Managing Travel Health Risks, Behaviors, & Outcomes: Best Practices - Seminar, April 28, 2000

Questions and Answers

DR. GRIZZARD: Yes, we invest in a number of things. We are a multi-functional organization. In addition to hosting riots and demonstrations, our Health Services Department is really multi-pronged. We have a medical unit or health unit which has three full-time physicians, two full-time nurse practitioners, two part-time physicians. We see about 100 to 130 patients per day. It serves both as a post-travel clinic, a mini-infectious disease unit, and also an urgent care unit. Approximately 85 percent of the population we serve in the World Bank/IMF community are non-United States residents. Many of them do not have a primary care provider, and as such, we fill that role to a certain extent. About half of our visits are urgent care.

There is a tremendous work ethic in this community that even exceeds the high sphincter tone of Washington, I believe the term is used. People here don't mind going outside for health care, as long as it's not more than ten yards from the front door. They really like to stay right around the Bank for just about everything that we can. There really is a tremendous devotion to work.

Our health unit really functions as a small group practice. It's quite different probably from most of your occupational health conceptions.

We also, as you have discovered, have a counseling service. We have about 1.5 to 2.8 FTEs in that, and, believe me, their time is full, as I think you will have imagined on the basis of today's presentations.

We have a classic travel unit that is, again, run primarily by the nursing staff. It has to do with immunizations, education for people who will be going on resident mission and also on short-term travel.

We have an ergonomics consultant, Danielle, who is joining us today, extremely valuable in this setting and very much appreciated by our population here.

We have an occupational health physician. We have a research unit that, while not bench work, focuses primarily on stress issues and issues related to occupational medicine.

We have a public affairs division, our own laboratory which focuses on number two, but also does the standard kind of studies you might need in a small group practice. We have a radiology unit and also a business office, medical management.

What I haven't mentioned is—and when we were talking about best practices, this is one of the things that I would mention. This is our field health service. This is a group of nurses backed up by physicians, and we deal with problems all over the world. Last night I was awakened at 11:00 a.m., and I needed to call someone in Vietnam. Not an emergency, as it turned out, fortunately, but this is the kind of problem we deal with.

The World Bank at last check had about 99 locations throughout the world where we have people, both individuals who are coming from Washington to spend time there and we also employ local nationals, and we also assume responsibility for a large portion of their health care. So it's a very interesting practice which is part centered right here in Washington with the 8,000 to 9,000 employees we deal with here, and an additional to 2,000 to—I don't know how many—3,000 or 4,000 overseas for that.

So that's pretty much what I do. I think you now have a nice idea of the eclectic panel members you have up here, and my purpose now is to turn the program over to you. We're now open for questions, and let's just say no limits here.

Fred?

MR. [NOT KNOWN]: This is probably a naive question, but [inaudible]. For those of you in the United States primarily in occupational medicine where we have a very litigious sort of environment and we're very conscious of medical practice and medical malpractice, how far do you go in situations in which the business makes a decision to send somebody to an area within an hour or two, and as someone alluded to, you are the person seen—or your unit is the person waving good-bye as they go to the airport, and you know that they're unprotected. And my question is: How does the group feel about how far we should go morally and ethically and maybe even legally in advising them and telling management that this is really unacceptable? How far would you carry it in the freedom that we sort of have in the United States?

DR. GRIZZARD: Fred, let me start by saying you don't have anyone up here who practices in the United States. The World Bank is international territory—

[LAUGHTER]

DR. GRIZZARD: You'd be amazed. I had the opportunity of meeting with some of our colleagues in various branches of the U.S. Government last week. They sent a contingency over to look at our unit and our new electronic medical record. And OSHA came up quite frequently in the discussions, and they, too, asked about openings, if we had any here.

Let me just answer one component of your question and then open it up to the other panel. At least among the population at the World Bank/IMF, people join this organization with the expectation that they're going to be traveling. Very rarely do they have to go somewhere that they did not completely anticipate on a moment's notice like that. And so, really, part of coming into this community is being prepared to travel with immunizations and familiarity with that, but also keep in mind that 80 to 85 percent come from some other nation.

Any other—do you want to address that question?

DR. REED: It's an issue which [inaudible] in the U.K. I think from a medical-legal perspective, occupational physicians in the U.K., travel medicine is potentially our biggest area of potential liability, because so many times we actually treat and administer medications and drugs and such like. It's a problem which we're actually very familiar with, and we always agonize about decisions like that, whether to encourage—the individuals will often be saying, well, how am I going to fool my company, I'm not going, I'm not prepared. We have to be very sensitive about how we actually handle that.

Where we're done the work on behalf of—quite often we do it on behalf of the company that actually has a corporate medical department, but it just can't be bothered doing it themselves or, you know, it's too late in the day so we have to do it. And occasionally when we've actually told people that they're really not covered properly, we are in deep trouble with their corporate medical department. They do not like that at all. They say that your function is not to advise them that, they're going, just make them—do what you can and get them out of there and don't even discuss that, which is really quite a bizarre attitude.

But for companies where we're effectively their medical adviser, there are ways around it. We do usually make them aware of the fact formally, make the organization aware of the fact that this was not—optimal preparation wasn't achievable in this situation, and we're trying to re-emphasize, you know, that the strategy is we've been advising them to look at to actually prevent that kind of thing happening, i.e., anyone that may travel at some point in the future or could be required to travel, get them prepared now, you know, for the zones in the world in which you're working, so that if you do have to send them on short notice, there's really not much to think about.

But it's that constant struggle, and we do have to be very sensitive. But some companies get so twitchy, they'll just cancel the contract with us if we make too much fuss. That's the reality that we have to live with. It's very awkward at times.

MS. ROBERTS: Esther Roberts, State Department, Medical Program. As a psychiatrist, I'm interested, especially since so much has been discussed about stress, either stress in preparation or stress as part of the missions, that various international travelers encounter, I'd be interested in knowing about screening, the value of it, whether or not it's being done as part of the screening process, and whether or not there are any correlations between that and the outcome as part of the traveler's experience.

MS. ROGERS: I'm not familiar with any companies who do short-term traveler screening. I don't even know if there's such a tool that even exists to do that or anyone undertaking that.

I do know of some organizations for the expatriate traveler. You know, when a whole family is moving over, there are some experts who consult organizations and bring a questionnaire, a survey, or a whole measurement system for analyzing the psychiatric or the psychological ability of the employee to adjust and adapt to the new culture and that sort of thing.

So I know that some of that out there exists. How successful it is? I don't know. And, interestingly, just before I came here, I met with two oil companies in Calgary who—sorry, one high-tech company and one oil company, both potentially new clients. And I asked them just out of interest, the occupational health nurses and physicians that I was talking to, how much of that data do you even see or are you made privy or whatever, because it happens quite externally to the organizations. It's done by an outside firm. And they're not privy to any of the information. They don't even really know where it goes. It goes somewhere to HR and the person's supposedly psychologically fit to go, and that's about it. Nothing else really happens with it.

DR. GRIZZARD: Any other—is there anybody in the audience who has experience with this?

MR. [NOT KNOWN]: I'm Joe (?) . I'm with GU Medical Systems. I've worked with four other major corporations in my career in the U.S., and my experience has been similar, that there's a lot more dollars at stake on a failed assignment of an expat, so companies are willing to spend more money in taking a look at that. And we look at a whole host of issues, both marital, financial, special educational needs of the children, a variety of things, because you don't want to find out those things once you've already invested the dollars to move somebody.

But on the short-term assignments, my experience has been, you know, the seasoned people that are in the trench that are doing the counseling have their antennas up, you know, and my nurses will sometimes pick something up that just doesn't ring right in the counseling session, and we'll follow up on that real quick. It could be somebody in a marital crisis that all of a sudden got hit with an assignment, and we actually have to intervene. Now, that's more by exception. It's more—you can't say it's a real process-oriented thing, but the seasoned people can pick that thing up.

Then we have an in-house relationship so we kind of know our people in that regard. So that's some of the advantages you have of an in-house department that's looking after the people. That doesn't sometimes translate in a consulting relationship.

DR. GRIZZARD: Could you expand just a little bit in this situation, Esther, and perhaps share some with us? With the employee, there are several issues, one of which is that you may have leverage over the employee, but sometimes not very much over the family. And all the attention appears to be focused on the individual whom you're sending overseas for the work, and yet the significant other may be the one who is at high risk for that. So if you could address that issue, and also there are always—what are the political implications of this? Is the system in which you're working such that even if you express a concern the organization's desire to have that particular person go to a particular place is so high that it's going to override this. Is this an issue in either of your environments?

MS. ROBERT: I almost hate to go on record, given our population. But we do have extensive psychiatric information in a more formalized manner, and certainly that's part of the job of the medical program that has a psychiatric component for screening of people prior to employment in the State Department. And certainly if problems arise during other assignments, then certainly we're aware of that, and it does have an impact in terms of personnel decisions about where to send people.

Having said that, I think it's awfully interesting to note that from my experience of some 20 years with the State Department, that those individuals who manifest the stress and also subsequently have an impact on the breaking of an assignment for an employee really come from both the dependent spouses as well as from the family members, usually in terms of children with educational needs. And, interestingly enough, with the number of psychiatric evaluations and evacuations back to the United States, that it's not those people who have necessarily been identified and sent overseas that we're aware of from screening who result in having to come back because of psychiatric issues.

So that's the reason I'm asking, both in terms of the kind of investment in a program that does screen and the correlation between that and subsequent outcome.

MR. [NOT KNOWN]: When we're dealing with expat situations, we do a variety of things besides the initial screening piece. There's an outreach to the family that's done by a consulting firm, and that outreach is just the initial touch. And then when they're in the country, they're touched again, and they're touched six months beyond that, and they're touched on repatriation so that the family is always connected, if you will, with a professional counseling organization that basically has kind of got the radar going for issues.

Oftentimes it's not so much letting management know that this isn't going to work, but more of a facilitation. And there are a variety of things that can be done. A situation where we've got a new spouse, newly married, just starting out and so forth, excited to be going, but she's been in her own job, in her own career, and she's giving all that up to travel to a country which is going to have absolutely no employment. A situation like that, we might be able to find some employment for a spouse like that and soften the cultural blow.

Another thing, too, would be oftentimes we'll pick up some real cultural differences and concerns, and we'll put more money in cultural immersion training before we send people sometimes if they have some special needs in that area.

Each situation is a little different, but oftentimes telling management that this is a no-go is not really accepted. They're really looking for solutions. These people need to go because of some technical expertise. Now how do we make it work? And that's usually the approach to take.

My style has been more not to tell management that this isn't going to work, but to say that, you know, this is high risk, that you are risking a failed assignment here and I'm going on record and letting you know that. And that may open up some purse strings, if you will, to open up some facilitations to help the thing work out.

So usually kind of ball-parking it in a risk fashion with some solutions, management is much more apt to listen in that regard because you're really coming to the table as a strategic partner then.

DR. GRIZZARD: Other questions?

[NO RESPONSE]

DR. GRIZZARD: Let me just ask one of our fellow panel members and the group as well. Over the course of the last probably two or three months there has been a lot in the ProMed e-mail, which is an epidemiologic service, talking about cases—in this case it was Lassa fever coming from West Africa and winding up some in Germany, some in the U.K. Is this an issue ever raised among your population? And if so, how do you deal with that?

Jay, could you say anything?

DR. KEYSTONE: First of all, even in the pre-travel side, even though I don't do it, I'm pretty confident that Phil does not raise the issue of Lassa, Marburg or Ebola virus acquisition to travelers. That would be the shortest travel consultation you'll ever have, and probably the last.

I think we have to look at the perspective here, and the perspective basically is, yes, we have seen in the last few years several cases of Lassa fever in individuals who have worked abroad. But let's look at it over the last 25 years, and there probably aren't more than a dozen or two dozen cases of the millions of travelers who travel globally, and even those who go to Sub-Saharan Africa, which, of course, is the big area.

So I would have to say this is a media issue, as the outbreak of Ebola was, and it has, I think, far more impact psychologically than it does in reality. And so I don't think it's appropriate to raise this except in certain circumstances. For example, you have a long-stay traveler going to a rural area of Sub-Saharan Africa. I think in a situation like that it is reasonable to indicate to them that rodents, for example, in their household—trying to keep their house rodent free would be an issue in terms of reducing the likelihood of Lassa fever.

In terms of Marburg—very tough. Don't eat the monkeys! And in terms of Ebola, we still don't know what the reservoir is.

So as I said, I think we have to keep all of this in perspective. We lose almost 3 million people a year from malaria, and we've lost maybe a half a dozen or a dozen travelers to Lassa fever in 25 years or 20 years. So I personally don't think this is an issue.

DR. REED: It's interesting. We had a very similar situation in Aberdeen where a shipping company whose sixth employee had died of malaria, they suddenly decided they really needed to do something a bit more serious about protecting and making sure that employees out there knew what they were doing.

But subsequent to that, and going into that in a really quite impressive way, actually they did swing into action eventually. The issue of Lassa actually came up as a result of that investigation, and that's the only time we've been asked about that, and we had just to give them some specific advice. But as Jay said, we very much played down the Lassa card.

We gave generic advice about avoiding rats and things, and I think they suddenly, very quickly realized that, in fact, it wasn't an issue that they had to be worried about. That's our own experience. But stories were going around the U.K. Certainly the media had hyped it slightly. But that was the only company that actually raised it as an issue. We didn't go out proactively talking about it on that basis.

MR. [NOT KNOWN]: This comes up all the time. I mean, I do a lot of corporate consulting and adventure travel outside of L.A., and people come up with these things. It's a media phenomenon, I agree. And I usually give them an analogy. I tell them, look, if you have—I have Japanese colleagues in Tokyo, and if you ask the kids, the teenagers, Do you want to come to L.A.?, initially they're very excited. Then they say, "What about drive-by shootings? What about carjackings? What about AIDS, this TB they don't have any treatment for?" And I look at these people in my nice suburban office, I say, "Do you ever worry about any of these things living in the L.A. area?" And, of course, they say no. So I say, "Well, the likelihood of you running into some strange virus in Africa is no less likely than running into these things in L.A." And it's common sense. You know where to go. I tell them, you know, serious diseases many times are situations of poverty. When you're a traveler, unless you're on assignment or in some kind of very risky place, you're not going to be near those places.

This kind of analogy makes things a lot clearer to people.

MR. [NOT KNOWN]: It's good for tourism in Canada, the drive-by shootings in L.A. I just want to let you know.

[LAUGHTER]

MR. [NOT KNOWN]: It really raises a larger issue in a sense that with the information explosion on the Internet and with CNN pretty much giving you everything in real-time live, we're constantly having to deal with a lot of issues that we haven't had to deal with in the past.

A couple that have come up recently—and I don't know if it's the backdrop with some of the distrust in the government that's going on right now that seems to be quite fashionable and seems to be on the rise. The issues with immunizations seem to be getting to be more of a problem, the military with their history of the anthrax controversy, and now we've got a Senate—excuse me, a House committee looking into the MMR and autism.

If you listen to some of the talk and you read some of the garbage that's on the Internet that's kind of masquerading as science, it's a concern. And I'm seeing some of that spilling over into some increased resistance on the part of people just to take immunizations. It's getting to be a harder sell. I don't know if anybody else has started to see some of that.

DR. KEYSTONE: Yes, in a word. There is a tendency for people to believe all that they see or hear in the media especially if it appears in electrons i.e. on the internet. It seems, for the public, to have much greater validity than the same thing printed in a newspaper. It's an unusual perception, but people, nevertheless, will bring in these articles from the net that they take as truth, and they're not reading it with the same critical eye that they are other sources of information.

Other questions? Yes?

MR. [NOT KNOWN]: [Off microphone] I have a question for Dr. Reed. You talked about fitness for travel standards. Can you give us an idea what that means?

DR. REED: It varies, actually. I mean, a lot of the fitness standards for travel essentially comes out of the oil industry standards, or, you know, the offshore operators in the U.K. will have fitness standards for working in offshore, remote, and hostile environment. They have effectively been hijacked by more national—international oil and gas forums and used as a fitness standard for work in remote locations around the world, and they're almost identical, in fact, in what they're trying to achieve.

I think the aim of that is just to reduce or minimize foreseeable repatriations or foreseeable medevacs which understandably cost them a lot of money. I have to say, though, that my personal view of those guidelines are that only in sections are they actually evidence-based, and I think a lot of them have just grown up utilizing questionnaires 30 years old and have just kept being recycled by people, and no one's ever—no one really sits down critically to examine what we're actually testing against and is it actually evidence-based. But sort of anecdotally and sort of empirically, I think, you know, we also—we'll assess people as we go along. Talking about psychiatric illness, you know, obviously, you've got to know about whether they've had a history of affective disorder or psychosis if you're going to be prescribing antimalarials. And if someone says yes to that, we will always actually—a physician will come down and speak to that individual and discuss their health issues in quite a bit of detail to determine whether they are actually fit to be traveling or there is a risk and try and deal with that.

We have had problems with people needing to be repatriated. Just last week before I came here, I was having to deal with a woman who had been repatriated from the Gambia who had a long history of bipolar affective disorder and, really, she shouldn't have been over there. She ceased taking her lithium when she was there and decompensated over the next six months and became a real big management problem. She was actually the spouse of a medical research worker, a virologist over there, and they've had to basically pull out of that three-year contract after only one year.

So it is an issue, but I think it's probably done sort of quasi-empirically at times, and I think the guidance in the literature, there's not really been much evidence there to determine with any certainty how effective these pre-travel assessments are. But, you know, we do our best, and I think we just try and make it as evidence-based as possible and justifiable and reasonable as possible so as not to bar people from going for unnecessary reasons. But we do see some—in the U.K., what a lot of companies will do, if the guy's unfit to be working offshore, they'll decide to send him to darkest Africa as if that's somehow better. It's actually almost certainly a lot worse with chronic medical conditions that require active monitoring where that facility won't be available. We do see that.

DR. KEYSTONE: Other groups that have looked at this issue and are, in fact, currently looking at it— a are the missionary groups across both Canada and the United States. They send long-stay missionaries to remote corners of the globe. Ken Gamble who does much of the health advice for missionaries in Canada, is currently working with a psychiatrist in the United States to develop a tool for pre-travel psychiatric assessment and has just completed editing a chapter on the long-stay traveler looking at both psychological and medical issues. It's going to be in a new textbook published in the U.K. by Zuckerman and Zuckerman on travel health.

But as I said, if you're interested, Ken would be a person to speak with. He's doing prospective studies on —the health of long-stay travelers, and in particular, missionaries. I think that it would be worthwhile liaising with him if you're looking for some type of tool.

MR. [NOT KNOWN]: Does anybody have any additional information on this topic? For example, looking back at the repatriation and/or disability cases over a period of time and seeing back if there was any type of clearance exam that was done, could these reasons for disability or repatriation have been identified at the time of some initial intake? Does anybody have any information on this?

Esther, do you, from the State Department?

DR. ROBERTS: Well, it is interesting that—no, we don't have any real studies about any of this. But certainly we have looked to the missionary group and some of the Peace Corps work previously in terms of identification. As I said, it's not really very clear. We do have in place the kind of program that provides this screening, but it doesn't necessarily prevent people from being identified subsequently for whom they have to provide psychiatric evacuations.

I do think it's important, especially in terms of some of the pre-screening, as you pointed out in connection with antimalarial medications, and especially in terms of some of the affective disorders and some of the information that's coming out in terms of either traversing time zones and the medication utilization in lithium, certainly in terms of sending people overseas with affective disorders, bipolar, the implications of that in terms of managing of medication, as it is for lithium levels, has been a real question.

DR. GRIZZARD: Other questions? We need you to speak up, gang. This is your opportunity. It's not yet 3 o'clock.

MS. [NOT KNOWN]: I have a question for Dr. Keystone. You had indicated you looked at how accurate sources of information were for—

DR. KEYSTONE: Yes.

MS. [NOT KNOWN]: I wonder if you could share that with us.

DR. KEYSTONE: We looked at various sources. At my age it's very hard to remember the data exactly, so do not quote me. l, , Several years ago we did a study looking at about 30 embassies and 17 consulates. We phoned them and said, "I'm going away to your country"—which was a malarious area—"Do I need any shots or do I need any pills?" And the bottom line to that study was one-third of the embassies gave completely incorrect information, you don't need shots and you don't need pills, for people going to known malarious areas. One-third referred them on, and one-third gave appropriate advice.

We have looked at family practitioners practicing or giving pre-travel advice, and the accuracy of that information was relatively low. Our studies and the others in the literature show that only about 10 to 25 percent of the consultations were correct.

We then went on and looked at travel clinics. That was the scary one. We've done two studies, one in the United States—well, one in Canada and the United States, and then a separate one was done using our questionnaire in the United States. It was interesting that the Canadians did better than the Americans—sorry, folks. I realize this is a competitive situation. But the reason probably is that most of our travel clinics are managed by nurses who are much more up-to-date and much better at giving pre-travel advice than physicians who are, quote, multi-tasking. You know, physicians don't multi-task quite as well. And so we found that in clinics, particularly public health clinics, that the nursing staff did much better than medical staff in private clinics.

In the United States, I think the accuracy of giving pre-travel malaria advice was on the order of about 70 percent; in Canada, it was about 85 to 90 percent. But even that's not great. These are travel clinics. These are clinics that are dedicated to giving pre-travel health advice.

And so we were actually quite surprised at the relatively poor response, and it wasn't just malaria but immunizations. At least 20 to 30 percent of the time, incorrect immunizations were given. Either they didn't need to be given or they should have been given. The results of these studies have been confirmed in work in Europe which showed similar findings.

One of the groups that probably doesn't have a lot to do with this meeting—well, actually, maybe it does, the World Bank—and that is VFRs. Some of you may not know what VFRs are. It's a relatively new travel medicine term. VFRs are "visiting friends and relatives". We're talking about new Americans and new Canadians who immigrate to Canada or the United States or Europe, and then they go home to visit their friends and relatives. Number one, they've lost their immunity to malaria. Number two, the disease situation in their home country will have changed over the years, particularly increasing malaria. Number three, they think they're immune to everything because ÔI was brought up in that countryÕ. They don't seek pre-travel health advice for themselves and, problematically, often don't do that for their children who they take back to visit their homeland.

And if you look at the data in the United States on typhoid fever, most of it is in Latin Americans and Asian Americans; that is, they're American citizens who go back to their home country and wind up with typhoid in either India or in Latin America.

If you look at malaria, the biggest group are new Americans going home and not getting pre-travel advice.

As I said, from the World Bank point of view, you have many people from all over the world, and they return home to visit. They may be at the World Bank for a number of years and go home, and they don't realize that the situation has changed.

So this is a group that, in fact, CDC in the United States is trying to focus on and doing research on now on how do we target this group. We just did a study, an airport study on South Asians going to India. I think we had roughly 320. And we found that only about 10 to 15 percent were on appropriate antimalarials; only a third sought pre-travel health advice. And, again, it's a group that just doesn't normally think about getting pre-travel advice before they go.

Yes, sir?

MR. [NOT KNOWN]: A follow-up. What did you—what was your position on telling the people at the time who were leaving that they were not adequately prepared?

DR. KEYSTONE: First of all, they were at the airport. It is very difficult at the airport to give pre-travel advice when their flight is leaving in 15 minutes.

MR. [NOT KNOWN]: No, I understand that, but—

DR. KEYSTONE: You're asking the ethics question.

MR. [NOT KNOWN]: This is a study. Was this done in the United States?

DR. KEYSTONE: No. This was done in Canada. It was an airport survey before people traveled. The studies that you've done in the United States are mostly post-travel surveys. These were airport surveys, and we did not then sit down and discuss pre-travel health advice with these individuals. What we wanted to know was, what have you done, did you see someone, what did you do, what did you take, rather than discussing with them—you couldn't have completed that study because you would have had to spend another half an hour with them as they're leaving in 15 minutes to give pre-travel advice.

MR. [NOT KNOWN]: No, I understand. I just want—I feel strongly enough about this point that just to gently say to the group that I have great difficulty accepting your position. In other words, I do absolutely understand that we could not give the counsel, but I think it's now accepted that we would have an obligation to say that, based on what we know, we want you to know that you are not adequately protected and that's all I can tell you at this point.

DR. KEYSTONE: Well, I guess I would argue with you that that kind of information could be equally detrimental, giving half a picture, a quarter of a picture, 10 percent of a picture. I understand your position. I think we would take the ethical perspective that had we not gone there, nothing would have changed. Okay? Your perspective is: But you did go there; therefore, you are obligated to give advice. And I think if we had had the opportunity or the time to do so, we would have done that, but we were doing this just before flight time, and it would be virtually impossible.

MR. [NOT KNOWN]: I absolutely understand. I think that kind of position will become more and more unacceptable. For example, in the United States now, we're in the position that—and I don't do this kind of work, but I know it's the case that if you do an innocuous examination called an insurance exam—which the company and the insurance people just simply want to know that everything is all right—if at that time you discover something, you just happen to note that there's a lesion on the skin that looks like a melanoma, you still would have the responsibility to say, "I think you should have that looked at by somebody," and that's the end of your responsibility. You would not simply be able to say "I'm only doing an insurance exam" anymore.

I just think it's an interesting ethical point, and I understand what you're up against. But I wanted to bring it up because I don't think we can lightly dismiss this any further, at least in the United States.

MR. [NOT KNOWN]: Well, those questionnaires aren't done by physicians in the airport. They're usually done byÑstudents.

DR. KEYSTONE: Well, in this case, they were done by medical students, early-year medical students who didn't have the expertise to provide that kind of advice.

However, your point is well taken, and I think perhaps if we were to do this again, one of the ways one might get around this is to havea pamphlet on malaria information.

MR. [NOT KNOWN]: Absolutely.

DR. KEYSTONE: In other words, you don't have to counsel them individually. You can say: Thank you for taking the time to do our survey; here is a two-page or a three-page—or a one-page information brochure on malaria. Then it's up to the individual as to whether he or she might want to change theÑapproach to malaria prevention when the destination country has been reached.

MS. BRAND: I'm Rosemary Brand (ph) from the Daily Telegraph in London. I work for a travel department, and it seems that people are becoming more and more resistant to taking conventional malaria prophylaxis. Is there any serious—is a serious look being taken at alternative remedies at all in this area?

DR. KEYSTONE: You mean complementary medications?

MS. [NOT KNOWN]: Yes.

DR. KEYSTONE: The whole problem with complementary medicine, to some extent, is the issue of evidence-based information to say that these antimalarials work. If you look in the complementary, let's call it—I don't know if it's literature, but what's out there, there's a lot of anecdotal suggestion that various herbal medications will protect against malaria.

But the point I'm making is until those who promote complementary medicine are willing to take a scientific approach, a rigorous look at the complementary medications to prevent a potentially life-threatening infection, I think it would be very difficult for us to promote them. . I know of no alternative or complementary medication used to prevent malaria.

MS. BRAND: Is any research being done into these products]?

DR. KEYSTONE: You're looking at a non-complementary physician—it's not that I'm uncomplimentary.

[LAUGHTER]

DR. KEYSTONE: You're looking at someone who doesn't have an expertise in complementary medicine. I'm kind of a Western classical trained, so I don't—does anyone out there have any knowledge about this area?

DR. KEYSTONE: But there are a number of alternatives now to mefloquine. I mean, the problem in the U.K. is mefloquine, and as I pointed out this morning, there are at least two or three alternatives to mefloquine that work well and that will have minimal side effects.

MS. [NOT KNOWN]: There's some [inaudible] chloroquine paludrine (ph).

DR. KEYSTONE: Well, the problem with chloroquine paludrine—and I'll just use my standard line. In the U.K., people always loved chloroquine paludrine because it was safe. It didn't work, but it was safe, and that was the problem. It's only about 65 percent efficacious in studies in Africa and, in fact, there are no studies on chloroquine paludrine anywhere in the world other than in Africa. So we don't recommend it. But there are, as I said this morning, several new medications. Malarone ( is now available in the U.K. Primaquine is very cheap and has been available for a number of years. And these are safe, very effective. And I think the biggest problem, I must tell you, is I don't think we make it clear to the public that we are preventing a potentially fatal infection. You know, that—mefloquine, terrible drug, nightmares, irritability. It's not a wonderful drug. It's certainly not a perfect drug. But let's look at , if you can't take anything else, what you're preventing. I think that has to be made very clear to the traveler. Your choice is mefloquine or death.

DR. KEYSTONE: Well, no, just—well, it is. I'm not saying mefloquine only. I'm saying if someone doesn't want to take another medication, you are taking a risk of death in certain countries of the world if you don't take antimalarials.

MR. [NOT KNOWN]: Jay, I think in less than the highest-risk environment, I think personal protection can be very adequate.

DR. KEYSTONE: A 70 to 75 percent—

MR. [NOT KNOWN]: I mean, if the persons really don't want to take medication, then they should be dedicated enough to do personal protection.

.

MR. [NOT KNOWN]: I was just going to say that in the last three and a half weeks among the World Bank/IMF population, we have had two in ICUs with malaria. The problem wasn't the drug. The problem was compliance.

DR. KEYSTONE: Absolutely.

MR. [NOT KNOWN]: Which is the number one reason for malaria, at least among the CDC studies. So no matter what drug you go to, you're still going to be faced with that issue.

Jay, what role do you delegate for doxycycline?

DR. KEYSTONE: I think doxycycline is a very good alternative. It's highly effective. Its primary role at the moment is along the Thai-Cambodian-Burmese border only in rural areas. Most people don't need antimalarials going to Thailand at all, except going into the rural jungle areas of the border.

The problems with doxycycline are usually not major side effects, but the troubling minor side effects: the UVA photosensitivity, which can occur in up to 20 percent of people and you need a UVA blocker; in women, Candida vaginitis. If you take the pill and it lands in your esophagus and doesn't go down, that is, if you take it in a reclining position—as you would in Passover, for those of you who know about that—and the tablet sticks in the distal esophagus, it can actually put a hole in your esophagus. And we've seen perforation and severe ulceration.

But, in general, if you tolerate it and take it with fluids, -it's an excellent antimalarial. And, you know, my argument, mefloquine or death, in a highly endemic area what I really should say is antimalarial or death. Yes, personal protection measures work. But, wait a minute, if we can't take one pill a week, how are we going to put our insect repellent on all the time when we need to, get under our bed net appropriately—

MR. [NOT KNOWN]: Impregnated—

DR. KEYSTONE: Wait a minute—okay.

MR. [NOT KNOWN]: —clothes.

DR. KEYSTONE: Good. Let me argue with that. Who's going to want to impregnate their clothes? Number two, most travelers don't travel with bed nets. You see, I think bed nets are great if you're living in the developing world, and I've lived there, and that's terrific.

MR. [NOT KNOWN]: Well, what I'm saying, if somebody's really objecting to taking mefloquine and they're really forcefully objecting to take it, they should be dedicated enough to do personal protection.

DR. KEYSTONE: I don't say to the patient, "If you don't take it, you're going to die." Trust me. We don't say that at all. The choice is always up to the patient, and that's one of my pet peeves about travel medicine. We should not be making judgments. We should not be saying you shouldn't go, I don't care whether you're HIV-positive or have leukemia or lymphoma or you're blind. What we should be doing is enabling travelers. And if someone strenuously does not want to take an antimalarial, We just say, That's fine, here are the alternatives. I don't want the alternatives. All right. Then here's the other thing you can do. And if you take personal protection measures and you use them rigorously, likely you're going to have about 75 to 80 percent protection. You may develop malaria. If you develop a fever, seek medical attention. If you seek medical attention, tell them you want to be tested for malaria. And if you seek medical attention, tell them you want to be tested for malaria three times.

MR. [NOT KNOWN]: With 20-some years' experience in the military, which are the most incompetent compliance people that there are, because18- to 25-year-old people just don't want to take pills, we stress personal protection first and then augment it with the mefloquine or any other—doxycycline or anything else, because we know either they'll go around naked or they'll go around with permethrin)-treated clothes and—

DR. KEYSTONE: But you provide them with permethrin-treated clothes. That's slightly different from what the rest of the world has available The other issue is, if you look at the data on compliance with personal protection measures, it's even less than it is with antimalarials.

MR. [NOT KNOWN]: Right. But I'm talking about a subgroup of population who's objecting to taking—

DR. KEYSTONE: Absolutely. I wouldn't disagree with you at all.

MR. [NOT KNOWN]: Raphael Mesquite (ph) from American Health Organization, which is a regional office of the World Health Organization. I'm not an expert in travelers' health. I'm the regional adviser on HIV/AIDS and STDs. But I function pretty much as a pro bono adviser to the organization on this issue because I'm a frequent traveler myself. And I have had more than once a problem. Number one, it's dreadful when you're about to land in Miami and everyone is in the line with the comb and the toothbrush in coach class.

I very often receive requests from frequent travelers, from sister organizations, and people who are living with HIV and AIDS and who have to travel to countries in the Caribbean or Latin America, wondering which are the special care they have to take in regards to opportunistic infections, which facilities are available for acute care, which are the conditions in which this person should develop [?] formation, whether there is a safe blood stock in the country, if we are 100 percent sure about that, and in case of expatriation, how fast this could be done.

At the beginning, when we tried to respond to all these requests, I realized that many of the offices of the organization in the country didn't have all this information gathered, so we started putting a system that is not 100 percent operational for the Western Hemisphere, but we are working on that, trying to have this information at hand for at least the sister agencies through the coordinator of the UN System so frequent travelers or people in mission can know where to go, who are the physicians who can help with an emergency, if they have an accident, can they trust the quality of the blood provided for transfusions or other [?] .

However, in my effort to transmit this information to the public, I have learned to use a lot of universal precautions, especially having to deal with what you described as a litigious environment. More than once I have faced the situation of people who, seeking for asylum here or in Canada, use their attorneys as spearheads to get this information to prove that the conditions in the country they are planning to visit, quote-unquote, but where they are originally from, don't have the conditions to provide the quality care they are looking for. And we are trapped with that because they use the statement of the WHO representative to make a case in court.

Another problem really serious to us—and I need your advice and help on this—is a problem of institutional culture. Many of our employees have this old-fashioned conception that we are—and maybe they are right because this is the raison d'etre of our organization—we are the servants of the admirals' club of theirs, of the Ministries of Health. And many times even if we have accurate information about certain conditions, they don't want it to be seen in public lest it tarnish the image of the country.

So how can we control that to make it public? I was thinking one option is to provide some general information about the country, the facilities, the advantages, and then refer the individual to some general recommendations for the region or the subregion, and in that specific space, draw the attention about the particular problems in the country. But we still have that difficulty and the political resistance to provide accurate information to the traveler.

DR. GRIZZARD: This is becoming more and more of an issue. I think you've really identified an important issue, and that is the safety of the blood supply. We were talking this morning about what are some of the risks that travelers face. Certainly the unanticipated moving vehicle accident, things like that, episodes in which you're likely to need if not blood, at least a plasma expander or something like that, which may necessitate or will necessitate the use of a needle into your skin and you're not really sure where that needle comes from.

We do supply here at the Bank for our people a syringe kit. One could, I think, ask what is really the value of that in many circumstances. Who's going to put it in? What happens after you get it in if other than drawing blood? Even if you supply plasma expanders, where do you keep those? Do you put them in each car? Do you keep them at a central unit? What happens when that runs out? Do you evacuate people from a country, let's just say, in which the authorities are unsure of the blood supply?

This is coming up more and more often. I don't have an answer for you right now, but I think this is something that, for those of us who have to deal with evacuation policies, we'll have to address in the fairly near future.

DR. KEYSTONE: There is a move, however, among travel medicine information providers, like Shoreland (ph) and others, to provide through their service lists of hospitals, what the blood supply is like, whether it's tested, whether it's quality tested, and I think you should know that they're becoming increasingly availablekids.

The Shoreland Encompass program—and by the way,this conflict of interest because I do work for Shoreland, does have a considerable amount of information on Latin American hospitals, on their staff, their services ,their expertise, whether the blood supply is safe, whether it's tested appropriately etc.. The hope is that this kind of information will be available about hospitals globally. There are other people who provide electronic information who are trying to look at that as well.

So I think that will be very useful for the corporate traveler to get that kind of information.

MR. [NOT KNOWN]: Jay, could you give us a little more information about that? One of the issues that we face is the time lag between the times the information becomes available on a blood supply at a hospital or what the facilities are in a particular location and keeping that updated. We are plugged into UN services, WHO services outside of that, and yet we find that the report we get was great for a year and a half ago. And we can't keep revisiting these. A comment?

DR. KEYSTONE: You're absolutely correct to be concerned about this. But my understanding, for example, for Shoreland ,is that they have developed reputable, reliable links with health care providers that they know, that they trust, and that that information is then updated through the system by someone who has made those kinds of contacts.

Now, this is not yet global. It's local.It is mostly for Latin America. MS.Kalata [NOT KNOWN]: There are currently over 60 countries around the world. DR. KEYSTONE: The information about this system can be obtained through ShorelandÕs web address, www.shoreland.com. I don't make enough money from Shoreland to be giving out their Web address. MS. [NOT KNOWN]: And that's public information.

DR. KEYSTONE: Well, no. That's the problem. Shoreland has two levels of information, my understanding, and honestly, as much as I work for them, I don't even know it all. They have the public website, which is tripprep.com. They have Travax (. And then they have Encompass that we've just talked about, which is a subscriber program. And the reason it is a subscriber Program is that it is very costly to maintain this database and send people directly to visit the institutions to gather that information.

MR. [NOT KNOWN]: Just remember, this is no guarantees.

DR. KEYSTONE: Absolutely.

MR. [NOT KNOWN]: These are not—there's no quality control [inaudible] several doctors, more than one doctor, looking in the same place saying, yes, they're doing this and looking at the dates on their reagents. But, I mean, that's not—it might not be still reality.

DR. KEYSTONE: But it may be a lot better than what you could get anywhere else.

MR. [NOT KNOWN]: That's right, absolutely. I just didn't want to say it was a blanket—

DR. KEYSTONE: No, no. And I certainly wouldn't—I agree with you.

DR. GRIZZARD: Coming back, real-time information is really very difficult to obtain.

Well, I tell you what. It's just about time to quit. I'd like to thank all of you for your questions, for your participation. It's getting close to 3:00. Get your coffee.

Jay, for those of us over 50, I'd just remind you that there are things you can do about this. As it said in the newspaper the other day, I take ginkgo for my memory, aspirin for my arthritis, and ginkgo for my memory.

[LAUGHTER]

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