Preparing for International Travel and Global Medical Care




Thorough pretravel preparation and medical consultation can mitigate avoidable health and safety risks. A comprehensive pretravel medical consultation should include an individualized risk assessment, immunization review, and discussion of arthropod protective measures, malaria prophylaxis, traveler’s diarrhea, and injury prevention. Travel with children and jet lag reduction require additional planning and prevention strategies; travel and evacuation insurance may prove essential when traveling to less resourced countries. Consideration should also be given to other high-risk travel scenarios, including the provision of health care overseas, adventure and extreme sports, water environments and diving, high altitude, and terrorism/unstable political situations.


Key points








  • Although more people are traveling, few seek pretravel consultation to mitigate avoidable health risks associated with traveling.



  • A comprehensive pretravel medical consultation should include an individualized risk assessment, immunization review, and discussion of arthropod protective measures, malaria prophylaxis, traveler’s diarrhea, and injury prevention.



  • Travel with children and jet lag reduction require additional planning and prevention strategies.



  • Travel and evacuation insurance is recommended when traveling to less resourced countries.



  • Consideration should also be given to other high-risk travel scenarios, including the provision of health care overseas, adventure and extreme sports, water environments and diving, high altitude, and terrorism/unstable political situations.






Introduction


During the first 9 months of 2016, nearly 1 billion tourists had already traveled around the world, a 4% increase from the prior year. The World Travel & Tourism Council projects that this number will increase to nearly 1.8 billion international travelers in 2025. Depending on their destination, approximately 22% to 64% of these travelers will experience some illness, most commonly diarrhea, respiratory infections, and skin conditions. Some travelers may even develop life-threatening conditions (eg, malaria), which could have been avoided with proper pretravel preparation.


On a typical 2-week trip, travelers lose an average of 3 days because of illness, with nearly 20% remaining ill after their return home and 10% seeking medical care for their illnesses.


For every 100,000 travelers visiting a developing country for 1 month :




  • 50,000 develop some health problem while abroad



  • 8000 need to see a physician



  • 5000 are confined to a bed



  • 300 are admitted to a hospital



  • 50 require air evacuation



  • 1 dies



With prevention of these potential hazards in mind, this article explores the key elements of preparation for travel and global medical care.




Introduction


During the first 9 months of 2016, nearly 1 billion tourists had already traveled around the world, a 4% increase from the prior year. The World Travel & Tourism Council projects that this number will increase to nearly 1.8 billion international travelers in 2025. Depending on their destination, approximately 22% to 64% of these travelers will experience some illness, most commonly diarrhea, respiratory infections, and skin conditions. Some travelers may even develop life-threatening conditions (eg, malaria), which could have been avoided with proper pretravel preparation.


On a typical 2-week trip, travelers lose an average of 3 days because of illness, with nearly 20% remaining ill after their return home and 10% seeking medical care for their illnesses.


For every 100,000 travelers visiting a developing country for 1 month :




  • 50,000 develop some health problem while abroad



  • 8000 need to see a physician



  • 5000 are confined to a bed



  • 300 are admitted to a hospital



  • 50 require air evacuation



  • 1 dies



With prevention of these potential hazards in mind, this article explores the key elements of preparation for travel and global medical care.




Pretravel consultation


Many travelers are unaware or unconcerned about the health and safety risks posed by travel, and few seek proper pretravel counseling. Travelers visiting friends and relatives are at especially high risk for illness (specifically, malaria and food-borne illnesses); they tend to have a false sense of immunity, visit higher risk destinations, stay abroad longer, eat local food, and do not seek pretravel advice or use protective measures. There is a known association between failing to seek pretravel consultation and the development of illnesses like malaria, which can have significant health and economic consequences. The average health care payer cost to prevent malaria is $162, whereas the cost of treating an adult with malaria is $25,250 (with an additional 6–24 work days lost).


A comprehensive pretravel medical consultation should include an individualized risk assessment; a review of immunizations; and a discussion of arthropod protective measures, malaria prophylaxis, traveler’s diarrhea (TD), and other travel-related education and risk reduction practices. This approach is particularly important for travelers who are headed to developing countries; planning adventure travel; planning an extended trip; immune compromised or with chronic medical conditions; children; and pregnant or planning pregnancy. Although consulting a specialist is advisable at any time before travel, a pretravel checkup should ideally occur at least six weeks in advance of the intended departure date to maximize the effect of immunizations and other preventive measures (eg, malaria chemoprophylaxis needs to be started in advance of travel).




Individualized risk assessment


A traveler’s individual risk of travel depends on several factors: medical history, itinerary (regions, season, dates), prior travel experience, activities (eg, adventure, mass gathering), accommodations, risk tolerance, and financial means. A traveler’s medical history should also include current medications, disabilities, immune status, immunizations, surgeries, allergies, and pregnancy/breastfeeding status.




Pretravel immunizations


All travelers should be screened to determine their need for pretravel immunizations including a review of their current immunization history. In addition to routine or domestic vaccinations, additional destination-specific vaccinations may be required depending on the traveler’s itinerary, anticipated activities, and duration of stay. Because of the associated health risks, pregnant women and immunocompromised patients should not receive live vaccines (eg, measles, mumps, rubella; polio [oral]; rotavirus; varicella-zoster; influenza [intranasal]; typhoid [oral]; yellow fever, and bacille Calmette-Guérin [for TB]). Live vaccines should be administered on either the same day or four weeks apart to avoid vaccine failure.


Routine Vaccinations


The risk of domestic vaccine-preventable diseases, such as influenza and hepatitis A, is higher in international travelers than that of more exotic vaccine-preventable illnesses, such as typhoid and Japanese encephalitis. Therefore, routine (domestic) immunizations should be reviewed to ensure that the traveler is up to date and booster doses should be provided as needed. A summary of recommendations for routine vaccinations is provided in Table 1 .



Table 1

Routine vaccinations










































































Indication Route Dosing Schedule
Haemophilus influenzae Type b All infants; children/adults with asplenia or sickle cell disease, or following leukemia chemotherapy or BMT; ages 5–18 y with HIV IM 3–4 doses: 2, 4, 6, 12–15 mo
Hepatitis A All travelers >1 y old IM 2 doses: day 0, 6–12 mo
Hepatitis B All travelers IM 3 doses: day 0, 1 mo, 6 mo
Herpes Zoster (Shingles) Adults >60 y old SC Single dose
Human Papillomavirus All children and young adults IM 3 doses: day 0, 1–2 mo, 6 mo
Influenza All travelers >6 mo old IM, intranasal, or ID Single dose
Measles, Mumps, Rubella All travelers SC 2 doses: day 0, 4 wk
Meningococcal Disease Living in crowded conditions (eg, dormitory); routine at 11–12 y; booster at 16 y IM Single dose
Pneumococcal Disease All infants and adults >65 y old IM or SC 4 doses (infants): 2, 4, 6, 12–15 mo
Polio All infants and children SC Single dose (if received primary childhood series)
Rotavirus All infants Oral 3 doses: 2, 4, 6 mo
Tetanus, Diphtheria, Pertussis All travelers IM Single dose (if received primary childhood series)
Varicella (Chickenpox) All travelers SC Two doses: (<13 y old) 12–15 mo, 4–6 y; (≥13 y old) 28 d apart

Abbreviations: BMT, bone marrow transplant; HIV, human immunodeficiency virus; ID, intradermal; IM, intramuscular; SC, subcutaneous.

Data from Ref.


Travel-Specific Vaccinations


Some travel-specific vaccinations are indicated based on the traveler’s anticipated itinerary, duration of travel, activities, and other risk factors. Some travelers may be required to show proof of vaccination (eg, yellow fever, meningococcal meningitis) to customs officials; therefore, it is advisable for travelers to carry their immunization records along with their passports. A summary of recommendations for travel-specific vaccinations is provided in Table 2 .



Table 2

Travel-specific vaccinations
































































Indication Route Dosing Schedule Duration of Protection
Cholera a Adults 18–64 y at high risk Oral Single dose 3–6 mo
Japanese Encephalitis Travelers to endemic areas IM 2 doses: days 0 and 28 1–2 y after initial; >6 y if booster at 1–2 y
Meningococcal b Travelers to meningitis belt of Africa or Saudi Arabia (pilgrimage) IM Single dose 3–5 y
Polio b Travelers to country with ongoing transmission; >4 wk travel to Afghanistan or Pakistan SC Single dose (if received primary childhood series) Lifelong (after primary series and booster as adult)
Rabies Travelers to rabies enzootic areas (especially remote, rural, or extended stay) IM 3 doses before exposure: 0, 7, and 21–28 d 2 additional doses (days 0 and 3) after exposure
Tick-borne Encephalitis a Travelers to endemic areas (Europe, Soviet Union, Asia) IM 3 doses: day 0, 1–3 mo, 5–12 mo 3 y
Tuberculosis (BCG) a Consider in health workers traveling to areas with high TB resistance to both isoniazid and rifampin ID Single dose 10–15 y
Typhoid All travelers to low-income nations Oral or IM 4 doses (oral)
Single dose (IM)
5 y (oral)
2–3 y (IM)
Yellow Fever Travel to endemic areas (tropical Africa or South America); avoid in children <9 mo old SC Single dose 10 y

Abbreviation: BCG, bacille Calmette-Guérin.

Data from Ref.

a Not routinely given in the United States.


b Meningococcal and poliomyelitis are childhood vaccines that may require boosters in adult travelers with specific itineraries.





Arthropod protective measures


Arthropods – mosquitoes, ticks, flies, and chiggers – can transmit infections such as malaria, dengue, and rickettsial diseases; some of these infections are only preventable by anti-arthropod protective measures. Such vector-borne illnesses account for most systemic febrile illnesses in travelers presenting to travel and tropical medicine clinics. Risk factors for vector-borne illnesses depend on the destination, setting (urban vs rural), length of stay, mode of transportation, season (dry vs rainy), and accommodation. Although some vectors, such as the female Anopheles mosquito, which transmits malaria, tend to bite from dusk to dawn, other vectors, such as mites and ticks, can bite day or night. Arthropod bites can be prevented through personal protective measures such as general avoidance techniques, insect repellents, and insecticide-treated materials ( Table 3 ). Insecticide-treated clothing in association with topical insect repellents (eg, diethyltoluamide [DEET] or picaridin) provides very effective protection against arthropod bites.



Table 3

Personal protective measures against arthropods



























Activity modification Avoid areas with known outbreaks
Avoid heavily vegetated areas (ticks, chiggers)
Avoid outdoors from dusk to dawn (malaria-endemic regions)
Protected environment Well-screened room, air conditioning, fan to reduce risk of malaria
Clothing: protective Expose as little skin as possible (long sleeves, loose fitting, tucking shirt into pants, tucking pants into socks)
Light colored (not blue) heavyweight clothing to reduce risk from mosquitoes, tsetse flies, and sand flies
Clothing/gear: insecticide treated Apply permethrin to clothing, shoes, and camping gear, or purchase impregnated clothing
May need reapplication after 5 washes
Insect repellent Apply a repellent containing DEET (20%–50%) or picaridin (20%) to exposed skin
Regularly reapply (DEET every 6–8 h, picaridin every 4 h)
Apply daytime for Aedes mosquitoes, dusk/nighttime for Anopheles and Culex mosquitoes
DEET is safe during second/third trimester of pregnancy and in children >2 mo old
Insecticide-treated bed nets Sleeping under pyrethroid insecticide–impregnated bed nets (recommended for all travelers to malaria-endemic regions)
Lasts months if not washed but needs retreatment to retain effectiveness
Spatial repellents Impregnated plastic strips, coils, candles, fan emanators, heat-generating devices reduce nuisance biting
Should not be used in lieu of other proven protective measures
Tick check Full-body and clothing check after activity and at the end of the day, using a mirror or companion

Abbreviation: DEET, diethyltoluamide.

Data from Ref.




Malaria chemoprophylaxis


The US Centers for Disease Control and Prevention (CDC) Web site ( www.cdc.gov/malaria/ ) can help determine the risk of developing malaria based on travel destination. Because there currently is not a vaccine for malaria, all travelers to malaria-endemic areas should be given strong consideration for chemoprophylaxis. Some patients are at higher risk for malaria than the general population, including those who are human immunodeficiency virus [HIV] positive, asplenic, or immunosuppressed.


When taken properly, chemoprophylaxis is highly effective in preventing malaria. Many chemoprophylactic agents need to be started before travel and continued for several weeks after returning (with duration depending on the agent) to be effective. Noncompliance is a significant risk factor for development of malaria; the most common reasons for nonadherence are forgetfulness, undesirable side effects, and not seeing mosquitoes. Determining the appropriate chemoprophylactic agent depends on geographic considerations (especially chloroquine sensitivity vs resistance), duration of travel, dosing schedule, cost, and host factors (medical conditions, medications). The most commonly used agents are chloroquine, doxycycline, mefloquine, and atovaquone/proguanil ( Table 4 ).



Table 4

Malaria chemoprophylactic agents












































Typical Adult Dosing Typical Pediatric Dosing Start (Preexposure) Continue (Postexposure) Advantages Disadvantages
Chloroquine 500 mg salt (300 mg base) oral once a week 8.3 mg salt (5 mg base)/kg/wk up to the adult dosage 2 wk 4 wk


  • Safe and well tolerated



  • Can be used during pregnancy



  • Can be used in children (all ages)




  • Global resistance outside of the Caribbean, Central America



  • May exacerbate psoriasis

Doxycycline 100 mg oral once a day 2 mg/kg/d up to adult dosage (for children ≥8 y) up to the adult dosage 2 d 4 wk


  • Least expensive



  • Can prevent leptospirosis and rickettsia



  • Good last-minute choice



  • Widely available globally




  • Esophageal irritation/ulceration



  • Skin photosensitivity



  • Vaginal yeast infections



  • Not for use in pregnancy and children <8 y old

Mefloquine 250 mg salt (228 mg base) oral once a week ≤9 kg: 5 mg/kg (4.6 mg/kg base) once per week
>9–19 kg: one-fourth of 250-mg tablet weekly
20–30 kg: one-half of 250-mg tablet weekly
31–45 kg: three-fourths of 250-mg tablet weekly
>45 kg: 250 mg once per week
2–3 wk 4 wk


  • Weekly dosing



  • Good long-term regimen



  • Can be used during pregnancy



  • Can be used in children (all ages)




  • Some areas of mefloquine resistance (southeast Asia)



  • Neuropsychiatric side effects



  • Avoid in patients with depression, psychosis, seizures, and atrioventricular conduction abnormalities

Atovaquone/proguanil 250 mg atovaquone/100 mg proguanil oral once a day 5–8 kg: one-half of a children’s tablet (62.5 mg atovaquone/25 mg proguanil) daily
9–10 kg: three-fourths of a children’s tablet daily
11–20 kg: 1 children’s tablet daily
21–30 kg: 2 children’s tablets daily
31–40 kg: 3 children’s tablets daily
>40 kg: 1 adult tablet daily
2 d 1 wk


  • Well tolerated



  • Good for short trips



  • Good last-minute choice



  • Can be used in children (≥11 kg) and off label in children (≥5 kg)




  • Expensive



  • Avoid with renal impairment



  • Not recommended for pregnant women, breastfeeding mothers, and children <5 kg


Data from Ref.


Some European authorities advocate the use of a standby self-treatment regimen in lieu of chemoprophylaxis, especially for long-stay travelers. In such circumstances, a traveler self-treats if the symptoms are suggestive of malaria and there is no access to a qualified medical facility. A full course of atovaquone/proguanil or artemether-lumefantrine is recommended in these situations.




Traveler’s diarrhea


TD is the most common travel-related ailment. TD is defined as the passage of 3 or more unformed stools per day plus 1 additional enteric complaint (eg, vomiting, cramps, abdominal pain), either within 24 hours of travel or up to 7 days after returning. Between 10% and 40% of travelers develop TD, usually within the first 2 weeks of travel, with symptoms lasting a median of 3 days. TD is predominantly transmitted by the fecal-oral route, with a bacterial cause in 80% to 90% of cases. Risk factors for TD include medications that reduce gastric acidity (antacids, proton pump inhibitors), pregnancy, young age, and immune compromise.


For travelers to high-risk areas, several approaches can reduce but not eliminate the risk for TD. Because contaminated food and water cause most TD, the following are recommendations regarding food and water safety: (1) eating well-cooked, hot food while avoiding raw food, uncooked meat/fish/eggs, shellfish, and mayonnaise; (2) consuming peeled fruits and vegetables (and avoiding salads, salsas, and cold sauces); (3) consuming pasteurized dairy products; (4) consuming bottled or disinfected (boiled, filtered, treated) water and avoiding tap/well water and ice/juice made from the like; (5) avoiding foods from market stalls and street vendors; and (6) avoiding uncovered or unrefrigerated foods. Hand washing before eating and after using the toilet can reduce risk by as much as 30%; if soap and water are not available, hand sanitizer (containing at least 60% alcohol) is advisable.


Prophylactic antibiotics for TD are not routinely recommended (except in rare circumstances). Bismuth subsalicylate (2 tablets 4 times a day for a maximum of 3 weeks) provides up to 65% protection. Adverse effects of bismuth subsalicylate include black tongue, dark stools, and decreased absorption of doxycycline, and contraindications include aspirin/nonsteroidal antiinflammatory drug allergy, bleeding disorders, and breastfeeding. There is currently insufficient evidence to support the use of probiotics for TD prevention.


The self-treatment of TD consists of oral rehydration, antimotility agents, and oral antibiotics. Adequate oral rehydration can prevent and treat dehydration. For mild dehydration, water or readily available liquids are sufficient, but avoid Gatorade, soft drinks, and juice because of their high sugar and low salt content. For moderate to severe dehydration, use oral rehydration salts (ORS), either commercial or prepared at home. To make ORS at home, add half a teaspoon of salt and 6 level teaspoons of sugar to 1 L of safe water (bottled, sealed, or disinfected). Antimotility agents like loperamide are safe and effective for the treatment of nondysenteric TD, with or without concomitant antibiotics. Avoid antimotility agents in patients with blood in the stool or fever, or in children less than six years of age. The early self-treatment of TD with antibiotics has been shown to reduce the duration of symptoms. For severe diarrhea, consider a single dose of a quinolone (500 mg of ciprofloxacin or levofloxacin) or azithromycin (1 g) for more rapid cessation. Azithromycin is preferred in south and southeast Asia because of fluoroquinolone-resistant enteropathogens.

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Dec 2, 2017 | Posted by in Uncategorized | Comments Off on Preparing for International Travel and Global Medical Care
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