Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign?
Authors: Trish M. Perl, Connie Savor Price
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions21 April 2020Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign?FREETrish M. Perl, MD, MSc and Connie Savor Price, MDTrish M. Perl, MD, MScUniversity of Texas Southwestern Medical Center, Dallas, Texas (T.M.P.) and Connie Savor Price, MDDenver Health and Hospital, Denver, and the University of Colorado School of Medicine, Aurora, Colorado (C.S.P.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-0643 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The international community has witnessed the emergence of novel coronavirus–associated respiratory diseases, including severe acute respiratory syndrome (SARS) in 2002 to 2003 and Middle East respiratory syndrome (MERS) in 2012 to 2013. In 2014, Ebola emerged in western Africa, where it had not previously been seen. Now, 18 years after SARS, we are in the midst of an epidemic known as coronavirus disease 2019 (COVID-19), caused by the novel SARS coronavirus 2 (SARS-CoV-2). With these infections come significant morbidity and mortality, tremendous health care disruptions and resource use, and collateral economic and societal costs.In the first 6 weeks of the current epidemic, the number of cases of COVID-19 has surpassed those of SARS and MERS during the course of those epidemics, raising questions about strategies to control the spread of infection. A major strategy has focused on "macro" public health responses, such as travel restrictions, public gathering and school closures, and city quarantines. However, experience with other respiratory viruses suggests that travel restrictions have a limited effect. Mateus and colleagues (1) found that such restrictions decreased new cases of influenza by only 3% and delayed but did not prevent influenza epidemics. Similarly, Errett and colleagues (2) identified minimal evidence to support the effectiveness of travel bans as a control measure for emerging infectious diseases. Read and colleagues (3) suggest that, because only 5% of infections have been identified, even a travel reduction that is 99% effective may reduce the epidemic outside Wuhan province by no more than 24.9%. Other investigators (4) estimate that almost 59 000 cases occurred in Wuhan and 3500 in other regions of China before the travel ban was implemented. Hence, the ban may simply reduce the progression of the outbreak by only 3 to 5 days within China. Finally, a recent report (5) suggests that 46% of cases would be missed by airport-based screening because of COVID-19's incubation period, the spectrum of symptoms, and the time during the incubation period in which persons may fly. Available data specific to COVID-19 suggest that screening and restricting travelers may have a limited effect on containment.Because travel interventions will not prevent transmission to new regions, vigilant infection control measures are critical: aggressive patient screening, active contact tracing, and isolation. Ebola, SARS, MERS, and COVID-19 all have nonspecific clinical presentations, but each emerged in a specific geographic area, and the epidemiologic links to these regions were key in guiding clinicians to implement proper barrier protections and patient evaluation. This led public health agencies, including the World Health Organization and U.S. Centers for Disease Control and Prevention, to recommend a systematic approach to patients presenting with a relevant exposure and symptoms of an acute respiratory viral infection, such as SARS-CoV or MERS-CoV. Early recognition of potential cases was critical in limiting transmission by enabling enhanced prevention and control of infections and preemptive care. Mathematical models developed during the SARS and MERS outbreaks support the effectiveness of such strategies. Identifying patients with potential exposure or symptoms facilitated prompt isolation and, in health care settings, led to additional prevention and case-finding measures. Of note, it triggered health care personnel to use personal protective equipment, patient isolation, and hand hygiene. In the SARS outbreak, these measures prevented transmission of SARS-CoV even without the availability of effective vaccines and therapy. Indeed, these interventions have demonstrated superior efficacy over travel restrictions: Respiratory virus infections were reduced by 46% through hand hygiene, 77% through masks or respirators, and 32% to 33% through gowns and gloves (6).Climate change, increasing global travel, and an evolving human–animal interface are likely to increase the frequency of novel infectious diseases. Although early identification of acute respiratory viral illness is key to trigger actions to interrupt the chain of transmission, it is often delayed. Surveillance systems using artificial intelligence are promising, as is more effective personal protective equipment, but patient vital signs are available now as powerful indicators of how quickly we need to intervene and what path to take.Vital signs—temperature, heart rate, respiratory rate, and blood pressure—help us assess a patient's health status, triage the patient to appropriate care, determine potential diagnoses, and predict recovery. Given the increasing frequency of emerging infectious diseases that are geographically linked, is it time to add a "fifth vital sign"? A simple, targeted travel history can help us put symptoms of infection in context and trigger us to take a more detailed history, do appropriate testing, and rapidly implement protective measures. An expanded set of vital signs may signal a lurking communicable infection and flag potential risks to health care personnel and other patients. Furthermore, electronic health records can integrate travel history with computerized decision support to suggest specific diagnoses in febrile returning travelers (7, 8).The lessons from SARS, MERS, and Ebola tell us that early case identification is critical to protect both patients and those caring for them. In 2014, a patient presented to a Dallas emergency department after returning from Liberia with low-grade fever, abdominal pain, dizziness, nausea, and headache (9). The patient had Ebola. Because clinicians did not obtain the 1 potentially distinguishing clinical clue—a travel history—patient and caregiver well-being was compromised.All members of the health care team need training on how to integrate key epidemiologic information, such as travel history, into their risk assessments, in the same way they are trained to ask about tobacco exposure to assess risks for cancer and heart disease. They need a simple script to elicit clues for emerging infectious diseases and must be informed about current emerging pathogenic threats, such as COVID-19. Travel history could serve as a warning sign that prompts protective measures. Of course, we must implement such a change thoughtfully, with attention to unintended consequences—as shown by the inclusion of pain scores as a vital sign, which may have contributed to the opioid misuse crisis. However, we believe that the urgent threat of communicable diseases makes collection of travel history necessary. The current novel coronavirus is a troublesome reminder—on the heels of SARS, MERS, and Ebola—that national, regional, and institutional planning must learn from the past and remain vigilant and focused on vital measures to protect us all.References1. Mateus AL, Otete HE, Beck CR, et al. Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review. Bull World Health Organ. 2014;92:868-80D. [PMID: 25552771] doi:10.2471/BLT.14.135590 CrossrefMedlineGoogle Scholar2. Errett NA, Sauer LM, Rutkow L. An integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure. J Emerg Manag. 2020;18:7-14. [PMID: 32031668] doi:10.5055/jem.2020.0446 CrossrefMedlineGoogle Scholar3. Read JM, Bridgen JRE, Cummings DAT, et al. Novel coronavirus 2019-nCoV: early estimation of epidemiological parameters and epidemic prediction. Preprint. Posted online 24 January 2020. medRxiv 20018549. doi:10.1101/2020.01.23.20018549 Google Scholar4. Chinazzi M, Davis JT, Ajelli M, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (2019-nCoV) outbreak. Preprint. Posted online 11 February 2020. medRxiv 20021261. doi:10.1101/2020.02.09.20021261 Google Scholar5. Quilty BJ, Clifford S, CMMID nCoV Working Group. et al. Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). Euro Surveill. 2020;25. [PMID: 32046816] doi:10.2807/1560-7917.ES.2020.25.5.2000080 CrossrefMedlineGoogle Scholar6. Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev. 2011:CD006207. [PMID: 21735402] doi:10.1002/14651858.CD006207.pub4 CrossrefMedlineGoogle Scholar7. Demeester RP, Bottieau E, Pini A, et al. Prospective multicenter evaluation of the expert system "KABISA TRAVEL" in diagnosing febrile illnesses occurring after a stay in the tropics. J Travel Med. 2011;18:386-94. [PMID: 22017714] doi:10.1111/j.1708-8305.2011.00566.x CrossrefMedlineGoogle Scholar8. Edberg SC. Global Infectious Diseases and Epidemiology Network (GIDEON): a World Wide Web-based program for diagnosis and informatics in infectious diseases. Clin Infect Dis. 2005;40:123-6. [PMID: 15614701] CrossrefMedlineGoogle Scholar9. Chung WM, Smith JC, Weil LM, et al. Active tracing and monitoring of contacts associated with the first cluster of Ebola in the United States. Ann Intern Med. 2015;163:164-73. [PMID: 26005809]. doi:10.7326/M15-0968 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Thomas w. Filardo, M.D.Chief Lexicographer and New Terms Editor, Stedman's Medical Dictionary2 April 2020 Travel is not a vital sign While no one doubts – or ought doubt – the importance of travel history in any complete patient history, such information does not comprise a sign at all, despite the critical nature of such information in the current COVID-19 pandemic: signs are measured physical variables, as others here have commented. Over the past decades there have been attempts to attach "the fifth vital sign" to a number of historical issues, some more properly fitting into the symptom category, others belonging within aspects of social or other sub-categories of the personal history: smoking status, health literacy, pain, sleep habits, contraceptive use; and likely others which have escaped my attention.Clarity in recording history and physical exam findings remains highly important; confusing the nature of signs, symptoms, and historical aspects cannot improve the quality of this essential information. Steven Yale MD, Halil Tekiner PhD, Eileen S. Yale MD, Joseph J Mazza MDUniversity of Central Florida, Department of the History of Medicine and Ethics Erciyes University School of Medicine, University of Florida, Marshfield Clinic Research Institute23 March 2020 Travel is Not a Vital Sign TO THE EDITOR: We concur with the comments made by Perl and Price1 regarding the importance that an accurate travel history be obtained given recent international emerging infectious disease outbreaks. Taking a detailed travel like a sexual, family, past, social, and occupational, history is essential in order to identify key findings that may assist in appropriate triage and diagnosis. These are not however, vital signs. The term "vital signs" had been used long before the idea of its application in the clinical decision making process gained importance in the 19th century. One of the earliest papers appeared in the literature was in 1866 as reported by Edward Seguin, "The cases are accompanied by a diagram, fac simile of the tables of "Vital Signs," used at the bedside to make the daily record of temperature, pulse-beats and respiration. This one only differs from ours in that on it are represented the curves for three cases, whereas usually but one case is put upon a table (2, p. 193)."Harvey Cushing in 1903 called for including blood pressure in the medical record, "At the present time, largely owing to the convenience of our timepieces, pulse-rate is commonly recorded alongside of the temperature and perhaps of the respiration on our clinical charts, to the utter neglect of a numerical record of that vascular quality which in many condition is incomparably of greater clinical consequence, namely, arterial tension (3, p 252)."The term "vital signs" was appropriately named as it represents a finding found on physical examination through observation (respiratory rate), palpation (pulse), and device (blood pressure and temperature) or signs that are vital or essential for life. Thus, in order to call something a vital sign it must meet the criteria as being 1) objective and quantifiable, 2) required for life. We contend that medical terminology be accurate and precise so that it can be easily communicated and understood. Thus, such terms as pain, physical activity, functional status, delirium, and travel are not vital signs since they do not meet the medical definition. In fact, the only other function that merits this definition, and that is sometimes included as a vital sign, is the oxygen level as measured by pulse oximetry.4 What these emerging infections should remind physicians is that despite technological advancements, the core information obtained from the history and physical examination remains paramount to appropriate diagnosis and delivery of meaningful cost-effective medical care. References1. Perl TM, Price CS. Managing emerging infectious diseases: should travel be the fifth vital sign? [published online ahead of print, 2020 Mar 3]. Ann Intern Med. 2020;10.7326/M20-0643. doi:10.7326/M20-0643.2. Seguin E. The use of the thermometer in clinical medicine Chicago Med J. 1866;23:193-201. 3. Cushing H. On routine determinations of arterial tension in operating room and clinic. Boston Med Surg J 1903;148:250-256. doi: 10.156/NEJM190303050481002/.4. Neff T. Routine oximetry. a fifth vital sign? Chest. 1988;94:227. doi: 10.1378/chest.94.2.227°. Richard M Fleming, PhD, MD, JD (FHHI-OI-Camelot); Matthew R Fleming, BS, NRP (FHHI-OI-Camelot); William C Dooley, MD (Oklahoma University Health Science Center); Tapan K Chaudhuri, MD (Eastern Virginia Medical School)FHHI-OI-Camelot; Oklahoma University Health Science Center; Eastern Virginia Medical School31 March 2020 PCR or FMTVDM: The question over who should be tested, depends upon the test being used and what you are trying to accomplish with the test – screening, or diagnosis and determination of treatment results. PCR swabs are touted as being important for our understanding of CoVid-19. While they do provide limited information about the prevalence of disease, taking into account sensitivity and specificity errors, they do not provide diagnostic information – and that is the information physicians and the general public are looking for – noting particularly that a PCR test will not tell you who is contagious, who is going to become critically ill, or the outcome of those individuals.As of yesterday, 29 March 2020, it appears we have accepted the loss of 100K to 200K Americans – or more – using the current approach of trying to flatten the curve and limit the spread of CoVid-19. Understanding that viruses are never eradicated and they will continue to recur year-after-year means we are willing to accept a yearly loss of people from CoVid-19. Even the potential future development of a vaccine does not – as we have seen with all vaccines – eliminate the yearly cycle of disease and death.More important than a PCR screening test, is the need for a diagnostic test [1]. One that can quantitatively measure the resulting inflammatory process and pneumonia [2-5] caused by CoVid-19 (CVP) as well as determine the effectiveness of treatment in each individual. The use of FMTVDM will allow us to direct patient treatment - determining which of the proposed treatments save lives, and which do not. References:1. The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) using same state single or sequential quantification comparisons. Patent Number 9566037. Issued 02/14/2017. 2. Fleming RM. Chapter 64. The Pathogenesis of Vascular Disease. Textbook of Angiology. John C. Chang Editor, Springer-Verlag New York, NY. 1999, pp. 787-798. doi:10.1007/978-1-4612-1190-7_64. 3. Fleming RM. The Fleming Unified Theory of Vascular Disease: A Link Between Atherosclerosis, Inflammation, and Bacterially Aggravated Atherosclerosis (BAA). Angiol 2000; 51: 87-89. 4. Fleming RM, Boyd L, Forster M. Reversing Heart Disease in the New Millennium - The Fleming Unified Theory, Angiology 2000;51(10):617-629. 5. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. 2020;47(4):753-755. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019- 04668-y https://rdcu.be/b22Dd Disclosures: FMTVDM issued to first author. Chia-Yen Dai, M.D., Ph.D., Ming-Lung Yu, M.D., Ph.D., Yuh‐Jyh Jong MD, DM Sci Kaohsiung Medical University Hospital, and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan 30 March 2020 Importance of the travel history: evolve with time We read with interest the paper by Perl et al. mentioned that travel history, a key epidemiologic information to integrate into risk assessments of the health care team, could serve as a warning sign that prompts protective measures for the novel SARS coronavirus 2 (SARS-CoV-2) infection (1). Habibi et al. recently described many of the travel restrictions by some countries during the 2019-nCoV outbreak are not supported by science or WHO that was advised by the International Health Regulations (2005) (2). Nevertheless, the first patient of coronavirus disease 2019 (COVID-19) in many countries, as the United States in January 2020 (3), actually has the common travel history to the Wuhan, China. In response to the outbreak of COVID-19, the Taiwan Centers for Disease Control (CDC) has call on the staff in the medical community to be vigilant and implement the "TOCC (travel history, occupation, contact history and cluster)" consultation and related infection control measures on January 2, 2020 (4). Taiwan's experience by far provides an exemplary model in earlier fighting COVID-19, with the quick response including travel restriction for persons from Wuhan city since January 23, 2020 and then from other cities and even whole China described in Taiwan by Wang et al. (5). As of March 28, 2020, total 283 laboratory-confirmed patients, significantly less than other countries were reported in Taiwan with two deaths after tests for 29,389 individuals (4). It is noteworthy that 241 (85.2%) of the 283 patients were imported cases with travel history to other countries (4) which indicates that traveling is still currently the major causes of COVID-19 in Taiwan. Of course, after declaring the outbreak of the new coronavirus is a pandemic on Mar 11, 2020 and currently 509,164 confirmed cases and 23,335 deaths globally by the World Health Organization on March 27, 2020, the travel history may become less important in the countries with a rapidly increased number of patients. Hence we believed that travel history plays a crucial and very important role on the spreading of the COVID-19 before the community infection or transmission developed. On the other hand, it has to be greatly noted that after the isolation or lockdown measures are eased, the possibility of the second waves of COVID-19 outbreak may occur again with the communication of people particularly by travelling. We consider that the importance of travel history indeed changes as the epidemic of COVID-19 evolves.References1. Perl TM, Price CS. Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign? Ann Intern Med. 2020 (Published online March 3, 2020) doi: 10.7326/M20-0643.2. Habibi R, Burci GL, de Campos TC, Chirwa D, Cinà M, Dagron S, et al. Do not violate the International Health Regulations during the COVID-19 outbreak. Lancet. 2020;395:664-6. 3. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382:929-36. 4. Taiwan Center for Disease Control. https://www.cdc.gov.tw/En5. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan. Big data analytics, new technology, and proactive testing. JAMA. (Published online March 3, 2020.) doi:10.1001/jama.2020.3151 Kristi L. Koenig, MD, FACEP, FIFEM, FAEMSUniversity of California at Irvine, County of San Diego HHSA EMS19 March 2020 Travel history should be first, not fifth: The Vital Sign Zero Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS [email protected] Professor Emerita of Emergency Medicine & Public Health, University of California at Irvine Medical Director, EMS, County of San Diego, Health & Human Services Agency No conflicts of interest Travel history should be first, not fifth: The Vital Sign Zero We appreciate the important letter by Perl and Price suggesting the need for an additional vital sign to aid in early detection of patients with a contagious emerging infectious disease that is geographically linked. This concept supports the 3I (Identify-Isolate-Inform) approach we advocate using during initial patient encounters, including for the current COVID-19 pandemic . However, our approach has been to consider this new public health vital sign to be the first parameter to assess and not a fifth, after the traditional four vital signs are measured. In fact, during the 2014 Ebola outbreak, we published the concept of a "Vital Sign Zero" to stress the importance of stopping to assess travel history prior to touching a patient to measure standard vital signs. For transmissible infectious diseases, it is critical to screen patients for an epidemiologic risk factor immediately so that they can be isolated and health care workers can don appropriate personal protective equipment prior to touching the patient to collect the four routine triage vital signs. As new viruses emerge, it will remain important to keep up to date on regions with epidemiologic disease links so that rapid screening and immediate isolation can be accomplished. This is an essential process needed to limit disease transmission to both health care workers and the public. In summary, we support the authors' suggestion, but believe that travel history should be the first and not the fifth vital sign. Perl TM, Price CS. Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign? Ann Intern Med. Mar 3, 2020. Koenig KL, Beÿ CK, McDonald EC. 2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus. Western Journal of Emergency Medicine. 2020. https://escholarship.org/uc/item/0ch1h302, Accessed March 7, 2020. Sisson P. How a San Diego doctor fought infectious disease with just three words. San Diego Union Tribune. https://www.sandiegouniontribune.com/news/health/story/2020-02-24/with-just-three-words-san-diego-doctor-has-helped-change-how-hospitals-handle-infectious-disease-risk, Feb 24, 2020.accessed Mar 7, 2020. Koenig KL. Identify, Isolate, Inform: A 3-Pronged Approach to Management of Public Health Emergencies. Disaster Med Public Health Prep. 2015;9(1):86-87. Koenig KL. COVID-19: A Call for Science-Informed Management, Evidence Aid. Mar 3, 2020. https://www.evidenceaid.org/covid-19-a-call-for-science-informed-management/, accessed Mar 7, 2020. Koenig KL. Ebola Triage Screening and Public Health: The New "Vital Sign Zero". Disaster Medicine and Public Health Preparedness, available on CJO2014. Available at: http://journals.cambridge.org/download.php?file=%2FDMP%2FDMP9_01%2FS1935789314001207a.pdf&code=a50034d4ef76f95114e1b68b258da7cd. Accessed Mar 7, 2020. Author, Article, and Disclosure InformationAffiliations: University of Texas Southwestern Medical Center, Dallas, Texas (T.M.P.)Denver Health and Hospital, Denver, and the University of Colorado School of Medicine, Aurora, Colorado (C.S.P.)Acknowledgment: The authors thank James "Brad" Cutrell, MD, for his comments and suggestions.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0643.Corresponding Author: Trish M. Perl, MD, MSc, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard Y7.312, Dallas, TX 75390; e-mail, Trish.[email protected]edu.Current Author Addresses: Dr. Perl: University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard Y7.312, Dallas, TX 75390.Dr. Price: Denver Health and Hospital, 777 Bannock Street MC-2600, Denver, CO 80204.Author Contributions: Conception and design: T.M. Perl, C.S. Price.Drafting of the article: T.M. Perl, C.S. Price.Critical revision of the article for important intellectual content: T.M. Perl, C.S. Price.Final approval of the article: T.M. Perl, C.S. Price.Administrative, technical, or logistic support: T.M. Perl, C.S. Price.Collection and assembly of data: T.M. Perl, C.S. Price.This article was published at Annals.org on 3 March 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byCOVID-19 and Tuberculosis: Two Knives in a SheathA Comprehensive Assessment of The Eight Vital SignsAutomated Travel History Extraction From Clinical Notes for Informing the Detection of Emergent Infectious Disease Events: Algorithm Development and ValidationBlood Pressure Sensors: Materials, Fabrication Methods, Performance Evaluations and Future PerspectivesEvaluation of remote monitoring device for monitoring vital parameters against reference standard: A diagnostic validation study for COVID-19 preparedness 21 April 2020Volume 172, Issue 8Page: 560-561KeywordsCOVID-19Cancer epidemiologyHealth careInfectious diseasesMiddle eastern respiratory syndromePulmonary diseasesRisk assessmentsSARS coronavirusUpper respiratory tract infectionsVital signs ePublished: 3 March 2020 Issue Published: 21 April 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...