Over the last several years, infections related to medical travel have received increasingly prominent news coverage. Most recently, a number of U.S. and Canadian patients became infected with an antibiotic-resistant strain of bacteria after undergoing surgery at a hospital in Tijuana, Mexico.[1]
While there is a potential risk of a post-operative infection in any hospital or clinic environment – regardless of its location or reputation[2], the risks are higher in clinical environments that do not adhere to strict hygienic regulations, or in locations with a higher incidence of infectious diseases. For example, many countries promoting themselves as medical travel destinations are located in tropical and subtropical regions where malaria, dengue fever, enteric fever, and other endemic infections exist. [3] Even in the U.S. and the European Union, there are currently several outbreaks of measles being reported. [4] [5] With the continued increase in medical travel[6], there is a higher risk of patients bringing infectious agents into a country or region, or returning home with difficult-to-treat infections.
In the remainder of this article we will look at infection prevention and control from the perspective of a medical travel patient and highlight best practices as advocated by the Global Healthcare Accreditation (GHA) Program Standards[7].
Developing an infection prevention & control plan for medical travel patients
For healthcare providers targeting medical travelers, it is important to strengthen your ability to detect, prevent, treat and control infections, so as to mitigate the opportunity for pathogens to enter the country, spread during care or after the patient returns home.
Because there are so many components in an infection prevention and control program - from proper hand hygiene to the sterilization of instruments and management of infectious waste, there needs to be a documented plan on how infection prevention and control is implemented in the medical travel program. According to the GHA standards[8]:
- The infection prevention and control program should have one or more qualified leaders and appropriate policies and procedures.
- The infection prevention and control program is planned based on best-practices as recognized by the World Health Organization (WHO) the National Center for Disease Control (CDC) or other recognized authority. The best practices should include at least:
- Hand hygiene and the proper use of barrier precautions such as masks, gowns, goggles, etc.
- Instrument cleaning, disinfection, sterilization and storage
- The proper disposal of infectious waste, sharps and needles
- Use and authorized re-use of single-use medical devices
- The proper cleaning and sterilization of endoscopy and similar equipment
- Infection risks and rates are monitored for medical travelers as a component of the organization’s risk management and quality improvement program.
- There is ongoing staff education on the organization’s infection prevention and control program as it relates to medical travelers.
These points are pretty self-explanatory; however, it is worth taking a closer look at the third bullet:
Monitoring infection risks & rates for medical travelers
Infection risks and rates should be monitored for medical travelers as a component of the organization’s risk management and quality improvement program.[9] In other words, in order to effectively monitor infection risks and rates for medical travelers, the organization must have the ability to segregate its data specific to medical travelers, and preferably, the ability to drill down to an even more granular level (eg. geographic region of origin, types of surgical procedures, length of stay, etc..). The unique insights gained will allow the organization to become more proactive and effective in mitigating the risk of infections among its medical travel populations. For example, if you know that patients from a certain region are 20 percent more likely to bring in an infectious agent, you can implement stricter protocols to monitor and educate these patients. It bears emphasizing, however, that before any of the above activities can be carried out, the organization must clearly articulate its definition of a medical travel patient.
- Is it someone who travels from outside the country for the primary purpose of seeking medical or dental services?
- Is it someone who travels from another region in the same country?
- Is it an expatriate who is seeking medical services?
- Might it be a tourist who becomes ill or experiences an injury while in the country?
It may be only one or all of the above choices, the important thing is to define your medical travel patient. Otherwise, how will you know who to segregate?
Infection prevention & control covers all phases of medical travel
For healthcare providers serving medical travelers, infection prevention and control should not wait until the patient arrives at the facility; it must begin with the patient assessment process prior to the patients' travel, continue through arrival and eventually on to departure back to the patient's home. The medical travel program should also be continuously vigilant as to infection risks in the home countries of its patient populations, regarding global communicable disease outbreaks and trends, and kept informed by monitoring data from its own program in terms of infections from its community and infections acquired during the care process. It is important for prospective patients to be informed of all risks so that they can plan and practice preventive measures and understand the impact on obtaining a visa and on the return to their home country. As infection risks change in the destination country, the communications with prospective patients should be updated and kept accurate during all phases of the medical travel care continuum.”[10]
For example[11]:
- There should be an understanding of the disease history and current health status of a patient (and family when relevant) prior to their acceptance and/or arrival at the destinatio
- The patient should be informed of any potential infection prevention and control restrictions related to a VISA application or entry into the destination country.
- The patient should be informed of infection risks in all phases of the medical travel care continuum that may impact their care, level of activity during recuperation and return to their home country.
- The organization or medical travel program keeps updated on domestic, regional and international infectious disease trends and alerts for traveling patients.
To achieve these objectives, the organization must have clearly defined policies and protocols as to how it assesses the patient prior to travel; how it communicates infection control information to the patient, and how it keeps abreast of the latest international disease trends and alerts.
Taking a proactive approach to infection prevention & control
With the increasing globalization of healthcare services, population migration and the threat of Antimicrobial resistance [12], healthcare providers should take a proactive approach to managing infection prevention and control. This includes ensuring appropriate planning across the entire medical travel care continuum, implementing best practices as advocated by organizations such as WHO and the CDC, staying current on the emergence and transmission of infectious diseases internationally, educating patients and staff regarding best practices, and monitoring infection prevention and control (for medical travelers) as part of a robust risk management and quality improvement program.
[1] https://windsorstar.com/health/canadians-who-had-surgery-at-tijuana-clinic-at-risk-of-infection-health-agency/wcm/a313d3cb-a952-4e99-bfae-204c18958eb4
[2] https://wwwnc.cdc.gov/travel/notices/alert/drug-resistant-infections-mexico
[3] https://academic.oup.com/cid/article/57/12/1752/379123
[4] https://ecdc.europa.eu/en/publications-data/monthly-measles-and-rubella-monitoring-report-march-2019
[5] http://fortune.com/2019/03/08/measles-outbreak-cdc-vaccines-2019/
[6] https://www.onlinevisatravel.com/global-medical-tourism-on-the-rise/
[7] GHA Standards 4.1, effective January 1st, 2019
[8] GHA Standards 4.1, Infection Prevention and Control, IC.1.1, IC.1.2, IC.1.3, IC.1.4
[9] GHA Standards 4.1, Infection Prevention and Control, IC.1.3
[10] GHA Standards 4.1, Infection Prevention and Control
[11] GHA Standards 4.1, Infection Prevention and Control, IC.2.1, IC.2.2, IC.2.3, IC.2.4,
[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768623/
*Medical travel is also commonly known as medical tourism or health tourism.
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