistar resorts may be
at risk of infection.
Typhoid fever is diagnosed with an incidence rate of 30/100,000 per
month among travelers to South Asia (Pakistan, Nepal, India); elsewhere
(except probably in Central and West Africa), this rate is 10 times lower
or even less. Those visiting friends and relatives import a fair proportion
of these infections, but tourists originating in industrialized countries
are also affected. The case fatality rate among travelers is 0%–1%.44 A
paper reviewing the morbidity seen in >37,000 travelers revealed that
580 presented with vaccine-preventable diseases. Of those, the most
common seen were enteric fever, acute viral hepatitis, and influenza.
Hospitalizations occurred with greater frequency in those diagnosed
with vaccine preventable diseases, and deaths also occurred.45
The risk of rabies is high in Asia (particularly in India), from where
90% of all human rabies deaths are reported, but there may be under-
reporting in other parts of the world. Bat rabies may occur in areas
that are thought to be rabies free, such as Australia and Europe. Many
among the monthly 0.2%–0.4% who experience an animal bite in
developing countries are at risk of rabies. Rabies is a particular risk in
those who are in close contact with indigenous populations over a
prolonged time (e.g., missionaries, those traveling by bicycle, those
working with animals, or those who explore caves) as well as children
(because of their attraction to animals and their lack of reporting bites).
Based on post-travel skin tests, the incidence rate of Mycobacterium
tuberculosis infection is 3000/100,000 person-months of travel, and
60/100,000 developed active tuberculosis. Transmission during long-haul
flights and also during prolonged train and bus rides is rarely reported.
Those who travel to work in hospitals, prisons, or orphanages may also
be at increased risk. Other transmission can be neglected, except if
there is repeated exposure, as may occur particularly among long-term,
low-budget travelers or expatriates.46 Migrants and refugees are of even
greater concern with respect to importation of tuberculosis.47
The risk of cholera was approximately 0.2/100,000 based on older
surveys, although asymptomatic and oligosymptomatic infections may
11
be more frequent, as demonstrated in Japanese travelers. But as a public
health issue this is irrelevant, as secondary infections do not occur.48
The case fatality rate among travelers is <2%.
For several potentially vaccine-preventable diseases, the risk of
infection is less than one per million. Although a few dozen cases of
Japanese encephalitis have been diagnosed in civilian travelers during
the last 25 years, the attack rate of symptomatic disease in civilians is
estimated to be 1 per 400,000–1,000,000. Sixty percent of these cases
occurred in tourists, including some short-term travelers to Bali and
Thailand.49
Only three international travelers have been diagnosed with plague
since 1966, the last in 2017 was associated with a large outbreak in
Madagascar.
Changes in climate and habitation are altering the epidemiology of
tickborne encephalitis, and the disease is now being reported from areas
previously not known to be endemic. Tickborne encephalitis is a serious
health risk particularly for those hiking or camping in endemic areas
between April and November. Basing on 38 reported cases among
international travelers, the attack rate can be extrapolated to be 0.5–1.3
per 100,000 overall in western and central European endemic areas for
the exposed at-risk population.50
Other Infections
Only a few selected types of infections will be mentioned in this section.
Those about which no more than anecdotal reports have been published
will be omitted.
Sexually Transmitted Diseases. According to most surveys, casual
sex, in almost 50% of cases without regular condom protection, is
practiced by 4%–19% of travelers while they are abroad, resulting in
HIV infection and other sexually transmitted diseases (STDs).51 In
Switzerland it is estimated that 10% of HIV infections are acquired
abroad. In the United Kingdom, the risk of acquiring HIV is considered
to be 300 times higher while abroad, compared to staying at home. A
third of heterosexuals acquired their infection in the United Kingdom;
the remaining two-thirds are thought to have been acquired in sub-
Saharan Africa.52,53
The WHO estimates that 75% of all HIV infections worldwide
are sexually transmitted, and that the efficiency of transmission per
sexual contact ranges from 0.1% to 1%. The transmission probability
of HIV is greatly enhanced by the presence of other STD and genital
lesions, as is often the case in female commercial sex workers and other
infected persons in developing countries. Typically, 14%–25% of cases
of gonorrhea and syphilis diagnosed in Europe were imported from
abroad.54 Only 14% of cases reported in 2013 were among young people
between 15 and 24 years of age; the majority of cases were reported in
people 25 years and older. More than half (58%) of the syphilis cases
were reported in men who have sex with men (MSM). Young adults
and MSM remain the key vulnerable groups for STDs in the EU/EEA.55
The first campaign targeting those over 50 years of age was launched to
highlight rising STDs and poor sexual health in this age group, many
of whom indulge in casual sexual activity abroad.56,57
Upper Respiratory Tract Infection (URTI). This is one of the most
frequent health problems, with attack rates varying from 8% to 34%
in Finnish short-term travelers.3,4 From interviews in Chinese hospitals,
there is anecdotal evidence that lower respiratory tract infections occur
particularly often in this country.
Other Arboviral Infections: Dengue, Chikungunya, Zika. In
Southeast Asia and other endemic areas, the seroconversion rate of
dengue in travelers is quite impressive. In Thailand the daily risk of
12 SECTION 1 Practice of Travel Medicine
dengue infections per 100,000 travelers has been estimated to be 2.14
and 7.03 for low and high dengue seasons, respectively.58 Similarly,
chikungunya endemicity has expanded mainly to the Americas, to a
limited degree also to Southern Europe. Many travelers have been affected;
the main problems associated with this infection are arthritis and
arthralgias.59
Most recently, a Zika epidemic mainly in Latin America and the
Caribbean has caused concern not only among the local population,
but also among travelers. Transmission occurs not only through Aedes
mosquitoes, but also through sex, blood transfusion, or rarely laboratory
exposure. The main fear is that intrauterine infection may result in
microcephaly of the newborn. Additionally, some patients subsequently
may suffer Guillain-Barré syndrome.60
Legionella. The rate of Legionella infections reported to European
surveillance is on a plateau with some 5000 cases having been reported
both in 2009 and 2010; 20% were associated with travel.61 In the United
States, about 6000 cases were reported in 2015, though this is probably
an underestimate because the disease is underdiagnosed. Legionnaires
disease is waterborne and typically transmitted from air-conditioning
and heating units, hot tubs, fountains, and water features. Common
contributing factors include inadequate disinfection, maintenance, and
monitoring; water stagnation; poor temperature control; and poor
ventilation. Interestingly, some outbreaks repeatedly occurred on the
same site.62
Leishmaniasis. Cutaneous disease has frequently been described in
travelers, with those infected with HIV being at particularly high risk,
but to the authors’ knowledge no systematic review with data has been
published.
Schistosomiasis. Using newer serologic tests, there are data to suggest
that schistosomiasis is an infection that both long-term and short-term
travelers, but particularly missionaries and volunteers, acquire in endemic
areas.63 Some returning travelers have symptoms, but many are diagnosed
by serology alone. It is currently unknown whether or not most exposed
travelers would ever develop typical signs and symptoms of chronic
disease.
Trypanosomiasis. Trypanosomiasis, in its African form, was reported
in only 29 cases in the United States in the 20th century, but the risk
seems to be increasing.
Noninfectious Health Problems
This covers a broad variety of problems, accidents, and illnesses, which
can be divided into environmental or host factors.
Environmental. Travel may result in stress, particularly fear of
flying—most prominent during take-off, landing, and turbulence—and
flight delays, which are frequent causes for anxiety.64 Motion sickness
may affect up to 80% of passengers in small vessels in rough seas, but
also affects passengers (albeit fewer) on jet flights. In-flight emergencies
occur in 1/11,000 passengers, the most frequent ones being gastro-
intestinal, cardiac, neurologic, vasovagal, and respiratory. Changes in
climate and altitude also create problems. In particular, high-altitude
sickness (described in Chapter 42) will affect every hiker if ascent to
high altitudes is rapid.
Health impairments related to diving are described in Chapter 43.
Other environmental issues occasionally come into play. For example,
consideration should be given to long-term travelers or expatriates with
chronic heart or lung disease planning on staying in regions where
there is excessive air pollution.
In addition to the accidents described in the mortality section, small
bruises acquired while swimming, and other marine hazards or lacerations
due to sporting activities, may take longer to heal in view of suprainfec-
tion. Sprained ankles and other sports injuries are frequent, particularly
among senior travelers who tend to fall, for example, in dimly lit hotels
and on stairs.
Host. Persons with pre-existing medical conditions may experience
exacerbations. This is particularly common in those with immunosup-
pressive illnesses, chronic constipation, diarrhea, or other gastrointestinal
ailments, whereas others, such as dermatologic conditions or degenerative
joint pain, may improve in a sunny, warm climate.65
CONCLUSION AND PRIORITIZATION
In conclusion, health professionals who advise travelers must keep the
described epidemiologic facts in mind when determining what preventive
measures are needed. Ultimately, the decision regarding to what degree
one wishes to protect future travelers is an arbitrary one; no one should
give the illusion that “complete protection” is possible. Prioritization
(e.g., with respect to vaccines) is possible, but one ought to have concrete
goals to reduce morbidity. However, even when prioritization is necessary,
consideration should be given to the specific individual, his or her
medical history, and travel circumstances. For travelers to malaria-intense
regions, despite financial limitations and unwillingness to continuously
use medication, chemoprophylaxis should still be strongly encouraged.
Advisors should keep in mind that TD is the most frequent health
problem and counsel accordingly, particularly including self-treatment
abroad.
Despite the need for prioritization, educational needs do not change
and efforts to provide as much information as possible are always
imperative. Although these measures can certainly mitigate health
problems, travel will always have some inherent additional risks compared
to staying at home.
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Network. Travel-associated Zika virus disease acquired in the Americas
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65. Carroll B, Daniel A, Behrens RH. Travel health part 1: preparing the
tropical traveler. Br J Nursing 2008;17(16):1046–51.

Starting, Organizing, and Marketing
KEY POINTS
• A travel health program requires trained personnel, specialized
supplies, and equipment.
• Keeping up to date with country-specific health information that
may change rapidly is key to providing pretravel health care.
• Depending on country or state regulations, nurses, nurse
practitioners, pharmacists, and other health care personnel can be
primary providers of pretravel health care.
INTRODUCTION
The delivery of travel medicine services has evolved over the past 35
years. Traditionally it has occurred in the setting of primary care or
specialized travel clinics. However, over the last decade there has been
a rapid expansion into other health care settings, such as occupational
health, college health, walk-in clinics, emergency departments, super-
markets, and pharmacies.1 This chapter will outline the key steps necessary
to establish a travel medicine practice. The principles outlined can be
applied by practitioners to a variety of settings throughout the world.
The body of knowledge in travel medicine differs from general
medicine, infectious diseases, and tropical medicine. Therefore it is best
practiced by health care personnel who are trained in the field, see
travelers on a regular basis, constantly update their knowledge, and
have the information and resources to provide quality pretravel care.2,3
Travel medicine providers must have up-to-date information on
the epidemiology of global illness, be able to administer a full panel
of immunizations against both common and uncommon vaccine-
preventable diseases, and have access to health and safety risk-reduction
recommendations of the World Health Organization (WHO) or national
bodies such as the United States (US) Centers for Disease Control and
Prevention (CDC) and the United Kingdom National Travel Health
Network and Centre (NaTHNaC). This level of care should be provided
in the setting of an individualized consultation, which will increase the
value of the service and distinguish it from a generalist’s office or clinic
focused only on immunizations (Table 3.1).
Administering immunizations without undertaking a complete risk
assessment of the traveler and his or her planned activities, and not
giving other comprehensive preventive advice, is not providing an
appropriate level of service.2 All travelers should receive up-to-date
guidance on how to avoid travel-related illness, health counseling for
self-care of acute and chronic medical conditions, required or recom-
mended immunizations, and information about health and safety
resources at their destination (see Table 3.1). Those who provide a
travel health service can follow the guidance as outlined in this chapter,
3
a Travel Clinic
David R. Hill and Gail Rosselot
• A travel clinic should determine whether it will provide posttravel
services. If not, then it is important to know specialist health
providers that can handle referrals.
• Challenges remain regarding whether to provide telephone or
telehealth consultations, email services, and the charges for such
services.
textbook, and other definitive resources (e.g., www.cdc.gov/travel,
http://www.who.int/ith/en/).
THE PRACTICE OF TRAVEL MEDICINE
An examination of the practice of travel medicine can help define those
elements that are necessary for the establishment of a new travel clinic.
There has been no comprehensive survey of travel medicine practice
throughout the world since a 1994 survey of the membership of the
International Society of Travel Medicine (ISTM).4 This survey demon-
strated that travel medicine was practiced in a variety of settings by
professionals with a wide range of training and experience in the
discipline. A few themes emerged:
• Nearly all clinics were from North America, Western Europe, and
Australia (94%).
• Most clinics saw only a modest number of patients—fewer than 20
patients/week were seen by 61% of clinics (14% saw <2 patients/
week), and only 13% saw more than 100 patients/week.
• Nearly all clinics provided advice about malaria, insect avoidance,
and the prevention and treatment of travelers’ diarrhea, and most
administered a wide range of vaccines.
• Although clinics were usually directed by physicians at that time,
advice and care were rendered nearly equally by physicians and
nurses. In many countries today, nurses provide the majority of
pretravel care. For example, in the United Kingdom most pretravel
care is delivered in general practice and the practice nurse is usually
the sole provider, giving advice under the direction of specific
protocols.5,6 Pharmacists are also playing a role in the delivery of
pretravel services.
Data from the World Tourism Organization indicate that for the
1.2 billion international arrivals during 2016, Europe continued to be
the most frequent destination (50%), with Asia and the Pacific the
second most visited region by a quarter of all arrivals. Many destinations
in the emerging economies of Latin America, Central and Eastern Europe,
Eastern Mediterranean Europe, the Middle East, and Africa are growing
15
 CHAPTER 3 Starting, Organizing, and Marketing a Travel Clinic 15.e1

Abstract Keywords
Over the past 15 years travel health services have grown beyond traditional Competencies
hospital and private clinics to include services based in corporations, Financing
universities, pharmacies, and public health departments. Today physicians, Immunizations
nurse practitioners, physician assistants, nurses, and pharmacists staff Marketing
these clinics and provide pretravel and sometimes posttravel care. Setting Personnel
up a successful travel health clinic requires trained personnel, written Pretravel services
policies and procedures, some specialized equipment and supplies, and Protocols
an ongoing commitment to staff education and clinic marketing. This Regulations
chapter outlines the steps necessary to start and manage a travel health Startup
service that can provide comprehensive, quality care to the international Travel clinics
traveler. It includes information on models of care, necessary equipment
and supplies, applicable government regulations, financial issues, and
resources for establishing and maintaining a travel health clinic.
16 SECTION 1 Practice of Travel Medicine
TABLE 3.1 Benefits of a Travel Medicine
Service
Comprehensive pretravel care
Knowledgeable and experienced providers (see Table 3.2)
Up-to-date advice (in verbal and written form) on a wide range of travel-
related health risks
Access to current epidemiologic resources and opinion of expert bodies
Availability of immunizations against all vaccine-preventable illnesses
Provision of medications/prescriptions for self-treatment/prevention of
travelers’ diarrhea, malaria, and environmental illness
Posttravel screening and referral
TABLE 3.2 Important Provider
Qualifications in Travel Medicine
Knowledgea
Geography
Travel-associated infectious diseases: epidemiology, transmission,
prevention
Travel-related drugs and vaccines: indications, contraindications,
pharmacology, drug interactions, adverse events
Noninfectious travel risks both medical and environmental: prevention and
management
Recognition of major syndromes in returned travelers (e.g., fever, diarrhea,
rash, respiratory illness)
Access to travel medicine resources: texts, articles, Internet resources
Prevention counseling techniques
Experience
6 months in a travel clinic with at least 10–20 pretravel consultations/week
Initial Training and Continuing Education
Short or long courses in travel medicine
Membership in specialty society dealing with travel and tropical medicine
(e.g., International Society of Travel Medicine, national societies)
Attendance at regional, national, and international travel medicine meetings
a
Knowledge can be formally assessed by the ISTM Certificate of
Knowledge exam or by examination in diploma or master’s-level
travel medicine courses.
at rates exceeding the advanced economies.7 In addition, the population
of travelers is changing; travelers from China now spend more dollars
on tourism ($261 billion) than any other travel population.
STARTING A TRAVEL HEALTH PROGRAM
Frequently Asked Questions
Who Is Qualified to Offer Travel Health Services? All provid-
ers wishing to offer travel health services should have training in
travel medicine (Table 3.2). There is ample evidence that health care
practitioners not familiar with the field make errors in judgment
and advice, particularly about the prevention of malaria.3,8–10 These
errors can lead to adverse outcomes for travelers, such as malaria cases
and even death to those who were advised to take no or incorrect
chemoprophylaxis.11–14
Training includes formal education and experience.15 A study of
general practitioners who provided travel medicine care in Germany
demonstrated a correlation between giving preventive advice on
important topics with specific training in the discipline.16 The Dutch
National Coordination Center for Traveler’s Health Advice found that
the quality of providers improved when they were registered with a
national body, took courses, and followed national guidelines.10 Although
there is an international exam that certifies knowledge in the field of
travel medicine (the ISTM Certificate of Knowledge exam), as well as
a faculty that recognizes expertise and accomplishment (Faculty of
Travel Medicine, Royal College of Physicians and Surgeons of Glasgow
[https://rcpsg.ac.uk/travel-medicine/home]), there is currently no
requirement that those who practice in the field have such qualifications
or recognition.
What Can Health Care Professionals Do to Develop Expertise
in Travel Health? Several national and international bodies have
defined the important elements of a travel health consultation, and the
necessary competencies to provide advice.4,17,18 Travel health providers
should have the requisite knowledge, training, and experience to deliver
the following key components of the consultation:
• risk assessment of the traveler and the trip
• provision of advice about prevention and management of travel-
related disease (both infectious and noninfectious)
• administration of vaccines, and recognition of key syndromes in
returned travelers
To develop the necessary knowledge, clinicians should develop and
maintain expertise through attending travel health conferences, enrolling
in short courses, or pursuing certification or a degree in travel medicine.
Resources for training include the following:
• Royal College of Physicians and Surgeons of Glasgow diploma-level
course in travel medicine (https://rcpsg.ac.uk/travel-medicine/home)
• master’s-level training courses in Europe
• ISTM certificate of knowledge in travel medicine
• American Society of Tropical Medicine and Hygiene (ASTMH)
certificate of knowledge in tropical and travel medicine19,20
• American Pharmacists Association advanced competency training
program Pharmacy-Based Travel Health Services for US pharmacists
who are permitted by their state to provide immunizations (http://
www.pharmacist.com/pharmacy-based-travel-health-services); other
countries (e.g., the United Kingdom and Canada) have also developed
training for pharmacists
• US CDC online resources (https://wwwnc.cdc.gov/travel/page/
clinician-information-center)
• ISTM (http://www.istm.org/) and American Travel Health Nurses
Association (ATHNA) (http://www.athna.org/) calendars of courses
and conferences on their respective websites
Experience in a travel clinic setting is the other component leading
to competence in travel medicine. It is only with regular assessment of
travelers who have multiple health conditions, and are planning a wide
variety of travel destinations and activities, that one can gain broad
competence in the field. Spending time in an established clinic can be
invaluable, with competency maintained by regularly performing pretravel
consultations.
Providers are encouraged to join national and international societies
that are devoted to travel medicine. These will often provide courses,
publish newsletters with travel medicine alerts, and link members through
discussion groups. Most importantly, anyone working in this specialty
must make a personal commitment to ongoing learning, as global health
risks are continuously changing. See Appendix: resources for additional
professional development opportunities.
Are There Different Models of Care Delivery? Most practices of
travel medicine have both physicians and nurses participating in the
care of patients. The specialty of travel medicine is ideally suited to the
 CHAPTER 3 Starting, Organizing, and Marketing a Travel Clinic
involvement of nurses, nurse practitioners, and physician assistants.
Pharmacists are also providing these services, as the pathways toward
recognition of pharmacists continue to evolve.21 Given the variety
of providers, each practice will need to decide how to divide the
responsibilities in accordance with applicable regulations of the health
professions.
For clinics in which both physicians and nurses provide care, there
are typically two models (Fig. 3.1). In the first, the physician obtains
the travel itinerary, planned activities, and the patient’s medical and
immunization history. The physician then delivers the health advice,
and decisions are made in conjunction with the travelers as to recom-
mended immunizations and other interventions. The care of the patient
is then transferred to a nurse (or to a person who has competency to
administer vaccines), who reviews vaccine adverse events, obtains
informed consent, and administers the vaccines. After giving the vaccines,
the nurse records vaccine administration information in either a paper
or electronic medical record (EMR).
In the second model, the nurse, nurse practitioner, or physician
assistant provides the complete pretravel care, from the medical and
travel history, to preventive advice, to administration, to recording of
vaccines.
In the United Kingdom, this model of independent care rendered
by nurses is supported by a legal framework known as Patient Group
Directions (PGD). These require a clear and detailed written protocol
that is agreed and signed by doctors, nurses, and pharmacists. The
document details the indications and situations when a nurse can select,
prescribe, and administer a prescription-only medication (e.g., vaccine
or antimalarial) without recourse to a physician. The PGD requires
that the nurse receive appropriate training, updating, and audit of
practice.
In US practices where a health professional without prescribing
privileges, such as a registered nurse, is the sole provider of care, it
is necessary to develop detailed protocols to follow. These should be
Patient registers
Waiting period in reception
Patient can complete demographic information related to travel
Patient can view or read educational materials
Patient is brought into consultation All travel care is
room. Travel and medical history provided in a single
obtained, and health advice is given room by a single
by one provider. provider
Patient is brought into second room. A
second provider, often a nurse, reviews
vaccine side effects, obtains informed
consent, and administers vaccines
Medical record completed and filed, or entered into a database
The patient pays for the service and returns to waiting room
for 15 to 30 minutes to be observed for development of
immediate reactions to vaccines
FIG. 3.1 A flow diagram for patient care in a travel medicine clinic. Two
options are presented: two-provider or single-provider care.
17
written, clinic specific (reflecting the standard of care within the region),
and include standing orders for administering vaccines and obtaining
prescriptions.22 Immunization Action Coalition has established an
online resource for the development of standing orders for clinics,
at https://www.standingorders.org/. The American Travel Health
Nurses Association maintains a set of clinic protocols on its website
(www.athna.org).
Pharmacy-based models of care have grown as pharmacists in the
United Kingdom, United States, Canada, and other countries expand
their training and professional role in pretravel care.21,23,24
What Policies, Procedures, and Resources Should Be in Place?
Before a clinic schedules its first patient, certain protocols and support
services should be in place:
• anaphylaxis protocols and management of vaccine adverse events
• vaccine storage (i.e., cold chain maintenance)
• needlestick and occupational exposure to bloodborne pathogens
management
• immunization documentation
• infection control and hazardous waste disposal
• Vaccine Information Statements (VIS; US CDC publications, or
equivalent) (https://www.cdc.gov/vaccines/hcp/vis/index.html)
• institutional guidelines for the use of consents and waivers
• vaccine adverse event reporting systems
• standing orders (or equivalent) for all vaccines offered
• dedicated vaccine-grade refrigerator and separate freezer unit, if
indicated
• staff member who is identified as the immunization coordinator
Over time, the clinic will need to add and update protocols and develop
a policies and procedures manual. A resource for travel clinic protocols
in the United States is the ATHNA Clinic Manual (www.ATHNA.org)
and Immunization Action Coalition (IAC) (www.immunize.org).
Is Special Documentation Required? There may be national, local,
or institutional regulations that apply to immunization records. The US
National Childhood Vaccine Injury Act (NCVIA) and CDC mandate
certain vaccination documentation (https://www.cdc.gov/vaccines/
hcp/acip-recs/general-recs/records.html). For efficiency, completeness,
and to meet current quality standards, it is advisable to use preprinted
documents (or EMR equivalent) when offering pretravel care.
What Support Services Are Needed? In some settings, health
care professionals provide all the services of a pretravel consultation,
including ordering and stocking supplies, taking phone calls, appointment
making, billing, and providing the full range of clinical care. In most
practices, however, clinicians provide clinical care; and administrative
staff manage other aspects of the service, such as processing the required
documents and payment requests from insurance companies where
applicable.
Should a Clinic Offer Travel Health Services Full Time? What
Are the Best Times for Clinic Sessions? When starting a clinic it
can take time to build patient volume. It may be advisable to start by
incorporating a few sessions per week and then adding appointments
as clinician expertise and patient demand increase. Many travelers will
seek care at the last minute and during nonworking or nonschool hours.
If they can be covered, early morning, late afternoon, evening, and
weekend appointments are popular.
What Vaccines Should Be Provided? Should the Clinic Offer
Yellow Fever Vaccine? Many clinicians are knowledgeable about
routine adult and childhood vaccines but are not familiar with travel
18 SECTION 1 Practice of Travel Medicine
vaccines. Some clinicians will start by offering only vaccines typically given
for international travel (e.g., hepatitis A and B, typhoid), in addition to
routinely administered vaccines such as influenza and measles, mumps,
and rubella. Others will want to offer comprehensive care and provide
all the travel immunizations licensed in their country. Regarding yellow
fever (YF) vaccination, under International Health Regulations (2005),
“State parties shall designate specific YF vaccination centers within their
territories in order to assure the quality and safety of the procedures
and materials employed.”25 Many countries have a specific procedure
that must be followed before becoming a YF vaccinating center. US
practitioners should consult CDC guidance about becoming a YF vaccine
center, at https://wwwnc.cdc.gov/travel/page/yellow-fever-registry-faq.
How Much Time Should Be Set Aside for Appointments? Ideally,
a pretravel risk assessment, counseling, and vaccine appointment would
be allotted 45–60 minutes. In reality, most appointments do not exceed
20–30 minutes, and when a travel medicine service is integrated into
primary care or a pharmacy setting, it may be less. Two-thirds of visits
to UK YF vaccination clinics are allotted only 11–20 minutes.26 If possible,
scheduling should be based on the complexity of the itinerary and
traveler. Some travelers need multiple visits for further assessment,
extended counseling (e.g., families with young children moving abroad),
or when multidose vaccines are administered.
How Should a Clinic Determine Charges? Around the world charges
are handled in different ways. In the United States, few private insurers
reimburse travel health care services; therefore many clinics operate on
a fee-for-service basis, with considerable variation in visit and vaccination
charges. To avoid potential conflicts with managed care contracts, US
clinics should learn about applicable billing rules. Clinics often issue
three charges for a visit: the consultation fee or visit charge, charges
for each vaccine, and a vaccine administration charge. In UK primary
care settings, the consultation is not billable as it is considered a free
service under the National Health Service (NHS); however, charges can
be made for certain vaccines. Retail sales of items such as repellent and
mosquito nets can generate additional income.
What Is It Going to Cost to Establish a Travel Health Program?
Travel services that operate within an existing clinic or primary care
service can be established with minimal additional investments. The
vaccine refrigerator and vaccine supply are two of the largest costs, but
careful equipment selection and maintaining a small vaccine inventory
can keep these costs to a minimum. Consultation rooms should have
computer access to epidemiologic information about communicable
diseases, as well as authoritative travel health recommendations. Subscrip-
tion to a national or commercial travel medicine database can be helpful.
Organizing a Clinic: Equipment and Supplies
Equipment
Refrigerator and freezer. A dedicated vaccine refrigerator capable
of maintaining vaccines at storage temperatures of 2°–8°C (optimal
5°C) is essential.27 If frozen vaccines are stocked (e.g., varicella), a separate
freezer unit that can sustain temperatures to at least −15°C is needed.
Each unit should have a temperature monitoring device (CDC recom-
mends continuous monitoring and digital recording using a buffered
temperature probe) that records temperatures at regular preset intervals,
not just the warmest and coldest temperatures. Ideally, these units should
be connected to a backup generator and an alarm system triggered if
proper temperatures are not maintained. Signage and plug locks can
help prevent inadvertent unplugging of the units.
US temperature monitoring charts should be maintained and
kept for a minimum of 3 years, or as dictated by site policy. Tempera-
ture charts (www.immunize.org/news.d/celsius.pdf), immunizations
sheets, and vaccine administration and storage guides are available
(https://www.cdc.gov/vaccines/hcp/admin/downloads/vacc-admin-
storage-guide.pdf). Similar information is available in Australia
and Canada.28-30
Computer. Computers in each consultation room can access the
practice EMR, a travel medicine database, and web-based information
services that can provide information about the status of a communicable
disease outbreak.
Supplies
Vaccine supply. Vaccines can be ordered directly from the manu-
facturer, a wholesaler, or a hospital or centralized pharmacy, depending
upon where the service is located. Hospital pharmacies usually have
purchasing contracts with agreed price structures. Initially a clinic can
store a minimum supply of vaccines and then track weekly usage to
anticipate the need for reordering. Overstocking of very expensive or
rarely used vaccines should be avoided. Vaccines should not be ordered
until the clinic has a designated immunization coordinator and the
refrigerator unit and separate freezer (if needed) can consistently maintain
proper temperatures over a period of 1 week. Cold chain maintenance
and vaccine storage and handling are management priorities.27 Only
designated yellow fever centers may order YF vaccine.
Vaccination supplies. For a comprehensive list, see www.immunize
.org/catg.d/p3046chk.pdf. Supplies include:
• gloves
• syringes of multiple sizes and needles for intramuscular, subcutaneous,
and intradermal use
• bandages, alcohol pads, and cotton gauze
• a topical anesthetic such as EMLA cream (Akorn Pharmaceuticals)
that can be applied to the immunization site in children prior to
injection
Managing adverse events.31
• procedures for the management of bleeding, anaphylactic or vasovagal
reactions
• adrenaline (epinephrine) compounds and antihistamines
• emergency equipment such as blood pressure cuffs properly sized
for the population served
Infection control and hazardous waste supplies. Every clinic must
comply with regulations concerning infection control and the disposal
of hazardous waste. “Sharps receptacles” should be mounted in a
convenient location that reduces the risk of needle-stick injuries.
Other patient supplies. These include pregnancy tests and a weighing
scale.
Documentation
Travel clinics need prescription capability, clinic letterhead for corre-
spondence and letters of medical exemption from YF vaccination, a
supply of International Certificate of Vaccination or Prophylaxis (ICVP),
and chart documents (or EMRs). The use of standard documents, forms,
and patient handouts helps to ensure comprehensive and consistent
pretravel care. Clinic documents should meet government guidelines
and may require legal review and medical director approval. Helpful
documents are pretravel consultation record, patient immunization
record, vaccine inventory log or database, and vaccination consents
and waivers.
The traveler encounter form should become part of the permanent
medical record. For insurance companies, a permanent medical record
documents the level of care that has been provided. For the traveler, it
is a record of the immunizations and advice they received and is useful
if they lose their immunization card at some time in the future. For
the travel clinic, it can be accessed to create a database (if not already
 CHAPTER 3 Starting, Organizing, and Marketing a Travel Clinic
entered directly into an EMR) of each traveler, and their preventive
measures.
A complete and accurate immunization record includes the following
information:
• vaccine type (generic abbreviation and/or trade name)
• dose
• date of administration
• manufacturer and lot number
• site of administration
• name and title of administrator
Additional vaccination information may be required by govern-
ments or institutions; for example, CDC mandates documentation that
Vaccine Information Statements (https://www.cdc.gov/vaccines/hcp/vis/
index.html) were given to the patient. In the event of a vaccine recall,
having this information in a computerized database will make the task
of identifying patients much easier, since records can be searched by
patient name, vaccine type, and lot number. An electronic record also
allows rapid access to the information in a patient’s chart if the traveler
calls some months or years after the visit. If your region maintains a
childhood or adult vaccine registry, it will be necessary to comply with
reporting requirements.
Information Resources for the Clinician
Clinicians require access to up-to-date information to determine destina-
tion risks and to learn about risk reduction measures. Authoritative
sources of advice are WHO, CDC, the European Centres for Disease
Control and Prevention (ECDC), and national resources such as those
provided in Australia, New Zealand, Canada, France, Germany, Swit-
zerland, The Netherlands, and the United Kingdom. Travel clinics will
most likely use both national and international resources. The travel
health sites of CDC, Canada, and the United Kingdom have fact sheets
for the provider and traveler (CDC: https://wwwnc.cdc.gov/travel/;
Canada: https://www.canada.ca/en/public-health/services/travel-health/
fact-sheets.html; NaTHNaC: https://travelhealthpro.org.uk/factsheets;
and Fit for Travel: http://www.fitfortravel.scot.nhs.uk/home.aspx).
A limited number of print resources are useful: the CDC Yellow
Book, a textbook of travel medicine and tropical medicine, an atlas,
and professional journals that focus on these fields. For a complete list,
see Appendix.
Subscription to a commercial database, or accessing a national
database provides health professionals with country-specific recom-
mendations for single- or multiple-destination itineraries and travelers
with customized information, disease risk maps, and other prevention
recommendations.
Communication forums, termed “listservs,” engage in discussion
about emerging infections, outbreaks, or tropical and travel medicine–
related cases. The ASTMH and ISTM listservs require membership in
the organization; the unmoderated listserv of the ISTM is active daily,
airing problems and solutions that are helpful for the travel medicine
provider. ProMed-mail (http://www.promedmail.org/), an open-access
program of the International Society for Infectious Diseases, is a moder-
ated reporting system for outbreaks of emerging infectious diseases.
Global Health Now, a service of the Johns Hopkins Bloomberg School
of Public Health, details developments in global health and infectious
disease (https://www.globalhealthnow.org). It is important to be aware
that listservs may post information that is anecdotal or does not comply
with national standards or practices.
As in any medical field, in travel medicine there are frequent dif-
ferences of opinion, whether regarding immunizations, antimalarials,
or management of travelers’ diarrhea. Despite this, clinics should try
to maintain consistency in their recommendations. Protocols can be
written that match the practice standard of the region, province, or
19
country in which the travel clinic is located, or national guidance can
be consulted.
Information Resources for the Traveler:
Patient Education
In the United States, CDC mandates that every clinician must provide
vaccine recipients with information about the risks and benefits of
immunizations. These are in the form of Vaccine Information Statements
(https://www.cdc.gov/vaccines/hcp/vis/index.html) and are available in
multiple languages.
An atlas, world map, and/or globe can help with destination counsel-
ing. Information on medical evacuation/assistance insurance and
demonstration samples of travel supplies and equipment (e.g., sample
repellents, mosquito netting, travel medical kits, water treatment equip-
ment) are also helpful.
As education is the mainstay of pretravel care, the clinician will need
to prioritize and efficiently counsel the traveler on a number of health
and safety issues. Many clinics give the traveler a customized report
generated by a commercial database that reinforces prevention advice.
Clinics may also develop their own information sheets based on national
or international guidance documents.
Travel clinics should be able to deliver advice about numerous travel
health topics, such as altitude illness, Aedes spp. exposures, and health
issues for special needs travelers such as pregnant women, seniors, and
those with diabetes, HIV/AIDS, or chronic cardiac or pulmonary disease.
Knowledge of how to access safe and reliable medical care overseas
is important. There are online directories for overseas travel clinics
such as those of the ISTM or the International Association for Medical
Assistance to Travelers (IAMAT, www.iamat.org), and to specialty
resources such as the Divers Alert Network (www.diversalertnetwork.org/).
Travel clinics that provide this complete range of health resources
will distinguish themselves from a generalist’s office and enhance their
level of care.
Despite these educational efforts for travelers, it is difficult to measure
the acquisition of knowledge during the pretravel visit,32,33 and equally
difficult to assess whether or not this knowledge is acted upon during
travel.34,35 Airport surveys of travelers departing to regions considered
at risk for malaria and/or vaccine-preventable disease document that
despite travelers having knowledge of the diseases, they often neither
take antimalarial chemoprophylaxis nor receive vaccines that are
indicated.36-38 This is especially true for travelers who are visiting friends
and relatives (VFR travelers).36,39-41 However, providing travelers with
consistent and clear advice about illnesses such as malaria, and allowing
them to discuss their concerns about chemoprophylaxis, can lead to
improved compliance.14,34,42,43
Legal Issues
Most clinicians practice in settings that already meet regulatory require-
ments; therefore little or no change may be necessary to ensure full
compliance with local, national, or institutional travel health guidelines.
Several US federal laws apply to the provision of travel health
services:
• National Childhood Vaccine Injury Act44
• Vaccine Adverse Event Reporting System (VAERS, https://vaers.hhs
.gov)
• Needlestick Prevention and Safety Act (https://www.osha.gov/SLTC/
bloodbornepathogens/index.html)
• Vaccines for Children Program (https://www.cdc.gov/vaccines/
programs/vfc/index.html)
In addition to federal laws, US state laws and institutional regulations
impact travel health practice. Each country has its own regulations and
standards for clinical practice. For instance, the need for signed consent
20 SECTION 1 Practice of Travel Medicine
varies, and in many countries in Europe and Africa, after the provision
of relevant information, a verbal agreement to receive vaccinations is
acceptable. Attention to medical-legal risks should be a management
priority.45
Professional Standards. Several professional groups have developed
written standards for the practice of travel health.2,46 In the United
States, the CDC acts as the standard for travel health recommendations.
The Royal College of Nursing in the United Kingdom and The American
Travel Health Nurses Association have developed competencies and
standards for travel health nursing, and Canada has issued competencies
for immunization care.17,47 Travel clinics that operate in settings such
as corporations, universities, and health departments should comply
with their standards.
FINANCIAL CONSIDERATIONS
Fees and Revenue for a Travel Health Practice
Worldwide, there is tremendous variation in the fee structure and
reimbursement for travel health services. In the United States, travel
clinics range from being entirely private, fee-for-service facilities to
hospital and pharmacy-based clinics in which fees are set by the sponsor-
ing institution with providers participating in insurance programs.
University student health clinics have differing payment structures.
Insurance carriers may not cover some or all vaccines and medications
prescribed for travel. In Canada, the travel visit and vaccine charges
are usually not covered by provincial health plans. In general practice
in the United Kingdom, some vaccines (such as typhoid, hepatitis A,
and polio) are covered under the NHS, whereas others are charged to
the traveler (e.g., YF, rabies, and Japanese encephalitis), and there is no
additional reimbursement for providing advice.
Fee-for-Service Care
Travel clinics that charge on a fee-for-service basis expect payment in
full at the time of the visit. Fee-for-service avoids many costly administra-
tive processes (enrolling in different insurance plans, billing insurance,
and billing patients for uncovered charges). However, clinics that are
fee-for-service should inform travelers about payment arrangements
when they book their appointments.
When a Clinic Participates in Insurance Plans
In the United States, travel medicine specialists who are participating
providers for third-party insurance carriers are required to accept the
terms of reimbursement of those carriers. The clinic cannot request that
the traveler pay more than the insurance company’s level of reimburse-
ment for a covered service. This frequently leads to underpayment,
particularly for vaccines that may cost the provider more than the
amount of the insurance company payment. For uncovered services,
the travel clinic can request a cash payment. If a clinic bills, a waiver
that informs the traveler that he or she is responsible for payment
for uncovered services will need to be agreed and signed before the
traveler can be billed. In US clinics that participate with insurance
plans, billing for care rendered by a registered nurse is subject to
requirements regarding the presence and function of prescribing
clinicians (physicians, nurse practitioners, and physician assistants).
Nurses can bill independently in entirely private clinics that are
fee-for-service.
US Medicaid does not cover any services related to travel, so Medicaid
patients have to self-pay for the counseling and vaccines that they receive.
Medicare will only cover routinely recommended vaccines for adults
(e.g., influenza, pneumococcal, tetanus-diphtheria and acellular pertussis,
and hepatitis B vaccines).
In many settings, patients require a referral from their primary care
physician in order for the clinic to bill the patient’s insurance company.
These referrals are best initiated when the appointment is booked.
Clinic Charges
Fees that may be reimbursable are the consultation fee (visit fee), vaccine
fees, and vaccine administration charges. Providers in some countries
charge for writing prescriptions, for completing an ICVP, and for
completing other documents.
Selling Travel-Related Products
Selling travel-related health items benefits travelers by allowing them
to immediately purchase items that may be difficult to locate elsewhere.
As may be permitted by law, some travel clinics will sell prepackaged
antimalarial drugs, standby treatment for travelers’ diarrhea or malaria,
and drugs to prevent acute mountain sickness.
COMBINING A TRAVEL CLINIC WITH
OTHER SERVICES
Combining a travel health service with a vaccination service is a natural
association, and may already be in place for occupational health, student
health services, and pharmacies. Vaccine clinics can immunize employee
or community groups, migrants who need immunizations for visas,
students who need immunizations for schooling, and veterinarians and
animal handlers who require rabies vaccination. The service can also
be open to others who require a vaccine but do not have access to a
physician who can provide it. Vaccine clinic visits are usually an efficient
use of resources, leading to increased productivity. A separate vaccine
clinic form should be generated that contains patient demographic
data; pertinent medical, immunization, and medication history; and
the reason for the vaccine.
Pretravel Physical Examinations and Posttravel Care
Clinics that are part of a general medicine practice, a university student
health service, or an occupational health unit with contracts with corpora-
tions or other organizations might perform physical examinations as
part of visa or program requirements.
Most consensus guidance on travel medicine competencies does not
indicate that an extensive knowledge of tropical disease is necessary for
travel medicine specialists. However, all travel health specialists should
be able to recognize key syndromes in the returned traveler such as
fever, skin disorders, diarrheal illness, and respiratory complaints, and
know how to refer these patients for appropriate care.14,48–50 For clinics
with personnel having expertise in infectious diseases and tropical
medicine, it is appropriate to evaluate and treat ill returned travelers
without referral. In these settings, there needs to be laboratory support
to diagnose or confirm suspected illness.
Services to Travelers During Their Journeys
Clinics with contracts with businesses, nongovernmental organizations
(NGOs), or educational institutions may provide health advice for ill
clients during their trips via email, videoconferencing, or communication
with local health providers.51 Before this can be done there should be
provider expertise in tropical and emergency medicine; 24/7 availability;
technical capacity to receive, process, and transmit confidential informa-
tion; and protocols for handling different clinical scenarios. Legal issues
may also need consideration.
Offsite Services
Travel clinics may be asked to come to a workplace or school setting
to provide pretravel advice and immunizations to individuals or groups.
 CHAPTER 3 Starting, Organizing, and Marketing a Travel Clinic
This can be a valued service in some communities and an opportunity
to generate additional revenue and goodwill. Clear protocols will need
to be followed to ensure vaccine cold chain compliance, appropriate
care for adverse events, documentation and handling of medical records,
confidentiality, and proper disposal of hazardous waste.
RUNNING A TRAVEL HEALTH PROGRAM
Staff and Administrative Issues
Clinical and administrative personnel should be trained to deliver efficient
services during the three phases of the visit: before the visit, when an
appointment is arranged; during the visit, when the traveler assessment
is made and a risk management strategy is developed and delivered;
and after the consultation is completed, when either follow-up care is
scheduled or the traveler calls with postvisit questions.
Before the Visit, Preparation of Reception Staff
Travelers frequently ask administrative staff questions about vaccines,
destinations, vaccine charges, insurance coverage, and more. Staff should
be prepared, and counseled not to answer risk management queries.
Travelers can be advised to wait for their appointment or to visit an
authoritative website to deal with nonadministrative queries.
The following can help facilitate the appointment:
• Obtain traveler-related information: age, date of birth, gender, medical
conditions, country of birth, native language.
• Have patients bring in immunization records, medication lists,
and a complete itinerary including dates and durations at each
destination.
• Determine the purpose of trip: holiday, business, study, VFR travel
(travel to visit friends and relatives), humanitarian work, medical
care abroad, or other reason.
• Schedule a consultation length appropriate to the traveler and the
trip. Sufficient time will be needed for complex journeys, multiple
family members, or travelers with special health needs.
• Provide information to the traveler about the visit, helping him or
her anticipate what to expect during the consultation, including
length of the visit.
• Determine if the traveler requires completion of special forms.
• Explain terms of payment.
• Try to confirm all appointments 24–48 hours before the visit.
• Ensure that sufficient quantities of vaccine are available.
Key Issues During the Pretravel Consultation
The key feature of the provider–traveler encounter is a risk assessment
that allows the advice and interventions to be individually matched to
the traveler. See Chapter 4 for a detailed description of the pretravel
visit, which includes the assessment of the traveler, specifics of the
itinerary and health risks, and provision of information to mitigate
these risks.
After the Consultation
Documentation should be completed and clinicians and administrative
staff prepared to handle any calls concerning vaccinations, clarification
of prescriptions, or prevention guidance.
Reporting Vaccine Adverse Events
All administrators of vaccines in the United States are required to report
adverse events via VAERS.44 The methods and forms for reporting can
be obtained by calling 800-822-7967 or accessing http://vaers.hhs.gov/
index. The Division of Immunization in Canada has a similar report-
ing system and can be reached by calling 866-234-2345 or accessing
https://www.canada.ca/en/health-canada/services/drugs-health-products/
21
medeffect-canada/adverse-reaction-reporting.html. In the United
Kingdom, suspected adverse event reports are made to the Medicines
Healthcare Products Regulatory Agency through the “Yellow Card Scheme”
at http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/
index.htm. Other countries and regions may have their own reporting
systems.
Service Evaluation
The hallmark of a quality travel health service is an ongoing commitment
to quality improvement. It is important to implement patient satisfaction
surveys at the time of the visit as well as posttravel outcome evaluations.
Regular chart reviews and competency-based training evaluations should
be built into the clinic’s professional development plan.
After the Trip
Most travelers will not need posttravel evaluation or care; however,
certain travelers should schedule a consultation. Reasons for a posttravel
visit include a traveler to a malaria risk area who develops a fever after
return, travelers who have been ill abroad or are ill upon return, long-stay
travelers, and travelers who worked in health care or other “at risk”
occupations.
Many travel health clinics will focus only on pretravel care. Clinics
that are part of general practice, a medical center practice, a university,
or other multispecialty group may have expertise in assessing returned
travelers who need evaluation.
MARKETING AND PROMOTING A TRAVEL
HEALTH PROGRAM
Despite the growth in international travel, it is estimated that only
10%–50% of travelers seek pretravel care.36,52 The reasons for this are
varied: Many travelers and health professionals are unaware of the
specialty of travel medicine or the value of specialized travel health
care. To increase awareness, a clinic should create a marketing plan for
the local community, including businesses, schools, nonprofits, missionary
groups, adoption agencies, and tour operators, to identify potential
travelers (Table 3.3). There are numerous components of this plan.
Word of Mouth
The value of a “satisfied customer” should not be underestimated.
Communication among travelers who have had a good experience at
your service can increase awareness and lead to referrals. Clarify for
the traveler the advantages of a comprehensive travel medicine service:
provider knowledge and expertise, availability of all travel vaccines,
customized prevention counseling, and access to written and online
resources on disease epidemiology and prevention.
Referrals
Health providers will refer patients to a clinic if they perceive that
patients have received excellent care in a timely fashion. All referring
clinicians should be sent a letter or other electronic form that can go
in a patient’s chart with details about administered vaccinations and
travel medications prescribed. A clinic can also include a brochure
describing the clinic and its services. Many generalists’ offices do not
want to stock costly and infrequently used vaccines, and find it difficult
to keep up with changing global patterns of disease and prevention
strategies.
Direct Marketing Methods: Internet, Print, and Media
The Internet and social media can promote a clinic’s services; clinic
websites can include essential content. Some clinics purchase ad space
on Google, Bing, and other sites. Clinics that offer YF vaccine can be
22 SECTION 1 Practice of Travel Medicine
TABLE 3.3 Marketing a Travel Medicine
Service
Development of clinic website
Word of mouth among travelers, referral physicians, health agencies,
community businesses, and travel agencies
News articles and releases to web, print, radio, or television media
concerning travel medicine care and travel health topics
Direct advertising in:
Internet/print media
Regional/state medical journals and specialty newsletters (adoption
groups, student travel, alumni magazines)
Development of a clinic brochure with mailings to:
Physicians and other health professionals
Retail travel agencies
Regional/state health departments
Businesses, schools, universities, and nonprofit groups that travel, such
as churches and museums
Letters to referring providers that detail vaccines administered and
medications prescribed
Education sessions for health professionals and lay public
listed in the CDC Yellow Fever Clinic online directory for US designated
centers. The ISTM website maintains a listing of travel clinics worldwide
that are directed by members of the society. IAMAT lists clinics with
English-speaking providers.
Other Marketing Approaches
Helpful initiatives are writing a timely news article around global health
events, doing radio or television interviews, taking advantage of hospital
or university marketing departments, and giving talks to professional
and lay groups on health and travel topics.
Mailings
Direct mailings with a clinic brochure can be sent to local physicians’
offices, schools and universities, local and regional businesses that have
international markets, and travel agencies and tour operators that
specialize in international or adventure travel. Meeting with the directors
of travel agencies, student health center staff, and corporate human
resource personnel can also encourage referrals.
Contract Services
Establishing contracts with the private sector is an excellent way to
guarantee patient volume and income.53 Under contracts, the clinic
agrees to provide certain services, and the corporation or other facility
agrees to have all or some of their travel health care administered through
your clinic. The clinic can seek an annual retainer or a set fee for each
visit and service. If vaccine services are also provided, contracts can be
established for community flu vaccinations, with veterinary offices for
rabies vaccination, or state or provincial health departments to provide
hepatitis B vaccine, as examples.
Brochures
A clinic brochure can contain information detailing reasons to obtain
pretravel care, services provided, hours of operation, directions to the
facility, contact numbers, and website address. Inclusion of statistics
about the travel population served by your clinic and pictures of travel
destinations can enhance its appeal. These can be mailed or emailed
to target groups for distribution.
TABLE 3.4 Top 10 Problems Encountered
in Travel Clinic Practices
1 Insufficient space, time, and staff to meet demands
2 Travelers presenting with a short time interval before departure
3 Telephone calls for advice
4 Need for standardized, up-to-date advice for clinic personnel
5 Conflicting and unreliable advice provided to travelers
6 Patient concern about the cost of service and vaccines
7 Difficulty in assessing patient compliance with and understanding
of advice
8 Difficulty in accessing new medications and vaccines
9 Failure of insurance carriers to pay for services
10 Travelers having preconceived ideas about their travel health needs
Adapted from Hill DR, Behrens RH. A survey of travel clinics
throughout the world. J Travel Med 1996;3:46–51.
MANAGEMENT CHALLENGES
A 1994 survey of travel clinics identified several challenges to the practice
of travel medicine.4 The top 10 cited by practitioners are listed in Table
3.4; these represent more than 80% of all problems listed. These concerns
remain a challenge today, and if those who are developing a clinic
anticipate them during the planning stages, then the clinic should be
able to deal with them more effectively.
Telephone, Email, and Text Advice
Giving travel advice over the telephone is controversial. Most clinics
are willing to provide advice to clinicians, but fewer are willing to provide
it to the general public. Clinics that have agreements with businesses,
NGOs, or schools and universities may choose to provide secure email
advice for their clients. To give advice appropriately takes both time
and expertise, and this effort for public enquiries may not translate
into patient visits to the clinic. Travel clinics can consider charging for
advice given by telephone or online.
If a clinic chooses to provide telephone, email, or text advice, it
should be clear who will respond to the requests, and when the response
will be made. The advice given should be from standard protocols to
ensure that answers are consistent between providers. Both the query
and the advice given should be documented. For telephone calls, a
standard form can be completed during the call, and a voice recording
system is advisable. Having these procedures in place will help with the
queries and provide documentation in the event of medico-legal issues.
Some larger travel medicine practices have developed automated
telephone response lines that usually charge for the service. These are
complex to develop, however, and need to be continuously updated to
remain current.
Giving general rather than specific advice to public inquiries is best
because the clinic has not established a formal physician–patient relation-
ship, and all of the medical and itinerary information usually cannot
be obtained over the telephone or via email to properly assess health
risks. Thus specific recommendations would be based on incomplete
data, and if these were acted upon with a deleterious outcome, the
clinic could become legally responsible. If advice is given to another
health care provider, it should be made clear that this provider assumes
responsibility for applying the advice to the traveler.
PROFESSIONAL DEVELOPMENT
Travel health care is not “just giving shots,” and clinicians need initial
training and ongoing education to provide comprehensive, quality care
 CHAPTER 3 Starting, Organizing, and Marketing a Travel Clinic
that is based on current standards. Physicians, nursing professionals,
pharmacists, and other health professionals who may be experienced
in immunizations are not automatically qualified to provide the other
components of a pretravel consultation. Traveler and trip assessment
and prevention counseling are separate skill sets; all clinicians should
be trained and competency assessed. ISTM, ASTMH, and ATHNA as
well as other national organizations offer travel medicine courses and
conferences. CDC has regular, free training opportunities through the
CDC Learning Center (www.cdc.gov/learning). Other countries, including
the United Kingdom, Australia, and Canada, offer educational programs.
Building in regular continuing education opportunities in travel medicine
should be standard practice.15
CONCLUSION
The development of travel medicine into a recognized specialty has
highlighted the importance of a comprehensive travel medicine service.
Advantages of this include provision of care by a health professional
who has formal training and experience and has access to information
and resources from expert bodies to provide the highest level of care
based on current recommendations. In a travel clinic, the traveler should
be given advice on a wide range of topics; be administered required or
recommended vaccines; and prescribed medication for prevention or
self-treatment of problems such as malaria, diarrhea, and high-altitude
illness. Providing pretravel care at this level will establish the service as
an important link in the care of international travelers.54
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KEY POINTS
• Communicate pretravel advice founded on evidence-based
research that is translated into practical measures for travelers to
prevent ill health, to manage minor problems, and to seek expert
medical assessment appropriately while abroad and upon return.
This will include individual risk assessment based on itinerary,
style, and duration of travel; written educational materials,
including links to reliable Internet sites to complement oral
advice; and specialized guidance on health management abroad
(self-treatment, seeking medical help).
INTRODUCTION
The pretravel consultation aims to provide evidence-based information
that addresses health problems while abroad and upon return home.
Travelers to the Global South are especially at risk for health hazards,
both noninfectious and infectious. Some risks are destination specific;
others are widely distributed. The growing body of evidence regarding
real risks for travelers needs to be translated into meaningful, personal-
ized, and practical advice.1–3 It is recognized that infants, children,
pregnant women, and older adults encounter specific risks. Certain
travelers, such as the growing population with immune suppression or
underlying health problems, face additional challenges.4,5 Some types
of travelers (e.g., travelers visiting friends and relatives [VFR]) have
demonstrated broader risk exposures but inaccurate perceptions of
risk.6 Some of the anticipated disorders are potentially fatal; many are
dangerous, and others may have long-term sequelae. Some can also be
transmitted to other people when returning from endemic areas. However,
the majority of health disturbances are of limited duration and mild
in character. Less than half of travelers to tropical and subtropical
countries are estimated to experience mild diarrhea, which usually does
not lead to severe consequences. Upper respiratory disorders are less
well characterized, but influenza may be encountered as frequently as
moderate to severe diarrhea during travel. Consequently, some travelers
need to adjust their travel plans at least temporarily due to illness, and
even the mild course may impair a leisurely atmosphere or seriously
interrupt a business transaction.7
The pretravel consultation therefore fulfills three main goals: (1)
assess the client’s fitness for travel, based on medical history and an
understanding of the purpose and type of travel; (2) analyze the
anticipated and real health risks; and (3) translate the findings into a
tailored counseling of prophylactic measures. Furthermore, counseling
should include suggestions for appropriate behavior and self-management,
4
Pretravel Consultation
Christoph Hatz and Lin H. Chen
• Provide travelers with clear and concise information from reliable
sources, focused on relevant health issues; add expert experience
where appropriate.
• Discuss and administer appropriate vaccinations and prescribe
medications for prevention and self-treatment.
• Review preventive measures against injuries; arthropod-borne
diseases; diarrheal, respiratory tract, and sexually transmitted
infections; new outbreaks; and cardiopulmonary complications
for persons with preexisting conditions.
and instruction about seeking medical care when health problems arise
during travel. Personal experience positively influences the credibility
of the person providing advice. Informing but not frightening travelers
is a key function of the advisor. Many travelers are overly anxious during
travel, possibly due to uncertainty about and fear of infectious diseases.1
Thus highlighting positive influences of travel on health may reassure
travelers.
LOGISTICS AND MECHANICS OF THE PRETRAVEL
CONSULTATION
The primary care physician who is acquainted with the traveler can
provide personalized and relevant tips for safe travel. Their insights
into their patient’s compliance are relevant (e.g., for malaria chemo-
prophylaxis and accident prevention). They are also more likely to have
the best approach to address sexual risks and their consequence; however,
this task is often relegated to a travel health advisor.
A comprehensive pretravel consultation may easily span more than
1 hour, especially for extended trips, multiple destinations, or a special
host. Most consultations, however, may only be allotted 30 minutes or
less. The advisors must therefore concentrate on what they perceive to
be the most important health risks and their prevention for each traveler.
This requires sound knowledge of the epidemiology in the targeted
destinations, and knowledge about the destination. Any personal experi-
ence of the advisor is an additional asset. Detailed itinerary and activity
plans refine the assessment of potential exposures, but travel plans are
frequently uncertain or imprecise prior to the trip.8,9 Travel medicine
providers must recognize potential deviations in itineraries and advise
accordingly.
Many sources provide guidance for travel medicine providers
electronically; choosing the right source is key to gain relevant
and evidence-based information. Using and adhering to national
25
 CHAPTER 4 Pretravel Consultation 25.e1

Abstract Keywords
Evidence-based pretravel information lays the foundation for providing Accidents
sound practical advice. Although a broad information platform exists Infectious diseases
in travel medicine, important gaps of knowledge remain. When specific Injury
research data are unavailable, a combination of expert opinion built Mental disorders
upon ample experience and information extrapolated from existing Pretravel advice
research can provide clinical guidance. Infectious diseases are key Prevention
components of the pretravel consultation, and advice on measures to Risk
prevent them is crucial. Noninfectious health problems, however, may Self-treatment
pose a greater risk than some of the tropical pathogens, and are often Skin problems
left aside in pretravel counseling. Accidents, mental health issues, and Travel
skin disorders merit discussion in every consultation, based on the risk
pattern the traveler might encounter.
26 SECTION 1 Practice of Travel Medicine
TABLE 4.1 Relevant Questions in Pretravel
Counseling
Itinerary Where? Standards of accommodation and food
hygiene standards?
Duration How long?
Travel style Independent travel or package tour? Business trip?
Adventure trip? Pilgrimage? High risk VFR in rural
areas with poor hygienic standards? Refugees?
Expatriates or long-term travelers?
Time of travel What season? How long until departure?
Special activities Hiking? Diving? Rafting? Biking?
Health status Chronic diseases? Allergies? Regular medications?
Address mental health issues
Vaccination status Basic vaccinations up to date? Special (travel)
vaccinations up to date?
Previous travel Tolerated (malaria) medication? Problems with high
experience altitude? Accidents? Animal contacts?
Special situations Pregnancy/breastfeeding? Disability? Physical or
psychologic problems during previous trips?
recommendations may be the best approach for advising travelers, and
is especially useful when the provider is not skilled in travel medicine
and able to contend with nuances in pretravel care. The content of
pretravel advice may be defined by checklists (Tables 4.1 and 4.2) or
in electronic modules. Referral to travel medicine experts with broad
experience is optimal for more complex situations requiring detailed
epidemiologic knowledge, special health risks, or advice for immuno-
compromised travelers.4,5
The impact and influence of the pretravel consultation are difficult
to measure, but are likely related to the expertise and communications
skills of the advisor. Limited data suggest that a face-to-face interview
by trained staff is an effective method of delivering counseling. Some
studies have shown improved travelers’ knowledge regarding malaria
risk and prevention following pretravel consultations,10,11 although the
travelers’ health beliefs greatly influence adherence. Moreover, data
regarding the benefits of counseling on safe sex, road traffic accidents,
drowning, and many other topics are largely lacking.1
COMPONENTS OF PRETRAVEL CONSULTATION
AND ORDER OF IMPORTANCE
Balancing the positive aspects of travel with potential risks and problems
while traveling leads to good travel consultations. The advisor may
choose to approach the travelers as “clients” rather than “patients.” If
compliance is the goal, then it appears logical that the traveler should
be convinced by evidence-based reasoning rather than threatened by
dramatic descriptions of negative events.
FITNESS TO TRAVEL
Ideally, international travelers should be stable in their physical and
mental health. Acute disorders are indications for trip cancellation.
Special risks for small children, pregnant women, senior travelers, or
people with chronic disorders require careful advice when balancing
the benefits and risks of a trip. For example, the pretravel counseling
for a pregnant woman who is obligated to travel to Africa or South
America for family reasons should aim to minimize potential health
dangers. Ultimately, the travelers need to decide for themselves, but the
advisor may also recommend against a trip if the risks are deemed too
high (e.g., malaria, Zika virus). Cardiovascular problems and injuries
are the most common causes of death during travel.12–14 The destination
and the type of travel influence the magnitude of health risks for
particular groups. Physical stress accompanies activities such as mountain
trekking and diving, as well as climatic challenges (temperature, humidity,
altitude, air pollution).
A priority in the pretravel consultation is to minimize unnecessary
exposures, particularly in vulnerable persons. Therefore travel to remote
and tropical destinations is typically discouraged for pregnant women
(especially in the first trimester) and very young children, given the
risks ranging from infectious diseases to general stress, dehydration,
and lack of appropriate medical care in remote areas. Immuno-
compromised travelers (HIV/AIDS, chronic diseases, medical conditions
requiring corticosteroids or immune modulators) also need special
attention and preparation. Additionally, the travel health advisor may
need to recommend deferring air travel due to the increased risk for
complications for certain travelers:
• with unstable or recently deteriorated angina pectoris
• within 3 weeks after uncomplicated and 6 weeks after complicated
myocardial infarction
• within 2 weeks after coronary bypass surgery
• with congenital defects, including Eisenmenger syndrome and severe
symptomatic valvulopathy
• within 2 weeks poststroke
• with lung disorders with dyspnea at minimal effort
• within 10 days postsurgical operations of thorax or abdomen
• within 24 hours after diving, and after diving accidents
ANALYSIS OF EXPECTED HEALTH RISKS
IN TRAVELERS
Major considerations in the pretravel consultation are travel style and
duration. Individual risks are assessed and discussed with the trav-
eler during pretravel counseling (see Table 4.1). An athlete flying to
Johannesburg will have different risks from a student traveling 3 months
through South Africa on an overland truck. The following sections
suggest ways to address relevant issues that merit mention or in-depth
discussion.
General Considerations
Communicating the prevention of potentially serious health problems
such as malaria is critical. At the same time, succinct reminders of
ordinary health problems are fundamental but often bypassed due to
time constraints. Some common health problems triggered by motion,
climate, and different socioeconomic conditions warrant discussion.
Acute, often benign respiratory infections, urinary tract infections, dental
problems, gynecologic problems, headaches or nausea, mental health
conditions, and injuries may receive little attention despite their frequent
occurrence and potential impact during travel. The threshold at which
signs and symptoms should lead to medical evaluation may depend on
the individual traveler and the available medical facilities in the destina-
tion country. The advisor must choose between issues that the traveler
“needs to know” and what is “nice to know.” The latter may include
information about Ebola, dangerous influenza viruses, cholera, or alleged
outbreaks of plague. These diseases will rarely be a true risk to the
overwhelming majority of travelers, but media sensation may fuel
unnecessary concern. In contrast, Zika virus infection, which affects a
small proportion of travelers (pregnant women) but impacts a much
larger group (women in their reproductive age and their partners),
requires special attention and diligent advice, as well as staying current
on new research and recommendations.
 CHAPTER 4 Pretravel Consultation 27

TABLE 4.2 Key Points of Pretravel Advice Practice

Food
“Peel it, cook it, boil it, or forget it”: This catchy recommendation is unfortunately not evidence based. Still, reasonable caution makes obvious sense: Eat freshly
prepared food, try to avoid raw, uncooked and undercooked vegetables, salads, and meat. Check that prepared meals are not contaminated by dirty plates and
cups, by water, or by insects.

Water
Drink industrially bottled water (properly sealed; carbonated), hot tea in clean cups. Avoid fresh dairy products of unknown quality. If no safe water is available,
disinfect with available means (filters are heavy!), iodine, or (although impractical for most travelers) boil it (see Chapter 5).

Mosquitoes
Around-the-clock prevention of mosquito bites especially relevant in areas endemic for malaria, dengue, chikungunya, Zika, and other arthropod-transmitted
pathogens. Note that a good number of arthropod-borne infections occur in some countries. Discussing them together and making the point of the importance of
repellents, protective (insecticide-treated) clothing, and mosquito nets emphasizes the importance of those measures.

Hydration/Dehydration
Adequate fluid intake is essential in hot climates. Thirst is not a good indicator for adequate fluid intake.
Rule of thumb: “Urine should have a light yellow color.”

Sun
Too much sun exposure can be dangerous, especially for children. Adequate protection is required: sunscreen, hat, cap, fine-meshed protective clothing,
sunglasses.

Walking Barefoot
Several parasites can enter the intact or damaged skin: larvae of worms (hookworm [larva migrans cutanea], Strongyloides), jigger fleas.
Even small skin lesions (scratched mosquito bites) can develop into superinfected ulcers. Wearing shoes or at least sandals helps reduce the risk.

Venomous and Poisonous Animals

Do not touch and do not step on anything that you cannot see. This reduces the risk of snake, scorpion, and spider injuries where such animals prevail. Use
adequate lighting when going for a walk at night. Robust shoes and long trousers are important preventive measures. Carrying antisera on trips to endemic areas
is discouraged (problems of cooling, safe administration).
Statistically, bee and wasp stings are the most frequently occurring dangerous events during travel for allergic people who have previous experience. They will
need respective medication, possibly including adrenaline injections (EpiPen) to carry along.

Sexual Contacts
Casual contacts are best avoided. Carry condoms at all times, just in case.

Accidents
Motor vehicle and cycle accidents, sports and other leisure injuries, violence and aggression, drowning, and animal bites may occur. Alcohol and drugs are often
cofactors in such accidents.
Check travel insurance needs prior to departing.

Altitude
High mountain hiking and trekking require individual counseling. Medication to prevent high-altitude sickness may be required.
High fluid intake and avoiding alcohol and drugs are necessary.

General Topics to Be Covered
Gastrointestinal disturbances occur not only in countries with lower
hygiene standards, but also more frequently in southern versus northern
industrialized countries.7 Fundamental preventive and management
measures for travelers’ diarrhea include good hydration and reasonable
use of medications; sophisticated and individualized advice is required
to translate the essence of the information into practice. The use of
antibiotics for self-treatment may be useful for certain travelers when
faced with moderate to severe symptoms. Treatment-related adverse
events raise concern, and the worldwide occurrence of antimicrobial
resistance has led to guidelines to limit the use of antibiotics for self-
treatment of mild travelers’ diarrhea.
Cardiovascular problems are reported in association with dehydra-
tion, high blood pressure, or preexisting heart disease. Complexity of
advice has grown along with the increasingly diverse traveler community
that includes older adults, persons with rheumatologic diseases, immune
suppression, and other underlying conditions. Preexisting diseases
understandably raise concern regarding one’s fitness to travel.
Travel medicine experts should recognize that neuropsychologic
problems may be overlooked, repressed, or misinterpreted. These
diagnoses comprise a wide spectrum from mild sleeping disorders and
slight anxiety to exhaustion and depression. Possible factors include
the abrupt change from workday life to holiday, and concern over safety
during travel. Learning as much as possible prior to the trip about the
destination and the lifestyle can help adjustment.
Travelers also often need recommendations regarding a travel medical
kit (see Chapter 8). Generally the kits focus on first-aid items (injuries,
skin and eye care) and some medications with broad indications such
as paracetamol, loperamide, antihistamines, but should also include
28 SECTION 1 Practice of Travel Medicine
specific medication for the traveler with preexisting conditions or for
special risks such as malaria. The further away from tourist routes, the
more medications and first-aid items may be necessary.
Road traffic accidents are an important risk worldwide, especially
in low-income countries and during night-time driving. Accidents may
result from a lack of attention, whether due to inappropriate use of
handheld devices such as cell phones, stress related, or due to a relaxed
state. Alcohol plays an important role as does driving at night when
there are poor roads, poor lighting, and various vehicles, pedestrians,
and animals sharing the road. More than 3500 traffic-related deaths
occur daily.15 Road traffic crashes cause up to 17 deaths per 1 million
visits by US citizens to some developing countries.14 Such figures indicate
that road accidents account for more deaths than any disease prevented
by travel vaccines. A modified nursery school motto cues travelers on
how to navigate traffic in countries with opposite-hand driving: “First
look right, then look left, then look right again before crossing a road.”
Also, reminding travelers that wearing helmets when on a motorbike
or cycling abroad may save more lives than being vaccinated against a
rare, exotic disease. The advice to check the safety equipment of transport
vehicles is appropriate but sometimes difficult to implement. More
practical are tips to request a spirited driver to slow down, or to stop
and exit the vehicle to avoid reckless driving.
Another component of travel advice is to caution about other risks
such as excessive sun exposure with possible sequelae of dermatologic
cancers. The topic of sexually transmitted infections is sometimes
awkward but should be addressed. Studies have shown that 5%–10%
of tourists have unplanned sexual contact with new partners.16–18 At
least one-third do not use condoms regularly, owing to their unavailability,
and it is known that alcohol use increases this risk. Skillful exploration
of the traveler’s openness for new experiences and foreign cultures may
circumvent clumsy or offensive discussion about sexual risks. Incidental
mention of unplanned sexual contacts, or only mentioning condoms,
may only impair the advisor’s credibility.
Health problems triggered almost exclusively by mobility include
motion sickness, jet lag, and other situations in an aircraft, ship, or
motor vehicle. Questions arise regarding dry air and increased pressure
in the middle ear in the aircraft cabin, thromboembolism associated
with prolonged immobility or dehydration, and fear of flying.19 Motion
sickness can sometimes be mitigated by medication. To respond to
jet lag, travelers can initiate adjustments to the time zone changes
even before departure by gradually changing their sleeping time at
home.20 To address the fear of flying, nonjudgmental discussion and
providing resources (courses offered by airlines, autogenic training,
medication) will greatly help the concerned traveler.21,22 Finally,
appropriate hydration during flight helps to maintain the sense of
well-being. The boosted diuresis, leading to modest ambulation from
frequenting the toilets, could lower the risk of thromboembolism
(see Chapter 52).
Potential health risks related to particular activities or exposures
should be discussed. A tourist going river rafting in Africa should be
informed about potential exposure to schistosomiasis. The agricultural
consultant spending 6 weeks with farmers in Southeast Asia should be
informed about protective measures against mosquito-borne infections
and vaccination against Japanese encephalitis. The trans-Africa biker
should be advised about rabies prevention, and the cave explorer in
East Africa should be informed about the risk of Marburg virus and
other diseases transmitted by bats.
APPLICATION OF PREVENTIVE MEASURES
Besides assessing and discussing behavioral aspects concerning preventive
measures for the above issues, counseling on chemoprophylaxis and
vaccinations is an important element of the pretravel consultation.
Communicating the importance of preventive measures against
malaria is challenging. The advice should balance the benefit of
chemoprophylaxis with the risk of possible adverse effects from the
medication.
Vaccine recommendations and requirements should also be deter-
mined by risk. Vaccine contraindications and the time available to
complete vaccinations before departure should be considered. Accelerated
vaccination schemes can be helpful. The pretravel consultation is often
the only time to update routine vaccinations for adults (e.g., tetanus/
diphtheria/pertussis, measles). Travel health advisors also need to consider
the cost of the visit, vaccines, and antimalarial medications. Sometimes
this will necessitate prioritization.
HEALTH PROBLEMS DURING AND
AFTER TRAVEL
Two general rules during and after travel to tropical and subtropical
countries are to investigate (1) every fever within 24 hours of onset,
and (2) every diarrheal episode with fever, abdominal cramps, and
bloody stool. Long-term travelers to tropical areas, even when
asymptomatic, may benefit from medical screening.23 In such cases an
investigation is recommended, including exposure history and physical
examination, blood chemistry and hematology, stool parasitology, as
well as selective screening of urine parasitology and other serologies
depending upon exposures (e.g., HIV).24 Unless overt symptoms exist,
some of these investigations may be performed about 3 months after
return to account for the incubation periods of possible pathogens.
Incubation period must be borne in mind. Falciparum malaria usually
appears within a few months after return, but manifestations of malaria
after 1 year and longer have been reported.25 Late-onset or recurrent
diarrhea may be a manifestation of giardiasis, amebiasis, or postinfectious
irritable bowel syndrome; pruritus with skin swellings can be due to
filariasis. When in doubt, a specialist in tropical diseases should be
consulted for such cases.
CHALLENGES REGARDING TRAVEL ADVICE
Much time and effort are needed to stay abreast with the growing
body of knowledge in travel medicine (see Table 4.2). The regular
provision of advice is necessary to obtain and maintain the routine. If
such practice is not possible, it may be advisable to work with checklists
for standard travel advice, and to refer clients to more experienced
colleagues for complex itineraries or special health considerations.
Studies on health problems associated with travel have mostly relied
on surveys or surveillance networks,26 and may not be sensitive in
capturing injuries that require immediate attention during travel or
evaluation by trauma specialists rather than travel medicine, tropical
medicine, and infectious disease specialists. Technologic advances such
as mobile phones and telemedicine platforms may allow improved data
capture.1
The advisor should be aware of the information sources that their
clients use. Some travelers obtain information from travel agencies,
which naturally emphasize the positive aspects of travel. Some travelers
receive information from friends and relatives; others visit pharmacies
for advice.27 The media publish abundantly about travel destinations
as well. A wide range of inadequate or conflicting information from
different perspectives often creates confusion rather than clarity.
Contradictory information unsettles travelers and raises their skepticism
about preventive measures, leading to poor compliance with recom-
mendations.27 Clear, accurate, and up-to-date information must therefore
be conveyed (Box 4.1).
 CHAPTER 4 Pretravel Consultation 29

Eating/fluid intake
Arthropod bites
Diarrhea

Mosquito bite protection Hepatitis A, typhoid, polio,

Malaria/dengue cholera,
antibiotics

Yellow fever/JE/TBE A
Who?
Where to?
Hepatitis
How long?
How?
Rabies,
B
diphtheria, tetanus
Climate, sun, water, altitude, Hepatitis B, HPV,
diving, underlying disorders, HIV/condoms, MMR,
travel pharmacy, thrombosis, varicella, flu, pneumoc.,
jet lag, insurance, contacts meningitis, pertussis
Accidents, animal Person contact,
bites, special risks sex

FIG. 4.1 Illustration of major components of the travel clinic consultation grouped by transmis-
sion routes. HPV, Human papilloma virus; JE, Japanese encephalitis; MMR, measles–mumps–rubella; TBE,
tickborne encephalitis. (Adapted from Furrer HJ, University Hospital, University of Bern, Berne, Switzerland.)

BOX 4.1 Organization and Order of
Components in a Travel Clinic Consult
1. Ask questions to assess risk associated with the trip.
2. Review and recommend vaccinations (routine, required, itinerary based).
3. Discuss vectorborne disease risk and prevention such as malaria chemo-
prophylaxis and insect precaution.
4. Discuss food and water precautions and prevention/treatment of travelers’
diarrhea.
5. Discuss sexually transmitted infections and bloodborne issues.
6. Assess and recommend environmental challenges and preventions (altitude,
pollution, etc.).
7. Determine other risks and their prevention/management based on itinerary
and activities (e.g., schistosomiasis, leptospirosis, diving).
The client is often overwhelmed with abundant information and is
likely to forget most of it. Thus there are five suggestions that may help
with all consultations:
1. Advise travelers in a personal, individualized conversation that
responds to their needs and allows for questions. The assessment
should explore details regarding travel itinerary and style, previous
travel experience and vaccinations, as well as existing health problems.
Offering concise information is best, but elaborate on areas of concern
to the traveler. Administering vaccinations is straightforward but
convincing the client of the need to adhere to antimalarial medica-
tion is more challenging. The concept of malaria suppression or
adequate mosquito bite protection usually takes time to convey.
Some travelers misunderstand chemoprophylaxis to be an immuniza-
tion, which may lead to discontinuation of the drugs after leaving
the endemic area.27 Shorter regimens after return appear to favor
compliance.
2. Remind travelers about the prevention of frequently occurring risks
such as sunburn, accidents and injuries, and mental health distur-
bances during travel.
3. Provide written material as additional information. Such information
must be consistent with the oral advice given and should not replace
the consultation.
4. Provide links to reliable Internet sources (WHO [www.who.int],
US CDC [www.cdc.gov/travel], other national recommendations)
to guarantee accurate guidance.
5. Provide and/or recommend carrying important documents such as
certificate of vaccination (or exemption letter), critical medical
records, list of allergies, blood type, travel health insurance informa-
tion, and emergency contacts.
One possible structure for the discussion of vaccines and other risks
is shown in Fig. 4.1.
Discussion of the combination vaccine against hepatitis A and B
allows the provider to steer the discussion elegantly from uncontrover-
sial hepatitis A to the sensitive, bloodborne, and sexually transmitted
hepatitis B.
Controversial information must be discussed to avoid confusion
and eventual noncompliance. Addressing discrepancies between different
sources of information illustrates controversies that travelers may
encounter. Many clients will have consulted other information sources
or received advice from nonprofessionals, which may vary due to the
limited amount of evidence on certain issues. One way to achieve an
impact on health behavior is to combine individualized advice based
on scientific evidence (body of knowledge) with enriched personal
experience.
ACKNOWLEDGMENTS
The authors thank Drs. Andreas Neumayr and Olivia Veit and
Professors Robert Steffen and Hansjakob Furrer for their valuable
suggestions.
30 SECTION 1 Practice of Travel Medicine
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KEY POINTS
• Potable water is one of the most important factors to ensure the
health of travelers and local populations in developing areas.
• The risk of waterborne illness depends on the number of
organisms consumed, volume of water, concentration of
organisms, host factors, and the efficacy of the treatment
system.
INTRODUCTION
Safe and efficient treatment of drinking water is among the major public
health advances of the 20th century. Without it, waterborne disease
would spread rapidly in most public water systems served by surface
water.1,2 Great progress in the global effort to provide safe drinking
water and sanitation has been made in the last 25 years; as of 2015,
90% of people worldwide have access to an improved drinking water
source. However, about 660 million people still lack access to potable
water, mainly in rural areas. Sixty-eight percent of the global population
uses an improved sanitation facility, yet 2.4 billion do not have access
to adequate sanitation. This results in billions of cases of diarrhea every
year and a reservoir of enteric pathogens for travelers to these areas.3,4
In certain tropical countries the influence of high-density population,
rampant pollution, and absence of sanitation systems means that available
raw water is virtually wastewater. Contamination of tap water commonly
occurs because of antiquated and inadequately monitored disposal,
water treatment, and distribution systems.5 Testing of improved water
sources in 13 developing countries showed that only 5 of 22 of these
urban water sources had any detectable free chlorine residual.6
Travelers have no reliable resources to evaluate local water system
quality. Less information is available for remote surface water sources.
As a result, travelers should take appropriate steps to ensure that the
water they drink has minimal risk of causing enteric infection. Look,
smell, and taste are not reliable indicators to estimate water safety. Even
in developed countries with low rates of diarrhea illness, regular
waterborne disease outbreaks indicate that the microbiologic quality
of the water, especially surface water, is not assured.7 In both developed
and developing countries, after natural disasters such as hurricanes,
tsunamis, and earthquakes, one of the most immediate public health
problems is a lack of potable water.
ETIOLOGY AND RISK OF WATERBORNE INFECTION
Infectious agents with the potential for waterborne transmission
include bacteria, viruses, protozoa, and nonprotozoan parasites.
5
Water Disinfection for
International Travelers
Howard Backer
• Methods of water treatment include the use of heat, ultraviolet
light, clarification, filtration, and chemical disinfection. The
choices for the traveler or international worker are increasing as
new technology is applied to field applications.
• Different microorganisms have varying susceptibilities to these
methods.
The list of microbial agents is similar to the list of microorganisms
that can cause travelers’ diarrhea (see chapter 18), since most can be
waterborne as well as foodborne (Table 5.1). Although the primary
reason for disinfecting drinking water is to destroy microorganisms
from animal and human biologic wastes, water may also be contami-
nated with industrial chemical pollutants or biologic organisms from
animals or the environment. Survival of enteric bacterial and viral
pathogens in temperate water is generally only several days; however,
E. coli O157:H7 can survive 12 weeks at 25°C.8 Most enteric organisms,
including Shigella spp., Salmonella enteria serotype typhi, hepatitis
A, and Cryptosporidium spp., can retain viability for long periods
in cold water and can even survive for weeks when frozen in water.
E. coli and Vibrio cholerae may be capable of surviving indefinitely in
tropical water.
The risk of waterborne illness depends on the number of organ-
isms consumed, which is in turn determined by the volume of water,
concentration of organisms, and treatment system efficiency.9,10
Additional factors include virulence of the organism and defenses
of the host. Microorganisms with a small infectious dose (e.g.,
Giardia, Cryptosporidia, Shigella spp., hepatitis A, enteric viruses,
enterohemorrhagic E. coli) may cause illness even from inadvertent
drinking during water-based recreational activities.11 Since total
immunity does not develop for most enteric pathogens, reinfection
may occur. Most diarrhea among travelers is probably foodborne;
however, the capacity for waterborne transmission should not be
underestimated.
The combined roles of safe water, hygiene, and adequate sanitation
in reducing diarrhea and other diseases are clear and well documented.
The World Health Organization (WHO) estimates that 94% of diarrheal
cases globally are preventable through modifications to the environment,
including access to safe water.1 Recent studies of simple water interven-
tions in households of developing countries clearly document improved
microbiologic quality of water, a 30%–60% reduced incidence of diar-
rheal illness, enhanced childhood survival, and reduction of parasitic
diseases, many of which are independent of other measures to improve
sanitation.12–15
31
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The English did not profit by the lady’s eloquence, for our forefathers
never had a more gallant or more difficult adversary to deal with than
Bertrand. Living, his name was a terror to them; and dying, he had
the sympathy of those who had been his foes. Charles V. made him
Constable of France, and appointed him a grave at the foot of his
own royal tomb. De Guesclin would never have been half the man
he was but for the good sense of his wife Tiphania.
There are many instances in romance which would seem to imply,
that so strained was the sentiment which bound knights to respect
ladies, it compelled them not to depart therefrom even in extreme
cases, involving lightness of conduct and infidelity. The great
northern chiefs, who were a sort of very rough knights in their way,
were, however, completely under the distaff. Their wives could
divorce themselves at will. Thus, in Erysbiggia Saga we read of
Borck, an Icelandic chief, who, bringing home a guest whom his wife
not only refused to welcome, but attempted to stab, administered
such correction to his spouse in return, that the lady called in
witnesses and divorced herself on the spot. Thereupon the
household goods were divided among them, and the affair was
rapidly and cheaply managed without the intervention of an
Ecclesiastical Court. More modern chivalry would not have tolerated
the idea of correcting even a faithless, much less a merely angry
spouse. Indeed, the amatory principle was quite as strong as the
religious one; and in illustration thereof, it has been remarked that
the knight must have been more than ordinarily devout who had God
on his right hand (the place of honor), and his lady on his left.
To ride at the ring was then the pleasantest pastime for knights; and
ladies looked on and applauded the success, or laughed at the
failures. The riding, without attempting to carry off the ring, is still
common enough at our fairs, for children; but in France and
Germany, it is seriously practised in both its simple and double
forms, by persons of all ages, who glide round to the grinding of an
organ, and look as grave as if they were on desperate business.
It is an undoubted matter of fact, that although a knight was bound to
be tender in his gallantry, there were some to be found whose
wooing was of the very roughest; and there were others who, if not
rough, were rascally.
The old Rue des Lombards, in Paris, was at one time occupied
exclusively by the “professed pourpoint-makers,” as a modern tailor
might say. They carried on a flourishing trade, especially in times
when men, like Bassompierre, thought nothing of paying, or
promising to pay, fourteen thousand crowns for a pourpoint. When I
say the street was thus occupied exclusively, I must notice an
exception. There were a few other residents in it, the Jew money-
lenders or usurers; and when I hear the old French proverb cited
“patient as a Lombard,” I do not know whether it originally applied to
the tailors or the money-lenders, both of whom were extensively
cheated by their knightly customers. Here is an illustration of it,
showing that all Jessicas have not been as lucky as Shylock’s
daughter, and that some Jews have been more cruelly treated than
Shylock’s daughter’s father—whom I have always considered as one
of the most ill-used of men.
In the Rue des Lombards there dwelt a wealthy Jew, who put his
money out at interest, and kept his daughter under lock and key at
home. But the paternal Jew did not close his shutters, and the
Lombard street Jessica, sitting all day at the window, attracted the
homage of many passers-by. These were chiefly knights who came
that way to be measured for pourpoints; and no knight was more
attracted by the black eyes of the young lady in question, than the
Chevalier Giles de Pontoise. That name indeed is one of a
celebrated hero of a burlesque tragedy, but the original knight was
“my Beverley.”
Giles wore the showiest pourpoint in the world; for which he had
obtained long credit. It struck him that he would call upon the Jew to
borrow a few hundred pistoles, and take the opportunity to also
borrow the daughter. He felt sure of succeeding in both exploits; for,
as he remarked, if he could not pay the money he was about to
borrow, he could borrow it of his more prudent relatives, and so
acquit himself of his debt. With regard to the lady, he had serenaded
her, night after night, till she looked as ready to leap down to him as
the Juliets who played to Barry’s Romeo;—and he had sung “Ecco
ridente il sole,” or what was then equivalent to it, accompanied by his
guitar, and looking as ridiculous the while, without being half so
silvery-toned as Rubini in Almaviva, warbling his delicious nonsense
to Rosina. Our Jew, like old Bartolo, was destined to pay the
musician.
Giles succeeded in extracting the money required from the usurer,
and he had like success in inducing the daughter to trust to his
promises. He took the latter to Pontoise, deceived her by a mock-
marriage, and spent all that he had borrowed from the father, in
celebrating his pretended nuptials with the daughter. There never
was a more recreant knight than Giles de Pontoise.
However, bills will become due, if noble or simple put their names to
them, and the Jew claimed at once both his debt and his daughter.
He failed in obtaining his money, but the lady he carried off by
violence, she herself exhibiting considerable reluctance to leave the
Château de Pontoise for the paternal dungeon in the Rue des
Lombards.
This step brought Giles to a course of reflection. It was not of that
quality which his confessor would have recommended, but rather of
a satanic aspect. “In the usurer’s house,” thought Giles, “live the
tailor to whom I am indebted for my pourpoint, the Jew who holds my
promise to pay, and the pretty daughter of whom I have been so
unjustly deprived. I will set fire to the house. If I burn tailor, money-
lender, and the proofs of my liabilities, I shall have done a good
night’s work, if I therewith can carry off little Jessica.”
Thereupon, Giles went down to the Rue des Lombards, and with
such aid as was then easily purchasable, he soon wrapped the
Jew’s dwelling in flames. Shylock looked to his papers and money-
bags. The knight groped through the smoke and carried off the
daughter. The Jew still held the promissory note of the Knight of
Pontoise, whose incendiary act, however, had destroyed half of one
side of the Rue des Lombards. Therewith had perished reams of
bonds which made slaves of chevaliers to Jew money-lenders. “Sic
vos non vobis,” thought Giles, “but at all events, if he has my bill, I
have possession of Jessica.”
The Jew held as much to his daughter as to his ducats. He
persecuted the pretended husband with a pertinacity which
eventually overcame Giles de Pontoise. A compromise was effected.
The knight owed the usurer three thousand golden crowns, and had
stolen from him his only daughter. Giles agreed to surrender his
“lady,” on condition that the money-lender should sign an acquittance
of the debt. This done, the Jew and daughter walked homeward,
neither of them well satisfied with the result of their dealings with a
knight.
The burnt-out Lombarder turned round at the threshold of the
knight’s door, with a withering sneer, like Edmund Kean’s in Shylock
when he was told to make haste and go home, and begin to be a
Christian. “It is little but sorrow I get by you, at all events,” said the
Jew to the Chevalier.
“Do you make so light of your grandson?” asked Giles. And with this
Parthian dart he shut his door in the face of the trio who were his
victims.
This knight was a victimizer; but below we have an illustration of
knights victimized through too daring affection.
The great Karloman may be said to have been one of those crowned
knights who really had very little of the spirit of chivalry in him, with
respect to ladies. He married, successfully, two wives, but to neither
did he allow the title of Empress. It is, however, not with his two
wives, but his two daughters and their chevaliers par amours, with
whom we have now to do.
In the Rue de la Harpe, in Paris, may be seen the remains, rather
than the ruins, of the old building erected by the Emperor Julian, and
which was long known by the name of the “old palace.” It served as
a palace about a thousand years and half a century ago, when one
night there drew up before it a couple of knights, admirably mounted,
and rather roughly escorted by a mob, who held up their lanterns to
examine the riders, and handled their pikes as if they were more
ready to massacre the knights than to marshal them.
All the civility they received on this February night was of a highly
equivocal nature. They were admitted, indeed, into the first and
largest court of the palace, but the old seneschal locked and barred
the gate behind them. An officer too approached to bid them
welcome, but he had hardly acquitted himself of his civil mission
when he peremptorily demanded of them the surrender of their
swords.
“We are the King’s own messengers,” said one of the knights, rather
puzzled at the reception vouchsafed to them;—“and we have,
moreover, a despatch to deliver, written in our gracious master’s own
hand,” remarked the second knight.
“Vive Louis le Debonnaire!” exclaimed the seneschal; “how fares it
with our sovereign?”
“As well as can be,” was the reply, “with a monarch who has been
engaged six whole weeks at Aix, in burying his father and
predecessor, Charlemagne. Here is his missive.” This missive was
from Louis the Frolicsome, or Louis the Good-Natured, or Louis of
Fair Aspect. He was morose, wittily disposed, and ill-featured;—but
then the poet-laureate had given him his fine name; and the king
wore it as if it had been fairly won. He had clipped, shaved, and
frocked, all his natural brothers, and then shut them up in
monasteries. He had no more respect for treaties than he had for
Mohammed, and by personal example he taught perjury and
rebellion to those whom he cruelly punished when they imitated their
exalted instructor. The seneschal perused the letter addressed to
him by his royal correspondent, and immediately requested the two
knights to enter the palace itself.
They were ushered into a lofty-arched apartment on the ground floor,
which ordinarily served as an ante-room for the guards on duty; it
was for the moment, however, empty. They who have visited the old
Palais de Thermes, as it is called, have, doubtlessly, remarked and
admired this solid relic of the past.
After entering, the seneschal once more lifted the despatch to the
flambeau, read it through, looked at the seal, then at the knights,
coughed uneasily, and began to wear an air of dislike for some duty
imposed upon him. He repeated, as if he were learning by rote, the
names Raoul de Lys and Robert de Quercy. “Those are our names,”
observed the first; “we have ridden hither by the king’s orders to
announce his coming; and having done so, let us have fire and food,
lest we be famished and frozen before he arrives.”
“Hem!” muttered the seneschal, “I am extremely sorry; but, according
to this letter, you are my prisoners, and till to-morrow you must
remain in this apartment;” and, seeing them about to remonstrate, he
added, “You will be quite at liberty here, except, of course, that you
can’t get out; you will have separate quarters to-morrow.”
It was in vain that they inquired the reason for their detention, the
nature of the charge alleged against them, or what they had further
to expect. The seneschal dryly referred them to the monarch. He
himself knew nothing more than his orders, and by them he was
instructed to keep the two friends in close confinement till the
sovereign’s arrival. “On second thoughts,” said the seneschal, “I
must separate you at once. There is the bell in the tower of St.
Jacques ringing midnight, and to-morrow will be upon us, before its
iron tongue has done wagging. I really must trouble one of you
gentlemen to follow me.” The voice was not so civil as the words,
and after much parleying and reluctance, the two friends parted.
Robert bade Raoul be of good cheer; and Raoul, who was left
behind, whispered that it would be hard, indeed, if harm was to come
to them under such a roof.
The roof, however, of this royal palace, looked very much like the
covering of a place in which very much harm might be very quietly
effected. But there were dwelling there two beings who might have
been taken for spirits of good, so winning, so natural, and so
loveable were the two spirits in question. They were no other than
the two daughters of Charlemagne, Gisla and Rotrude. The
romancers, who talk such an infinite deal of nonsense, say of them
that their sweet-scented beauty was protected by the prickles of
principle. The most rapid of analysers may see at once that this was
no great compliment to the ladies. It was meant, however, to be the
most refined flattery; and the will was accepted for the deed.
Now, the two knights loved the two ladies, and if they had not,
neither Father Daniel nor Sainte Foix could have alluded to their
amorous history; nor Father Pasquale, of the Convent of the
Arminians in Venice, have touched it up with some of the hues of
romance, nor Roger de Beauvoir have woven the two together, nor
unworthy ægomet have applied it to the illustration of daring lovers.
These two girls were marvellously high-spirited. They had been
wooed by emperors; but feeling no inclination to answer favorably to
the wooing, Charlemagne generously refused to put force upon their
affections, and bade them love only where their hearts directed
them. This “license” gave courage to numberless nobles of various
degrees, but Rotrude and Gisla said nay to all their regular
advances. The Princesses were, in fact, something like Miss
Languish, thought love worth nothing without a little excitement, and
would have considered elopement as the proper preceder of the
nuptial ceremony. Their mother, Hildegarda, was an unexceptional
woman, but, like good Queen Charlotte, who let her daughters read
Polly Honeycombe as well as Hannah More, she was a little
confused in the way she taught morals, and the young Princesses
fell in love, at the first opportunity, with gallant gentlemen of—as
compared with princesses—rather low degree. In this respect, there
is a parallel between the house of Karloman and some other houses
of more modern times.
Louis le Debonnaire had, as disagreeable brothers will have, an
impertinent curiosity respecting his sisters’ affairs. He was, here, the
head of his family, and deemed himself as divinely empowered to
dispose of the hearts of these ladies, as of the families and fortunes
of his people. He had learned the love-passages that had been
going on, and he had hinted that when he reached the old palace in
Paris, he would make it as calmly cold as a cloister, and that there
were disturbed hearts there, which should be speedily restored to a
lasting tranquillity. The young ladies did not trouble themselves to
read the riddle of a brother who was for ever affecting much mystery.
But they prepared to welcome his arrival, and seemed more than
ordinarily delighted when they knew that intelligence of his
approaching coming had been brought by the two knights then in the
castle.
Meanwhile, Raoul de Lys sat shivering on a stone bench in the great
guard-room. He subsequently addressed himself to a scanty portion
of skinny wild boar, very ill-cooked; drank, with intense disgust, part
of a flask of hydromel of the very worst quality; and then having
gazed on the miniature of Rotrude, which he took from beneath the
buff jerkin under his corslet, he apostrophized it till he grew sleepy,
upon which he blew out his lamp, and threw himself on an execrably
hard couch. He was surprised to find that he was not in the dark.
There was very good reason for the contrary.
As he blew out his lamp, a panel in the stone wall glided noiselessly
open, and Robert de Quercy appeared upon the threshold—one
hand holding a lamp, the other leading a lady. The lady was veiled;
and she and the knight hurriedly approached Raoul, who as hurriedly
rushed forward to meet them. He had laid his armor by; and they
who recollect Mr. Young in Hotspur, and how he looked in tight buff
suit, before he put his armor on, may have some idea of the rather
ridiculous guise in which Raoul appeared to the lady. But she was
used to such sights, and had not time to remark it even had she not
been so accustomed.
Raoul observing that Robert was accompanied only by Gisla, made
anxious inquiry for Rotrude. Gisla in a few words told him that her
sister would speedily be with them, that there was certain danger,
even death, threatening the two cavaliers, and probable peril
menacing—as Gisla remarked, with a blush—those who loved them.
The King, she added, had spoken angrily of coming to purify the
palace, as she had heard from Count Volrade, who appears to have
been a Polonius, as regards his office, with all the gossip, but none
of the good sense, of the old chamberlain in Denmark.
“Death to us!” exclaimed Robert. “Accursed be the prince who
transgresses the Gospel admonition, not to forget his own or his
father’s friends.” “We were the favored servants of Charlemagne,”
said Raoul. “We were of his closest intimacy,” exclaimed Robert.
“Never,” interrupted Raoul, “did he ascend his turret to watch the
stars, without summoning us, his nocturnal pages, as he called us, to
his side.” “He dare not commit such a crime; for the body of
Charlemagne is scarcely sealed down in its tomb; and Louis has not
a month’s hold of the sceptre.”
“He holds it firmly enough, however, to punish villany,” exclaimed
Louis himself, as he appeared in the doorway leading to a flight of
stone stairs by which Gisla had indicated the speedy appearance of
Rotrude.
And here I would beseech my readers to believe that if the word
“tableau!” ought to be written at this situation, and if it appears to
them to be too melo-dramatic to be natural, I am not in fault. I refer
them to all the histories and romances in which this episode in
knightly story is told, and in all they will find that Louis makes his
appearance exactly as I have described, and precisely like Signor
Tamburini in the great scene of Lucrezia Borgia.
Louis having given expression to his startling bit of recitative,
dragged forward Rotrude, whom he had held behind him, by the
wrist. The background was occupied by four guards, wearing hoods;
and I can not think of them without being reminded of those same
four old guards, with M. Desmousseaux at their head, who always
represented the Greek or Roman armies upon the stage of the
Théâtre Français, when Talma was the Nero or the Sylla, the
Orestes or the Capitolinus of the night.
With some allusion to Rotrude as a sacred dove, and to himself as a
bird-catcher, Louis handed his sister to a stone bench, and then
grew good-natured in his remarks. This sudden benevolence gave a
chill to the entire company. They turned as pale as any Russian
nobleman to whom Nicholas was extraordinarily civil.
“We know the winding passages of the palace of Thermes,” said
Louis, laughingly, “as well as our sisters; and I have not gone
through them to-night for the purpose of terrifying the sister whom I
encountered there, or the other sister whom I see here. I am a kind-
hearted brother, and am marvellously well-disposed. I need only
appeal to these four gentlemen of my guard, who will presently take
off their hoods, and serve as witnesses this night in a little ceremony
having reference to my dear Rotrude.”
“A ceremony! this night!” exclaimed the two princesses.
“Ay, by the nails of the cross! Two ceremonies. You shall both be
married forthwith. I will inaugurate my reign by a double wedding,
here in the old palace of Thermes. You, Gisla, shall espouse Robert,
Count de Quercy, and you, Rotrude, shall wed with Raoul, Baron de
Lys. You might have aimed higher, but they are gallant gentlemen,
friends of my deceased sire; and, by my sooth, the nuptials shall not
lack state and ceremony! Here are our wedding-gifts to the
bridegrooms.”
He pointed to two showy suits of armor, the pieces of which were
carried by the four guards. The knights were in a dream of delight.
They vowed eternal gratitude to the most noble of emperors and
unparalleled of brothers.
“We have no great faith in human gratitude,” said Louis, “and shall
not expect from you more than is due. And you, my sisters,” added
he, “retire for awhile; put on what you will; but do not tarry here at the
toilette of men-at-arms, like peasant-girls looking at the equipping of
two pikemen.”
The two princesses withdrew; and there would have been a smile
upon their lips, only that they suspected their brother. Hoping the
best, however, they kissed the tips of their rosy fingers to the knights,
and tripped away, like two pets of the ballet. They were true
daughters of their sire, who reckoned love-passages as even
superior to stricken fields. He was not an exemplary father, nor a
faithful husband. His entourage was not of the most respectable; and
in some of his journeys he was attended by the young wife of one of
his own cavaliers, clad in cavalier costume. It was a villanously
reprobate action, not the less so that Hermengarde was living. The
mention of it will disgust every monarch in Europe who reads my
volume; and I am sure that it will produce no such strong sensation
of reproof anywhere as in the bosom of an admirable personage
“over the water.”
The two princesses, then, had not so much trouble from the prickles
of principle as the romances told of them. But, considering the
example set them by their imperial father, they were really very
tolerable princesses, under the circumstances.
“Don your suits, gentlemen!” exclaimed the king.
The four guards advanced with the separate pieces of armor, at
which the two knights gazed curiously for a moment or two, as two
foxes might at a trap in which lay a much-desired felicity. They were
greatly delighted, yet half afraid. The monarch grew impatient, and
the knights addressed themselves at once to their adornment. They
put aside their own armor, and with the assistance of the four mute
gentlemen-at-arms they fitted on the brassards or arm-pieces, which
became them as though the first Milainer who ever dressed knight
had taken their measure. With some little trouble they were
accoutred, less as became bridegrooms than barons going to battle;
and this done, they took their seats, at a sign from the king, who
bade the four gentlemen come to an end with what remained of the
toilette.
The knights submitted, not without some misgiving, to the services of
the four mysterious valets! and, in a short time, the preparations
were complete, even to the helmet with the closed visor. This done,
the knights took their places, or were led rather to two high-backed
oaken chairs. As soon as they were seated there, the four too-
officious attendants applied their hands to the closed head-pieces;
and in a very brief space the heads of the cavaliers sunk gently upon
their breasts, as if they were in deep slumber or as deep meditation.
Two o’clock rang out from the belfry of St. Jacques, as the two brides
entered. The king pointed with a smile to the bridegrooms, and left
the apartment with his attendants. The ladies thought that the lovers
exhibited little ardor or anxiety to meet them; for they remained
motionless on their oaken chairs. The daughters of Charlemagne
advanced, half-timidly, half-playfully; and, at length, finding the
knights not disposed to address them, gently called to each by his
name. Raoul and Robert continued motionless and mute. They were
in fact dead. They had been strangled or suffocated in a peculiar sort
of armor, which had been sent to Charlemagne from Ravenna, in
return for a jewelled vase presented by that emperor to the ancient
city. “In 1560,” says Monsieur Roger de Beauvoir, himself quoting an
Italian manuscript, there were several researches made in this part
of the palace of Thermes, one result of which was the discovery of a
‘casque à soufflet,’ all the openings in which could be closed in an
instant by a simple pressure of the finger on a spring. At the same
instant the lower part of the neck-piece tightened round the throat,
and the patient was disposed of. “In this helmet,” adds the author,
“was found the head of a man, well preserved, with beard and teeth
admirable for their beauty.” I think, however, that in this matter M. de
Beauvoir proves a little too much.
Father Daniel, in his history notices the vengeance of Louis le
Debonnaire against two young nobles who were, reputedly, the
lovers of Gisla and Rotrude. The details of the act of vengeance
have been derived from an Italian source; and it is said that an Italian
monk, named Pagnola, had some prominent part in this dreary
drama, impelled thereto by a blow dealt to him at the hands of Raoul,
by way of punishment for some contemptuous phrases which the
monk had presumed to apply to the great Charlemagne.
Love and sword-blades seem to have been as closely connected as
“Trousseaux et Layettes,” which are always named together in the
shop-fronts of a Parisian “Lingere.” There was once an ample field
for the accommodation of both the sentiments of love and bravery in
the old Chaussée d’Antin, when it was merely a chaussée or
highway, and not the magnificent street it now is. It was, down even
to comparatively modern times, the resort of lovers of every degree,
from dukes and duchesses to common dragoons and dairymaids.
They were not always, however, under this strict classification.
But whatever classification or want of it there may have been, there
was a part of the road which was constantly the scene of bloody
encounters. This was at the narrow bridge of Arcans. Here if two
cavaliers met, each with a lady at his side, it was a matter of honor
not to give way. On the contrary, the latter was to be forced at the
point of the sword. While the champions were contending, the ladies
would scarcely affect to faint; they would stand aside, remain
unconcerned on their jennets or mules, till the two simpletons had
pinked one another; or lounge in their cumbrous coaches till the
lovers limped back to them.
It was on this bridge, of which no vestige now remains, not even in a
museum, that the Count de Fiesque one evening escorting Madame
de Lionne, encountered M. de Tallard, who was chaperoning Louison
d’Arquien. Each couple was in a carriage, and neither would make
way for the other to pass. Thereupon the two cavaliers leaped from
their coaches, drew their swords, planted their feet firmly on the
ground, and began slashing at each other like two madmen, to the
great delight of a large crowd who enjoyed nothing so much as the
sight of two noble gentlemen cutting one another’s throats.
The ladies, meanwhile, flourished their handkerchiefs from their
respective carriage-windows, for the encouragement of their
champions. Now and then each laughed aloud when her particular
friend had made a more than ordinary successful thrust; and each
was generous enough to applaud any especial dexterity, even when
her own lover thereby bloodily suffered. The two foolish fellows only
poked at each other with the more intensity. And when they had
sufficiently slit their pourpoints and slashed their sleeves, the ladies,
weary of waiting any longer for a more exciting denouement, rushed
between the combatants, like the Sabine ladies between the
contending hosts; each gentleman gallantly kissed the lady who did
not belong to him; and the whole four gayly supped together, as
though they had been the best friends in the world.
This incident fairly brings us to the questions of duelling and death,
as illustrated by chivalry.
 DUELLING, DEATH AND BURIAL.
“Le duel, ma mie, ne vaut pas un duo, de Lully.”
Crispin Mourant.

As an effect of chivalry, duelling deserves some passing notice. Its

modern practice was but an imitation of chivalric encounters,
wherein the issue of battle was left to the judgment of God.
Bassompierre dates the origin of duelling (in France) from the period
of Henri II. Previous to that king’s reign, the quarrels of gentlemen
were determined by the decree of the constable and marshals of
France. These only allowed knightly encounters in the lists, when
they could not of themselves decide upon the relative justice and
merits of the dispute.
“I esteem him no gentleman,” said Henri one day, “who has the lie
given him, and who does not chastise the giver.” It was a remark
lightly dropped, but it did not fall unheeded. The king in fact
encouraged those who resorted, of their own will, to a bloody
arbitrament of their dissensions; and duelling became so
“fashionable,” that even the penalty of death levelled against those
who practised it, was hardly effectual enough to check duellists. At
the close of the reign of Henri IV. and the commencement of that of
Louis XIII. the practice was in least activity; but after the latter period,
as the law was not rigorously applied, the foolish usage was again
revived; and sanguinary simpletons washed out their folly in blood.
But duelling has a more remote origin than that ascribed to it by
Bassompierre. Sabine, in his “Dictionary of Duelling,” a recently-
published American work, dates its rise from the challenge of the
Philistine accepted by David! However this may be, it is a strange
anomaly that an advocate for the savage and sinful habit of duelling
has appeared in that France which claims to be the leader of
civilization. Jules Janin has, among his numberless feuilletons
published three reasons authorizing men to appeal to single combat.
The above M. Janin divides the world into three parts—a world of
cravens; a world in which opinion is everything; and a world of
hypocrites and calumniators. He considers the man who has not the
heart to risk his life in a duel, as one lost in the world of cravens,
because the legion of cowards by whom he is surrounded will
assume courage at his expense.
Further, according to our gay neighbor’s reasoning, the man is lost in
this world, in which opinion is everything, who will not seek to obtain
a good opinion at the sword’s point.
Again, says M. Janin, the man is lost in this world of hypocrites and
calumniators who will not demand reparation, sword in hand, for the
calumnies and malicious reports to which he has been exposed. It
would be insulting to the common sense of my readers to affect to
point out to them the rottenness of reasons like these. They could
only convince such men as Buckingham and Alfieri, and others in
circumstances like theirs; Buckingham after killing Lord Shrewsbury
at Barnes, and pressing the head of Lady Shrewsbury on his bloody
shirt; and Alfieri, who, after a vile seduction, and very nearly a
terrible murder in defence of it, went home and slept more peacefully
than he had ever slept before: “dopo tanto e si stranie peripizie d’un
sol giorno, non ho dormito mai d’un sonno piu tenace e piu dolce.”
Alfieri would have agreed with M. Janin, that in duelling lay the
safeguard of all that remains to us of civilization. But how comes it
then that civilization is thus a wreck, since duelling has been so long
exercising a protective influence over it?
However few, though dazzling, were the virtues possessed by the
chivalrous heroes of ancient history, it must be conceded to them,
that they possessed that of valor, or a disregard of life, in an eminent
degree. The instances of cowardice are so rare that they prove the
general rule of courage; yet these men, with no guides but a
spurious divinity and a false philosophy, never dreamed of having
recourse to the duel, as a means of avenging a private wrong.
Marius, indeed, was once challenged, but it was by a semi-
barbarous Teutonic chief, whom the haughty Roman recommended,
if he were weary of his life to go and hang himself. Themistocles,
too, whose wisdom and courage the most successful of our modern
gladiators may admire and envy, when Eurybiades threatened to
give him a blow, exclaimed, “Strike, but hear me!” Themistocles, it
must be remembered, was a man of undaunted courage, while his
jealous provoker was notorious for little else but his extreme
cowardice.
But, in truth, there have been brave men in all countries, who have
discouraged this barbarous practice. A Turkish pacha reminded a
man who had challenged a fellow Spahi, that they had no right to
slay one another while there were foes to subdue. The Dauphin of
Viennois told the Count of Savoy, who had challenged him, that he
would send the count one of his fiercest bulls, and that if the count
were so minded, his lordship of Savoy might test his prowess against
an antagonist difficult to overcome. The great Frederick would not
tolerate the practice of duelling in his army; and he thoroughly
despised the arguments used for its justification. A greater man than
Frederick, Turenne, would never allow himself to be what was called
“concerned in an affair of honor.” Once, when the hero of Sintzheim
and the Rhine had half drawn his sword to punish a disgusting insult,
to which he had been subjected by a rash young officer, he thrust it
back into the sheath, with the words: “Young man, could I wipe your
blood from my conscience with as much ease as I can this filthy
proof of your folly from my face, I would take your life upon the spot.”
Even the chivalrous knights who thought duelling a worthy
occupation for men of valor, reduced opportunities for its practice to
a very small extent. Uniting with the church, they instituted the
Savior’s Truce, by which duels were prohibited from Wednesday to
the following Monday, because, it was said, those days had been
consecrated by our Savior’s Passion. This, in fact, left only Tuesday
as a clear day for settling quarrels by force of arms.
There probably never existed a mortal who was opposed by more
powerful or more malignant adversaries than St. Augustin was. His
great enemies the Donatists never, it is true, challenged him to any
more dangerous affray than a war of literary controversy. But it was
in answer to one of their missiles hurled against him, in the form of
an assertion, that the majority of authors was on their side, he aptly
told them that it was the sign of a cause destitute of truth when only
the erring authority of many men could be relied on.
The Norman knights or chiefs introduced the single combat among
us. It is said they were principally men who had disgraced
themselves in the face of the enemy, and who sought to wipe out the
disgrace in the blood of single individuals. It is worthy of remark too,
that when king and sovereign princes had forbidden duelling, under
the heaviest penalties, the popes absolved the monarchs from their
vows when the observance of them would have put in peril the lives
of offending nobles who had turned to Rome in their perplexity, and
who had gained there a reputation for piety, as Hector did, who was
esteemed so highly religious, for no other reason than that he had
covered with rich gifts the altar of the father of Olympus.
Supported by the appearance that impunity was to be purchased at
Rome, and encouraged by the example of fighting-cardinals
themselves, duelling and assassination stalked hand in hand abroad.
In France alone, in the brief space of eighteen years, four thousand
gentlemen were killed in rencontres, upon quarrels of the most trivial
nature. In the same space of time, not less than fourteen thousand
pardons for duelling were granted. In one province alone, of France,
in Limousin, one hundred and twenty gentlemen were slain in six
months—a greater number than had honorably fallen in the same
period, which was one of war, in defence of the sovereign, their
country, and their homes. The term rencontre was used in France to
elude the law. If gentlemen “met” by accident and fought, lawyers
pleaded that this was not a duel, which required preliminaries
between the two parties. How frequent the rencontres were, in spite
of the penalty of death, is thus illustrated by Victor Hugo, in his
Marion Delorme:—

“Toujours nombre de duels, le trois c’était d’Angennes

Contre d’Arquien, pour avoir porté du point de Gènes.
Lavarde avec Pons s’est rencontré le dix,
Pour avoir pris à Pons la femme de Sourdis.
Sourdis avec Dailly pour une du théâtre
De Mondorf. Le neuf, Nogent avec Lachâtre,
Pour avoir mal écrit trois vers de Colletet.
 Gorde avec Margaillan, pour l’heure qu’il était.
D’Himière avec Gondi, pour le pas à l’église.
Et puis tous les Brissac avec tous les Soubise,
A propos d’un pari d’un cheval contre un chien.
Enfin, Caussade avec Latournelle, pour rien.
Pour le plaisir, Caussade a tué Latournelle.

Jeremy Taylor denounced this practice with great earnestness, and

with due balancing of the claims of honor and of Christianity. “Yea;
but flesh and blood can not endure a blow or a disgrace. Grant that
too; but take this into the account: flesh and blood shall not inherit
the kingdom of God.”
What man could endure for honor’s sake, however, is shown in the
Memoirs of the Sieur de Pontis, who, in the seventeenth century,
was asked to be second to a friend, when duels were punishable by
death to all parties concerned in them. The friend of De Pontis
pressed it on him, as a custom always practised among friends; and
his captain and lieutenant-colonel did not merely permit, but ordered
him to do what his friend desired.
Boldly as many knights met death, there were not a few who did their
best, and that very wisely, to avoid “the inevitable.”
Valorously as some chevaliers encountered deadly peril, the German
knights, especially took means to avoid the grisly adversary when
they could. For this purpose, they put on the Noth-hemd or shirt of
need. It was supposed to cover the wearer with invulnerability. The
making of the garment was a difficult and solemn matter. Several
maidens of known integrity assembled together on the eve of the
Nativity, and wove and sewed together this linen garment, in the
name of the devil! On the bosom of the shirt were worked two heads;
one was long-bearded and covered with the knightly helmet, the
other was savage of aspect, and crowned like the king of demons. A
cross was worked on either side. How this could save a warrior from
a mortal stroke, it would be difficult to say. If it was worn over the
armor, perhaps the helmeted effigy was supposed to protect the
warrior, and the demoniacal one to affright his adversary. But then,
this shirt similarly made and adorned, was woven by ladies when
about to become mothers of knights or of common men. What use it
could be in such case, I leave to the “commères” to settle. My own
vocation of “gossip” will not help me to the solution.
But if chivalry had its shirts of need in Germany, to save from death,
in England and France it had its “mercy-knives” to swiftly inflict it.
Why they were so called I do not know, for after all they were only
employed in order to kill knights in full armor, by plunging the knife
through the bars of the visor into the eye. After the battle of Pavia,
many of the French were killed with pickaxes by the peasantry,
hacking and hewing through the joints of the armor.
How anxious were the sires of those times to train their children how
best to destroy life! This was more especially the case among what
were called the “half-christened Irish” of Connaught. In this province,
the people left the right arms of their male infants unchristened. They
excepted that part coming under the divine influences of baptism, in
order that the children, when grown to the stature of fighting men,
might deal more merciless and deadly blows. There was some such
superstitious observance as this, I think, in ancient Germany. It can
not be said, in reference to the suppressing of this observance, as
was remarked by Stow after the city authorities had put down the
martial amusement of the London apprentices—contending against
one another of an evening with cudgels and bucklers, while a host of
admiring maids as well as men stood by to applaud or censure—that
the open pastime being suppressed, worse practice within doors
probably followed.
Stout fellows were some of the knights of the romantic period, if we
may believe half that is recorded of them. There is one, Branor le
Brun, who is famous for having been a living Quintain. The game so
called consists of riding at a heavy sack suspended on a balanced
beam, and getting out of its way, if possible, before the revolving
beam brought it round violently against the back of the assailant’s
head. When Palamedes challenged old Branor, the aged knight
rather scornfully put him aside as an unworthy yet valiant knight.
Branor, however, offered to sit in his saddle motionless, while
Palamedes rode at him, and got unhorsed by Branor’s mere inert
resistance. I forget how many knights Branor le Brun knocked over
their horses’ cruppers, after this quiet fashion.
It was not all courtesy in battle or in duel. Even Gyron, who was
called the “courteous,” was a very “rough customer” indeed, when he
had his hand on the throat of an antagonist. We hear of him jumping
with all his force upon a fallen and helpless foe, tearing his helmet
from its fastenings by main force, battering the knight’s face with it till
he was senseless, and then beating on his head with the pommel of
his sword, till the wretched fellow was dead. At this sort of
pommelling there was never knight so expert as the great Bayard.
The courtesy of the most savage in fight, was however undeniable
when a lady was in the case. Thus we hear of a damsel coming to a
fountain at which four knights were sitting, and one of them wishes to
take her. The other three object, observing that the damsel is without
a knight to protect her, and that she is, therefore, according to the
law of chivalry, exempt from being attacked. And again, if a knight
slew an adversary of equal degree, he did not retain his sword if the
latter was a gift from some lady. The damsel, in such case, could
claim it, and no knight worthy of the name would have thought of
refusing to comply with her very natural request. Even ladies were
not to be won, in certain cases, except by valor; as Arthur, that king
of knights, would not win, nor retain, Britain, by any other means.
The head of Bran the Blessed, it may be remembered, was hidden in
the White Hill, near London, where, as long as it remained, Britain
was invulnerable. Arthur, however removed it. He scorned to keep
the island by any other means than his own sword and courage; and
he was ready to fight any man in any quarrel.
Never did knight meet death more nobly than that Captain Douglas,
whose heroism is recorded by Sir William Temple, and who “stood
and burnt in one of our ships at Chatham, when his soldiers left him,
because it never should be said a Douglas quitted his post without
orders.” Except as an example of heroic endurance, this act,
however, was in some degree a mistake, for the state did not profit
by it. There was something more profitable in the act of Von Speyk,
in our own time. When hostilities were raging between Holland and
Belgium, in 1831, the young Dutch captain, just named, happened to