It all began in 2002 with Severe Acute Respiratory Syndrome (SARS), the government sent out a request to get travel histories on all patients with respiratory symptoms. Next came bird flu, then H1N1 and Middle Eastern Respiratory Syndrome (MERS) and with each new outbreak, healthcare workers were asked to get travel histories. Then came Ebola and again travel history became important. And now, the mosquito-borne Zika virus is the newest disease for which travel history is important.
There is another infection that also requires travel history and it is not respiratory or vector-borne. It is carbapenem-resistant enterobacteriaceae (CRE). This is a superbug organism for which we currently have no treatment. This organism has come to us originally by way of India and believed to be the result of medical tourism—persons going to other countries for less expensive surgery and other healthcare procedures. Currently, carbapenemase-resistant Klebsiella pneumoniae (CRKP) is the most common form in the U.S., where approximately 22 states now report cases of CRE infection. CRKP is resistant to almost all available antimicrobial agents and therefore has a high mortality rate.
Patient assessment for possible CRE infection would include patients presenting with sepsis, urinary tract infection, wound infection, or if they have indwelling devices. Critical travel history would include any hospitalizations over-night outside the U.S. in the previous 6 months. So, with this organism, the focus is on signs of sepsis and medical devices and procedures conducted outside the U.S., rather than respiratory signs and symptoms.
Cases in the U.S. have primarily been noted in patients who received medical care in India, Greece, Italy, Pakistan or Vietnam. However, one outbreak occurred at the UCLA Medical Center in 2015 and was related to exposure to duodenoscopes. Investigation revealed that there was a breach of approved cleaning measures that led to the outbreak, which resulted in two deaths and more than 170 persons possibly exposed. This highlights the fact that history of previous hospital stay is also important with CRE, since outbreaks have been reported in the U.S.
At this point, the handwriting should be on the wall: Travel history is an essential part of patient assessment in today’s world. We are a very global society. All patient assessment sheets should be revamped on a national basis to make sure this is a standard part of assessment for all patients. The importance of this should also be added to the National Registry Clinical skills sheets and textbooks chapters. EMS personnel are often the first contact a patient may have and this assessment will assist all members of the healthcare community,
1. Centers for Disease Control and Prevention (CDC). (n.d.) Carbapenem-resistant enterobacteriaceae (CRE) Infection: Patient FAQs. Retrieved on March 15, 2016, from http://cdc.gov/hai/organisms/cre/cre-patientFAQ.html
2. CDC. Morbidity and mortality weekly report: Guidance for control of infections with carbapenem-resistant or carbapenemase-producing enterobacteriaceae in acute care facilities. March 20, 2009/58(10);256-260.
3. CDC. (n.d.) CDC Statement: Los Angeles County/UCLA investigation of CRE transmission and duodenoscopes. Retrieved on March 15, 2016, from http://cdc.gov/hai/outbreaks/cdcstatement-LA-CRE.html.