Travel health (th) is a specific medical discipline designed to prevent and manage illnesses associated with international travel. TH is usually delivered through primary healthcare (PHC) with support from specialised units and central public health authorities. There is an ever-increasing number of international travellers often visiting dest- inations with new health risks not known at home. Every effort should be made to protect these travellers against health risks, such as malaria or yellow fever, at their destinations. International travel reached 1.4 billion travellers in 2019.1 As international travel is increasing in popularity, so too is the risk of associated disease outbreak. Known culprits are megacities with high population density, centralised food production, an ageing population and an increasing number of immunocompromised people.2 Concurrently, travellers and migrants may carry with them infections from the countries they visited or moved from and the receiving country must ensure that these infections do not pose a risk to the resident population. Risk of spreading infections by travellers from one country to another is regulated through the International Health Regulations of the World Health Organization (WHO).3 Oman is a culturally diverse country and has a heterogeneous population of around 4.6 million people. Of these, approximately 2.7 million (58.8%) are Omani nationals and 1.9 million (41.2%) are expatriates.4 Omanis, as is the global trend, are travelling across borders more than ever before. Throughout history, Oman and Tanzania and particularly Zanzibar, remain intricately connected locations. East Africa has always been a common travel destination for Omanis and this rise in popularity in international travel is making it even more so; in fact, direct flights from Muscat to Zanzibar have resulted in strengthened trade links. Other common ports of call are Mecca, Saudi Arabia, where many Omanis travel for Hajj and Umrah, and South Asia, particularly India, Bangladesh and Pakistan, home to the large migrant expatriate population who live and work in Oman.5 In addition, many Omanis go for medical tourism especially to Thailand and India. Oman's Ministry of Health (MoH) is in the process of establishing a TH service at a national level; this is part of meeting the needs for national health security, meeting the requirements and preparedness for epidemics and the commitment of the government to reach univ- ersal health coverage. Oman has a sophisticated and well-organised PHC system that offers care at no cost to citizens. The system is poised to provide pre-TH care to Omanis looking to travel internationally.5 In this editorial, we will discuss the needs of the population and how the MoH will expand its services to address these requirements. Protecting Travellers in Oman The purpose of the TH service is to establish and integrate pre-TH services into PHC in Oman’s public and private healthcare facilities. The TH service shall ensure that PHC physicians and nurses are equipped with up-to-date information of public health threats abroad and of imported infectious diseases into Oman. Although a pre-TH service is already well established for Hajj travellers, it still needs to be expanded and made accessible to all travellers. The existing pre-TH service includes a sustained supply of relevant vaccines and drugs, especially for malaria chemoprophylaxis. A recent review of severe malaria cases imported into Oman underline the need 1Directorate General of Disease Surveillance and Control and 2Primary Health Care, Ministry of Health, Oman; 3World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt *Corresponding Author’s e-mail: salabri@gmail.com األمهية املستقبلية للصحة املتعلقة ابلسفر يف الشرق األوسط فرصة سلطنة ُعمان لتعزيز خدماهتا �سيف العربي، �سعيد اللمكي، ا�سكيلد بيرت�سن، اأحمد املنظري The Future Importance of Travel Health in the Middle East Oman’s opportunity to enhance its services *Seif Al-Abri,1 Said Al-Lamki,2 Eskild Petersen,1 Ahmed Al-Mandhari3 editorial Sultan Qaboos University Med J, May 2020, Vol. 20, Iss. 2, pp. e121–124, Epub. 28 Jun 20 Submitted 23 Nov 19 Revision Req. 28 Jan 20; Revision Recd. 8 Apr 20 Accepted 6 May 20 https://doi.org/10.18295/squmj.2020.20.02.001 This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://creativecommons.org/licenses/by-nd/4.0/ The Future Importance of Travel Health in the Middle East Oman’s opportunity to enhance its services e122 | SQU Medical Journal, May 2020, Volume 20, Issue 2 for prophylaxis as only 1 in 13 of these cases had taken preventive measures.6 The TH service will be supported by the “TRAVAX” decision support computer system (Glasgow, UK, https://www.travax.nhs.uk/) maintained by Public Health Scotland, providing on-line up-to- date information. One study found that only 22.5% of residents of Oman departing from Muscat International Airport had received pre-travel advice, only 6.9% had taken any pre-travel preventive measures like a prescription for malaria chemoprophylaxis or immunisations and only 38.2% had TH-insurance coverage.7 Another study among primary care physicians found that 58.3% had given a pre-travel consultation during the month prior to travel and 79.6% had given a post-travel consultation, concluding that TH does currently occur in PHC.8 To people looking forward to a trip abroad, the expanded TH service will provide statistics on the use of vaccines and malaria prophylaxis and disseminate information on side effects from vaccines and malaria prophylaxis that may arise. Travellers will also receive counselling on non-communicable diseases and some recommendations in case they are travelling for medical tourism. Protecting the Country Infections travel with people. To ensure rapid diagnosis, treatment and notification, any illness acquired abroad that may be of national public health concerns must be dealt with swiftly and systematically. The TH service will strengthen the existing surv- eillance of infectious diseases in the country by ensuring early diagnosis and providing adequate treatment of infections acquired outside of the country at all levels of healthcare and in both public and private facilities. PHC facilities will receive information on imported infectious diseases into Oman via the existing weekly bulletin published by the Directorate General of Disease Surveillance and Control. This ensures that surveillance of imported infections prevent public health events and are in accordance with the International Health Regul- ations of the WHO. Post-travel surveillance in travellers and migrants can be difficult; better access to expert consultations on illness in travellers and migrants is needed. We propose to establish a “fever service”—a hotline for public and private TH clinics and hospitals in Oman providing access to specialised physicians and nurses functioning as nodal centres for comprehensive pre- and post-travel advice. The model is the “imported fever service” established in the UK where patients difficult to diagnose at their local health centre or hospital can be discussed with specialists.9 A recent review of imported infections in Oman from 1999 to 2013 found that approximately 8% of notifiable infections in Oman were travel related. In addition, 78 cases of dengue fever, 80 cases of measles and 2 cases of polio were all imported. Of the imported infections, 73% came from Asia, 23% from Middle Eastern countries and 4% from Africa.10 The outbreak of dengue fever in Muscat, Oman, in 2018 to 2019 due to travel illustrate how an imported disease can cause an outbreak.11 Reintroduction of malaria is a continued risk with between 900 and 1,500 travel-related cases diagnosed every year. A few limited local ‘first generation’ malaria outbreaks have occurred, the largest in Mabela, Muscat Governorate in 2015 with more than 50 cases. However, the outbreak was effectively controlled within two months.12 A case of imported cholera resulted in a secondary case after delayed diagnosis.13 The dengue and malaria outbreaks were identified through the routine surveillance of infectious diseases in the country. The dengue outbreak was able to happen because the vector, Aedes aegypti, has become established in Muscat; this illustrates how ecological factors related to vector characteristics can allow new pathogens to be introduced by travellers.14 Surveillance also needs to include multi-drug resistant bacteria. Considerable work has been done between the Gulf Cooperation Council countries and it is well established that resistant bacteria is spread between countries via travellers whether they are asympt- omatic carriers or arrive with a presenting infection.15–17 A case of colistin-resistant Escherichia coli isolated in Oman, where the plasmid carrying the gene coding for colistin resistance could be traced to China, illustrates the international spread of multidrug-resistant bacteria.18 Indeed, it has been suggested that travellers from countries with a high level of multidrug-resistant gram-negative bacteria should be screened.19 Addressing the Expatriate Population Travel-related infection in Oman is primarily imported by migrant expatriates who are responsible for a stagg- ering and unfortunate 86% of travel-related infections.8 This places the experience of expatriates of utmost importance and an issue that needs addressing. Most people relocating to Oman for work come from South Asia and since the primary risk factor for travel-related illness transmission is visiting family and friends, this puts this group at high risk of importing infections such as malaria.5 Though healthcare services are provided free of charge for citizens, expatriates have limited access to the system yet are able to access an enhanced level Seif Al-Abri, Said Al-Lamki, Eskild Petersen and Ahmed Al-Mandhari Editorial | e123 of TH. Accessing this service is helpful in two-fold, it improves the health of the migrant working population while reducing the risk of disease transmission to the country at large.5 Now is the time to target the residents of Oman who need the services most. The opportunity is present and the need is paramount. Currently, clinical care is provided at no cost to expatriates who have pre-existing communicable diseases such as malaria and tuberculosis. The challenge remains to remove barriers to access and decrease/eliminate the cost to deliver pre-TH care that includes vaccination and treatment of communicable diseases for expatriates. Regarding malaria specifically, there is an increasing concern about asymptomatic malaria and its impact on countries, such as Oman, which are free of the disease yet where the Anopheles mosquitos that transmit malaria exist. In reaction to this and other travel-related illness concerns, the MoH is working with the private health sector to set up private TH clinics poised for access by expatriates to receive an enhanced level of TH care thereby improving their personal health status and reducing the risk to the indigenous population of Oman. International Collaboration Oman participates in GeoSentinel, an international disease surveillance network established by the Inter- national Society for Travel Medicine, collecting data on illness in returning travellers. GeoSentinel’s aim is spotting new trends in the worldwide movement of disease.20–22 Oman will be an active participant in the GeoSentinel collaboration and will benefit from pre- publication access to information on new international disease trends and access to an international network of highly experienced TH specialists and public health experts. Governance The TH service will be executed by PHC centres under the supervision and guidance of the MoH. Regular meetings between the Directorate General of Disease Surveillance and Control, Directorate General of PHC, and Directorate General of Health Services will ensure continuous adjustment according to the needs of the traveller, the PHC services and public health surv- eillance. The MoH will continuously evaluate public and private healthcare services and publish statistics of the activities. The MoH will also ensure that the necessary vaccines and drugs such as malaria chemoprophylaxis are available. Evaluation of training workshops will be implemented and it will be ensured that training opportunities are matched with the development of the service. Oman is prepared for enhanced pre- and post- TH services to tackle travel-related illnesses which threaten the health of the country’s population. Oman’s geographical position in the Middle East and its melting pot culture pose three risk factors for travel-acquired illness: (1) pilgrimages for Hajj and Umrah; (2) strong bonds with East Africa; and (3) a large population of migrant expatriates from South Asia. However, Oman is well prepared and positioned to meet these challenge because of the country’s state-of-the-art public health laboratory and diagnostic resource facilities, broad access to a well-operating PHC system, and sophisticated electronic health records and notification system that operates throughout all MoH health centres.5 The future of travel medicine is at a proverbial crossroads and the move to seize the opportunity to enhance these services in Oman will be of great benefit to both expatriates and nationals. References 1. World Tourism Organization. International Tourism Highlights, 2019 Edition. From: https://www2.unwto.org/publication/inter national-tourism-highlights-2019-edition Accessed: Apr 2020. 2. Petersen E, Petrosillo N, Koopmans M, ESCMID Emerging Infections Task Force Expert Panel. Emerging infections-an increasingly important topic: review by the Emerging Infections Task Force. Clin Microbiol Infect 2018; 24:369–75. https://doi. org/10.1016/j.cmi.2017.10.035. 3. World Health Organization. International Health Regulations. 2nd edition. Geneva, 2005. From: https://www.who.int/ihr/pub lications/9789241596664/en/ Accessed: Apr 2020. 4. National Centre for Statistics & Information. From: https:// ncsi.gov.om/Pages/NCSI.aspx Accessed: Apr 2020. 5. Schlagenhauf P, Jones ME. Travel medicine in Oman--Chances and challenges. Travel Med Infect Dis 2015; 13:351–2. https://doi.org/10.1016/j.tmaid.2015.09.009. 6. Al Farsi F, Chandwani J, Mahdi AS, Petersen E. Severe imported malaria in an intensive care unit: A case series. IDCases 2019; 17:e00544. https://doi.org/10.1016/j.idcr.2019.e00544. 7. Al-Abri SS, Abdel-Hady DM, Al-Abaidani IS. Knowledge, atti- tudes, and practices regarding travel health among Muscat International Airport travelers in Oman: Identifying the gaps and addressing the challenges. J Epidemiol Glob Health 2016; 6:67–75. https://doi.org/10.1016/j.jegh.2016.02.003. 8. Kurup PJ, Al Abri SS, Al Ajmi F, Khamis HA, Singh J. Knowledge, attitude and practice of travel medicine among primary care physicians in Oman: The need for intervention. East Mediterr Health J 2019; 25:40–6. https://doi.org/10.26719/ emhj.18.027. 9. Imported Fever Service (IFS). From: https://www.gov.uk/gui dance/imported-fever-service-ifs. Accessed: Apr 2020. 10. Al-Abri SS, Abdel-Hady DM, Al Mahrooqi SS, Al-Kindi HS, Al-Jardani AK, Al-Abaidani IS. Epidemiology of travel-assoc- iated infections in Oman 1999-2013: A retrospective analysis. Travel Med Infect Dis 2015; 13:388–93. https://doi.org/10.10 16/j.tmaid.2015.08.006. https://doi.org/10.1016/j.cmi.2017.10.035 https://doi.org/10.1016/j.cmi.2017.10.035 https://doi.org/10.1016/j.tmaid.2015.09.009 https://doi.org/10.1016/j.idcr.2019.e00544 https://doi.org/10.1016/j.jegh.2016.02.003 https://doi.org/10.26719/emhj.18.027 https://doi.org/10.26719/emhj.18.027 https://doi.org/10.1016/j.tmaid.2015.08.006 https://doi.org/10.1016/j.tmaid.2015.08.006 The Future Importance of Travel Health in the Middle East Oman’s opportunity to enhance its services e124 | SQU Medical Journal, May 2020, Volume 20, Issue 2 11. Al-Abri SS, Kurup PJ, Al Manji A, Al Kindi H, Al Wahaibi A, Al Jardani A, et al. Control of the 2018-2019 dengue fever out- break in Oman: A country previously without local transmission. Int J Infect Dis 2019; 90: 97–103. https://doi.org/10.1016/j. ijid.2019.10.017. 12. Simon B, Sow F, Al Mukhaini SK, Al-Abri S, Ali OAM, Bonnot G, et al. An outbreak of locally acquired Plasmodium vivax mal- aria among migrant workers in Oman. Parasite 2017; 24:5. https://doi.org/10.1051/parasite/2017028. 13. Al Mayahi Z, Al-Shaqsi N, Elmutashi HA, Al-Dhoyani A, Al Hattali A, Salim K, et al. Two cases of cholera O1 in South Batinah, Oman, April 2019: Lessons learned. Epidemiol Health 2019; 41:e2019033. https://doi.org/10.4178/epih.e2019033. 14. Kilpatrick AM, Randolph SE. Drivers, dynamics, and control of emerging vector-borne zoonotic diseases. Lancet 2012; 380:1946–55. https://doi.org/10.1016/S0140-6736(12)61151-9. 15. Sonnevend Á, Ghazawi AA, Hashmey R, Jamal W, Rotimi VO, Shibl AM, et al. Characterization of Carbapenem-Resistant Enterobacteriaceae with High Rate of Autochthonous Trans- mission in the Arabian Peninsula. PLoS One 2015; 10:e0131372. https://doi.org/10.1371/journal.pone.0131372. 16. Balkhy HH, Assiri AM, Mousa HA, Al-Abri SS, Al-Katheeri H, Alansari H, et al. The strategic plan for combating antimicrobial resistance in Gulf Cooperation Council States. J Infect Public Health 2016; 9:375–85. https://doi.org/10.1016/j.jiph.2016.03.003. 17. Pál T, Ghazawi A, Darwish D, Villa L, Carattoli A, Hashmey R, et al. Characterization of NDM-7 carbapenemase-producing Escherichia coli isolates in the Arabian peninsula. Microb Drug Resist 2017; 23:871–8. https://doi.org/10.1089/mdr.2016.0216. 18. Mohsin J, Pál T, Petersen JE, Darwish D, Ghazawi A, Ashraf T, et al. Plasmid-mediated colistin resistance gene mcr-1 in an Escherichia coli ST10 bloodstream isolate in the Sultanate of Oman. Microb Drug Resist 2018; 24:278–82. https://doi. org/10.1089/mdr.2017.0131. 19. Petersen E, Mohsin J. Should travelers be screened for multi- drug resistant (MDR) bacteria after visiting high risk areas such as India? Travel Med Infect Dis 2016; 14:591–4. https://doi. org/10.1016/j.tmaid.2016.11.014. 20. Angelo KM, Libman M, Caumes E, Hamer DH, Kain KC, Leder K, et al. Malaria after international travel: A GeoSentinel analysis, 2003-2016. Malar J 2017; 16:293. https://doi.org/10.1 186/s12936-017-1936-3. 21. Angelo KM, Libman M, Gautret P, Barnett E, Grobusch MP, Hagmann SHF, et al. The rise in travel-associated measles infec- tions-GeoSentinel, 2015-2019. J Travel Med 2019; 26:taz046. https://doi.org/10.1093/jtm/taz046. 22. Gautret P, Angelo KM, Asgeirsson H, Lalloo DG, Shaw M, Schwartz E, et al. Rabies post-exposure prophylaxis started during or after travel: A GeoSentinel analysis. PLoS Negl Trop Dis 2018; 12:e0006951. https://doi.org/10.1371/journal.pntd.0006951. https://doi.org/10.1016/j.ijid.2019.10.017 https://doi.org/10.1016/j.ijid.2019.10.017 https://doi.org/10.1051/parasite/2017028 https://doi.org/10.4178/epih.e2019033 https://doi.org/10.1016/S0140-6736%2812%2961151-9 https://doi.org/10.1371/journal.pone.0131372 https://doi.org/10.1016/j.jiph.2016.03.003 https://doi.org/10.1089/mdr.2016.0216 https://doi.org/10.1089/mdr.2017.0131 https://doi.org/10.1089/mdr.2017.0131 https://doi.org/10.1016/j.tmaid.2016.11.014 https://doi.org/10.1016/j.tmaid.2016.11.014 https://doi.org/10.1186/s12936-017-1936-3 https://doi.org/10.1186/s12936-017-1936-3 https://doi.org/10.1093/jtm/taz046 https://doi.org/10.1371/journal.pntd.0006951