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General Physicians Do Not Take Adequate Travel Histories Victoria A. Price, MRCP,∗ Rachel A.S. Smith, MBChB,∗ Sam Douthwaite, MRCP,† Sherine Thomas, MRCP,‡ D. Solomon Almond, FRCP,∗ Alastair R.O. Miller, FRCP,‡ Nicholas J. Beeching, FRCP,‡ Gail Thompson, FRCP,‡§ Andrew Ustianowski, FRCP, PhD,† and Mike B.J. Beadsworth, FRCP, MD, DTMH‡ ∗
Acute Medical Unit, Royal Liverpool University Hospital, Liverpool, UK; † Department of Infectious Diseases and Tropical Medicine, Monsall Unit, North Manchester General Hospital, Manchester, UK; ‡ Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK; § Health Protection Agency, Centre of Emergency Preparedness and Response, Porton Down, Salisbury, Wiltshire, UK DOI: 10.1111/j.1708-8305.2011.00521.x
Background. Our aim was to document how often travel histories were taken and the quality of their content. Methods. Patients admitted over 2 months to acute medical units of two hospitals in the Northwest of England with a history of fever, rash, diarrhea, vomiting, jaundice, or presenting as ‘‘unwell post-travel’’ were identified. The initial medical clerking was assessed. Results. A total of 132 relevant admissions were identified. A travel history was documented in only 26 patients (19.7%). Of the 16 patients who had traveled, there was no documentation of pretravel advice or of sexual/other activities abroad in 15 (93.8%) and 12 (75.0%) patients, respectively. Conclusions. There needs to be better awareness and education about travel-related illness and the importance of taking an adequate travel history.
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lobal international travel has risen from an estimated 25 million trips in 1950 to 903 million in 2007.1 A large proportion (46%) include tropical and subtropical destinations, and it is predicted that travel to East Asia, the Middle East, and Africa will continue to grow by 5% per year.1 International travel from the UK mirrors this pattern, with an increase from under 30 million trips in 1987 to nearly 70 million in 2007, including 9.8 million outside European or North American destinations.1 Since 1996, the number of visits to tropical countries has increased at an average annual rate of 8%.1 Within the same time period (1987–2007), travel from elsewhere to the UK has been estimated to double from around 16 to 32 million visits, 4.5 million originating from outside North America or Europe.1 Several groups have reviewed the changes in patterns and increasing frequency of infections imported to the UK by travelers and the implications for British hospitals.2 – 6 The importance of taking a travel history to establish the possibility of imported infection was emphasized Corresponding Author: Mike Beadsworth, FRCP, MD, DTMH, Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK. E-mail:
[email protected]
almost 50 years ago by Maegraith in his classical publication ‘‘Unde venis?’’ (Where do you come from?).7 However, anecdotal experience suggests that questions about travel are still omitted from most routine medical histories. There are few published data on whether British health care workers take adequate travel histories and act upon them. In a study in an accident and emergency (A&E) setting, travel histories were only recorded in 2% of over 900 patient attendances in 1 week and in only 5.3% of 310 patients with non-traumatic conditions, ie, those with the potential of having an imported disease.8 The absence of a travel history may affect patient management and also has wider public health implications. British guidelines on the management and control of viral hemorrhagic fevers9 rely almost solely on epidemiological evidence such as an appropriate travel history, and similar risk assessment algorithms have been developed for emerging infections such as severe acute respiratory syndrome,10 drug-resistant tuberculosis,11 and pandemic influenza.12 International surveillance has shown that most patients with travel-related diseases present with gastrointestinal symptoms, fever, or skin disorders.13 The aim of this study was to determine how often generalists documented travel histories from patients admitted to emergency and acute medical units (AMU) with these © 2011 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2011; Volume 18 (Issue 4): 271–274
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sentinel presenting syndromes. The secondary aim was to assess the adequacy of these histories to guide patient and public health management. Methods All patients admitted over two sequential months in 2008 to the AMU of a Northwestern teaching hospital and a district general hospital, with a history including at least one of fever, rash, diarrhea/vomiting, jaundice, or being ‘‘unwell post-travel,’’ were included. Patients were retrospectively identified from clinical coding and ward databases in one center and were prospectively identified by reviewing the case notes of all new admissions to the AMU (independent of route) on a daily basis in the other hospital. The initial clerking recorded in the case notes was assessed using an agreed proforma by two independent assessors. The grade and type of professional taking the initial history, the route of referral, and the general demographics of the patient were recorded. If present, the travel history was reviewed for key travelrelated information (Table 1). Patients seen initially by infectious diseases physicians were excluded from the analysis. This audit was registered with both hospitals’ audit departments and data were anonymized for data protection purposes. Results During the study period, 132 relevant patient admissions were identified, 71 (54%) in the teaching hospital and 61 in the district general hospital. Fifty-six (42.4%) patients were male and the median age was 46 years (range 16–97). As many as 39 (29.6%) patients had been referred by a general practitioner, 87 (65.9%) had been admitted through A&E, 3 (2.3%) from other sources, and 3 (2.3%) had no route of referral documented. A travel history was documented in the case notes of only 26/132 (19.7%) patients, 16 (62.5%) of whom had traveled abroad. Most patients were initially clerked by junior doctors (foundation year 1, senior house officer, and registrar grades) and travel histories were recorded in 16/99 (16%) patients clerked by a doctor below registrar grade compared to 7/25 (28%) at registrar (ST3) grade or more senior (p = 0.28) (Figure 1). The most common presenting complaints were diarrhea and/or vomiting in 71 patients (53.8%) and fever in Table 1
Figure 1 Status of person clerking patient. FY1, foundation year 1; PRHO, pre-registration house officer; SHO, senior house officer; SpR, specialist registrar.
39 patients (29.5%). Other presenting complaints were rashes in 13 (9.8%), jaundice in 19 (14.4%), and ‘‘unwell post-travel’’ in 5 (3.8%) patients. Travel histories were poorly recorded, irrespective of the nature of the presenting complaint (Figure 2). Two patients had delay in diagnosis of a travel-related illness because no initial travel history was taken. Both were treated successfully. For the 16 patients who had traveled abroad, the destination was recorded in 14 (87.5%), a reason for travel in 12 (75%), and the interval between travel and presentation in 12 (75%) (all within 1 y). A sexual history was only recorded for four (25.0%) and location within destination country in three (18.8%). Questions about pretravel health advice were only recorded for one patient (6.3%). Duration of travel was recorded in eight patients (50.0%). Of the five patients presenting with fever after travel, none had adequate documentation of a viral hemorrhagic fever risk assessment.9 Discussion Less than 20% of patients admitted into acute hospital settings with potentially relevant symptoms had any form of travel history documented. When histories were recorded, they were often insufficient to allow adequate patient and public health management. This has immediate implications for the patients involved and for the staff attending to them, and more wide-ranging public health implications due to the risk of missing significant communicable diseases.
Travel history questions
Travel destination (including urban/rural) Reason for traveling Dates of travel & time between return and presentation Sexual history and other risk behaviors Any pretravel health advice obtained and precautions taken against disease Viral hemorrhagic fever assessment for patients presenting with fever
Figure 2 Frequency of symptoms. J Travel Med 2011; 18: 271–274
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There are several British guidelines for the assessment and treatment of patients with travel-related infections including malaria,14 other infections,15 eosinophilia,16 and pandemic influenza,12 and concern continues about the rarer viral hemorrhagic fevers.17 These all require a travel history to be taken to identify patients at risk. Inadequate early risk assessment has affected the clinical and public health management of patients with viral hemorrhagic fevers,18 and delays in diagnosis and treatment have been implicated in deaths due to imported falciparum malaria.19,20 However, specific data regarding morbidity or mortality when histories are not taken on admission are lacking. In our study, at least two patients were identified to have delayed diagnosis of a travel-related illness because no initial travel history was taken. Both patients survived. The Northwest of England has a population of around 7 million,21 as well as large student populations, and it contains England’s third busiest airport and other international airports and major seaports. The hospitals that participated in this study assess over 15,600 acute medical admissions per year, many of whom are likely to have traveled overseas. Patients who presented to generalists were included and those initially reviewed by infectious diseases specialists were excluded, to avoid any potential bias in either referrals or history taking. Although we acknowledge the limitations of a small retrospective case note study, our aim was to capture a snapshot of documentation in different institutions, which we believe to be generalizable to the rest of the UK. The results are similar to those obtained in a study of British emergency room physicians who were asked to review case scenarios of five patients with imported illness diagnoses. In this theoretical setting, a travel history was only requested in 24/145 (16%) cases.22 To improve history taking, we should consider ways in which we can improve both undergraduate and postgraduate awareness of these issues. This will require improved and on-going education. More specific interventions could include a travel history question to be answered at initial patient registration by para-medical staff, and/or the inclusion of travel-related questions in preprinted clerking proformas. However, preprinted history proformas are not yet in use in the two hospitals included in this study. After presenting the results of this study in a hospitalwide meeting, we have introduced an active program of education for all staff working within A&E and the acute medical assessment units. This has taken the form of teaching sessions on a regular basis. Posters are displayed in acute receiving areas to remind staff of the need to take travel histories. We plan to assess the impact of these changes. Until travel histories are obtained more consistently, delays in appropriate patient diagnosis and management will continue to occur, with potentially fatal consequences.
Conclusion Insufficient and inadequate travel history recording was seen in this study, which may directly impact on patient and public health management. A multifaceted approach is needed if the detection and treatment of travel-related illnesses are to be improved. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. Office of National Statistics. Travel trends. 2007. Available at: http://www.statistics.gov.uk/downloads/theme_trans port/Travel_Trends_2007.pdf. (Accessed 2010 Dec 14) 2. Cossar JH, Reid D, Fallon RJ, et al. A cumulative review of studies on travellers, their experience of illness and the implications of these findings. J Infect 1990; 21:27–42. 3. Doherty JF, Grant AD, Bryceson ADM. Fever as the presenting complaint of travellers returning from the tropics. QJM 1995; 88:277–281. 4. McKendrick M. Infectious diseases and the returning traveller—experience from a regional infectious diseases unit over 20 years. J Appl Microbiol 2003; 94 :25–30. 5. Harling R, Crook P, Lewthwaite P, et al. Burden and cost of imported infections admitted to infectious diseases units in England and Wales in 1998 and 1999. J Infect 2004; 48:139–144. 6. Health Protection Agency. Foreign travel associated illness, England, Wales, and Northern Ireland. 2007 report. Available at: http://www.hpa.org.uk/Topics/Infectious Diseases/InfectionsAZ/TravelHealth/EpidemiologicalRe ports/. (Accessed 2010 Dec 14) 7. Maegraith B. Unde venis? Lancet 1963; 1:401–404. 8. Smith SM. Where have you been? The potential to overlook imported disease in the acute setting. Eur J Emerg Med 2005; 12:230–233. 9. Advisory Committee on Dangerous Pathogens. Management and control of viral haemorrhagic fevers. London: Stationery Office, 1996. Available at: http://www.hpa.org. uk/web/HPAwebFile/HPAweb_C/1194947382005. (Accessed 2010 Dec 14) 10. Health Protection Agency. Contingency plan for SARS, from 6 December 2003 interim contingency plan for severe acute respiratory syndrome (SARS), updated 27 February 2009. Available at: http://www.hpa. org.uk/webc/HPAwebFile/HPAweb_C/1194947314808. (Accessed 2010 Dec 14) 11. National Institute for Health and Clinical Excellence. CG33 Tuberculosis: quick reference guide. March 2006. Available at: www.nice.org.uk/nicemedia/pdf/CG33quick reffguide.pdf. (Accessed 2010 Dec 14) 12. British Infection Society, British Thoracic Society and Health Protection Agency. Pandemic flu: clinical management of patients with an influenza-like illness during an influenza pandemic. J Infect 2006; 53(Suppl 1): S1–S58. 13. Gautret P, Schlagenhauf P, Gaudart J, et al. Multicenter EuroTravNet/GeoSentinel study of travel-related J Travel Med 2011; 18: 271–274
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