View the Disease Management Project
Table of Contents

Revised October 25, 2004

Steven D.
Mawhorter, MD

Department of
Infectious Diseases

Print Chapter

This chapter was adapted from an article that originally appeared in the October 1997 edition of The Cleveland Clinic Journal of Medicine.

Definition

Prevalence

Pre-Travel
Counseling
for All Travelers

Immunization

Specific Conditions

Patients with
Pre-existing Medical Conditions

Conclusions

Resources
for Travelers

References

International tourism is a growing industry. The World Tourism Organization estimates there were 675 million international travelers in 1999, roughly a 50% increase in the last decade.¹ While most international travel occurs between developed countries, in 1990 10.7 million persons from the United States and Canada traveled to developing countries,¹ many of which lack pure water systems and disease-control programs. Despite recent events of international instability, tourist travel, and increased international business travel maintain millions of visits to developing country destinations annually. Travel to these countries requires specific preparation to avoid illness, and general health advice should be sought before international travel.

Physicians are often called upon to prepare their patients for travel and to treat them afterward. A primary care provider might serve this role, but the constantly changing and highly specialized information makes a dedicated travel medicine expert more likely to be able to handle the individual needs of varied travelers and their unique itineraries. A study by the Centers for Disease Control² found that primary care physicians and even the embassy staff of foreign countries could not completely prepare their patients.

This chapter focuses on aiding the primary care physician to partner with travel medicine experts. It emphasizes areas of travel medicine that are commonly encountered and therefore most practical for primary care physicians to address.

A functional definition of the goals of travel medicine is to:

• Counsel patients about how to avoid risky behavior and exposure to infectious agents or disease vectors [pre-travel counseling]
• Immunize against illness when it is difficult to limit exposure
• Use preventive or symptom-triggered medications when immunizations do not exist

There are no consensus guidelines on travel-related health issues in the United States. However, the Canadian Health System (Health Canada) maintains a web site with its own set of guidelines on topics related to travel medicine. It should be noted that, like any guidelines, these represent only a starting point for care, which must be individualized to each person coming for travel advice. Moreover, one must realize that as medicine availability varies from country to country, some recommendations may not fit with available resources in the reader's home country. For example, there is no oral cholera vaccine in the United States.

The CDC has revised its Travel notice definitions to more common vernacular. The four-tiered system is designed to help travelers and health care professionals assess risk in the ever-changing landscape of international travel.

Fifty percent to 75% of travelers to the tropics and subtropics report minor medical complaints, many of which are preventable. This high incidence emphasizes the importance of pre-travel counseling.³ Overall, up to 10% of travelers alter their planned activities because of illness (mostly traveler's diarrhea), 5% become ill enough to require medical attention abroad, and 2% are too ill to be able to immediately return to work after their return.³

Fatal illness while traveling is extremely rare. Although 1 per 100,000 Swiss travelers to developing countries died while traveling compared with 0.3 per 100,000 travelers to North America, both mortality rates were lower than for persons who did not travel.⁴ Such statistics reflect the general good health of most travelers.

Pre-travel counseling should be sought before international travel begins. The following health issues and priorities should be addressed.^1,5 The traveler should first be advised about required immunizations based on international regulations. In addition, many other immunizations are recommended to reduce the impact of destination-specific health risks. Second, issues of malaria risk, prevention and chemoprophylaxis should be reviewed. Third, general health advice should include:

• Food and beverage precautions
• Insect bite avoidance
• Accident and injury prevention
• Risk behavior management: drug use, casual sex, personal safety, high-altitude adjustment

These reflect the most prominent health-related issues associated with international travel, especially travel to lesser-developed countries. Tailoring the advice to the individual traveler is important.

The importance of sun screen and insect repellent should be stressed. It is essential to reinforce food and water precautions, including brushing one's teeth with purified or bottled water and avoiding ice in drinks.

Jet lag is a common, unavoidable condition without any specific therapy. Over the years many remedies have been sought, but no "magic bullet" has been found. Adequate hydration and avoidance of excess alcohol are two of the most useful tips.⁶ Melatonin is involved in the circadian cycles in many animals, leading to considerable interest in its potential utility in treating jet lag. Studies of melatonin in travelers showed small and inconsistent reductions in jet lag symptoms.^7,8 The safety of melatonin has not been established, although it is widely available in health food stores. Some evidence supports exposure to outdoor sunlight at the travel destination, which may speed acclimatization.^7,8 Important events and meetings are best scheduled at least 48 hours after arrival if possible.

Electronic Resources
Patients with access to the Internet can review helpful information about medical preparation for foreign travel from several sources (also see Appendix). One of the most notable is the CDC travel information section. The World Health Organization also posts information related to international travel health concerns. A particular advantage of these sources is that they allow the patient to review information related to their specific travel plans, which will generate focused questions for review during pre-travel counseling.

More than a dozen vaccines are available for diseases with a high prevalence in developing countries (Table 1). Some are the familiar vaccines recommended for all Americans, while others are for diseases mostly found in the developing world or in specific travel destinations. Which vaccines a traveler needs depends on the itinerary and the patient's current immunization status. Primary care physicians should make sure that travelers are up to date in their routine immunizations before going abroad; however, immunizations for rare and travel-related diseases are best left to experts in travel medicine.

Vaccines for Primary Care Administration:

Adults who have not completed primary vaccination series need to complete them for full protection.⁹ Given that vaccine-based immunity to tetanus, diphtheria, and polio wanes over time and these diseases are highly prevalent abroad, booster vaccination is recommended. Pregnant or immunocompromised travelers should seek specific advice from a travel medicine specialist.

Tetanus-diphtheria
After the initial series, boosters should be given every 10 years. Many of the now independent Soviet states have experienced diphtheria outbreaks, which can be life threatening but are vaccine-preventable.

Influenza Vaccine
Influenza vaccine should be given every fall to persons older than age 65 and to younger people with chronic disease. Recent guidelines encourage much broader use of influenza vaccination. Of note, the peak influenza incidence in the Southern Hemisphere is during their winter season, June through August.

Pneumococcal Vaccine
Pneumococcal vaccine should be given to all persons older than age 65 years.

Polio
A single booster of inactivated polio virus vaccine provides life-long protection in adults who have received the primary series. The exceedingly rare reports of wild-type polio in the Western hemisphere make the vaccine optional for travel there.

Measles
For travelers born after 1957, a second measles booster (if not previously given) should be considered, given the high prevalence of measles in the developing world.

Hepatitis A Vaccine
Hepatitis A vaccine is highly recommended for nearly all international travelers. Hepatitis A is highly prevalent and is spread through contaminated food and water. Nearly all international travelers should receive the recently developed hepatitis A vaccine. This inactivated-virus vaccine achieves 80% to 98% immunity within 15 days after one intramuscular dose.¹⁰ A booster dose at 6 months provides prolonged immunity, up to 10 years or more. This vaccine eliminates the need for passive immunization with immunoglobulin in most cases, and is less expensive, less risky, and has a lower side-effect profile. Minimal arm soreness at the site of injection and self-limited headaches are occasionally reported. Safety and efficacy have been shown in patients as young as 2 years. Travelers who present within 2 weeks of departure can still expect the vaccine to be effective. A new combination of hepatitis A and B vaccine (TwinRix®) produces higher titers to each agent compared with univalent vaccine.

Hepatitis B Vaccine
Hepatitis B vaccine was recently added to the routine vaccine schedule for children. However, unvaccinated adults typically receive this vaccine only when they expect high-risk exposure to blood or body fluids. The schedule (three shots over 6 months) does not make this vaccine "travel-friendly." Travelers planning extended travel to developing countries, or traveling to adopt from an endemic area, may benefit from vaccination, a decision best made in consultation with a travel specialist. Off-label accelerated protocols to achieve protective immunity within 4 weeks exist, but again should be performed by those with specific expertise.

Vaccinations Best Left to Travel-Medicine Specialists:

Some travelers to high-risk areas need vaccinations against meningococcus, yellow fever, and typhoid. Uncommon diseases such as anthrax, rabies, plague, and Japanese encephalitis are also preventable with immunizations. However, the rarity of these diseases and the fairly significant local side effects of their vaccines are reasons to use these vaccines only in travelers at especially high risk.⁹ Knowing when to give these vaccines requires the expertise of a travel-health specialist.

Meningococcal Vaccination
Meningococcal vaccination is recommended for patients traveling to the "meningitis belt" of sub-Saharan Africa and other focal areas, depending on disease prevalence. Physicians must review travel health advisories frequently to stay abreast of this critical information. Because of crowded conditions and extensive international mingling, this vaccine is required for all pilgrims on the Hajj to Mecca.

Yellow Fever
Yellow fever occurs throughout most of urban and rural South America and Africa. The live-attenuated vaccine is highly effective, but can only be given at a State-approved center. While direct travel to a nonendemic area requires no vaccinations, some countries require proof of vaccination before entry if the traveler's itinerary includes any areas of possible yellow fever exposure.⁹ Hence, most travelers to South America and Africa need to go to a travel clinic that can give yellow fever vaccine.

Typhoid
The recommendation for typhoid vaccination is itinerary-specific. The original inactivated vaccine had a high incidence of bothersome local reactions. Currently, an oral live-attenuated vaccine (Ty21a) and an improved inactivated injectable vaccine (Vi antigen) are available. Special instructions are needed for the oral vaccine, including avoiding coadministration of antibiotics.

General Issues Related to Travel Vaccination:

Coadministration
Multiple vaccinations are often recommended for travel to developing countries. This raises important practical issues about vaccine coadministration. Inactivated vaccines can be given on the same day without altering their immunogenicity,⁹ although local reactions such as arm soreness may be greater when this is done. Studies have revealed that diphtheria, pertussis, and tetanus; inactivated poliomyelitis vaccine (or oral poliovirus vaccine); Hemophilus influenzae type b; measles, mumps, and rubella; and hepatitis B vaccine may all be given on the same day with consistent efficacy.

In theory, live-virus vaccines may impair the immune responses of each other, and it is suggested that they be given more than 30 days apart. The live-attenuated yellow fever and oral poliovirus vaccines are not affected by coadministration.

Immunoglobulin
If it is necessary to give immunoglobulin for passive antibody protection, inactivated vaccines may be given at the same time with no impact on their efficacy. Measles-mumps-rubella vaccine is best given at least 14 days after immunoglobulin, and 6 months after whole-blood or red-blood-cell transfusion.

Adverse reactions
The most typical adverse reaction is arm soreness. It is often helpful to take acetaminophen regularly for 2 to 3 days after vaccine administration to diminish local arm soreness. The most common adverse allergic vaccine reaction is an egg protein allergy. Because influenza vaccine is developed in embryonic chicken eggs, as is the yellow fever vaccine (see below), caution must be exercised. Also, measles and mumps vaccines are developed in chicken embryo cell cultures. In general, if patients can eat eggs and egg products without reaction they can receive the vaccines without reaction. Protocols exist to enable vaccination of patients with significant allergy.¹¹

Rare patients are allergic to the vaccine antigen, animal proteins, antibiotics, preservatives, or stabilizers used in vaccine preparations. No currently recommended vaccines contain penicillin or penicillin derivatives. Measles-mumps-rubella vaccine contains trace amounts of neomycin. However, nearly all people with neomycin "allergy" actually show a delayed-type hypersensitivity contact dermatitis rather than a systemic allergic response.⁹ This reaction is not a contraindication to receiving the vaccine.

Rare anaphylactic reactions to diphtheria and tetanus vaccines are reported. Skin testing to tetanus toxoid is available to determine if a patient truly has this sensitivity.

The six leading health problems of travelers are listed in Table 2. Motor vehicle accidents are the leading cause of morbidity and mortality in travelers. Traveler's diarrhea and hepatitis A are examples of common food- and water-borne illnesses. Malaria is a vector-borne illness, and gonorrhea is a sexually transmitted disease. Although routes of acquisition vary, most of these disorders are preventable.

Motor Vehicle Accidents:

Motor vehicle accidents remain the leading cause of accidents and mortality around the world for travelers. Hence, the most life-impacting advice we give is to "buckle up" and drive defensively. When renting a car overseas, travelers should specifically request one with seat belts; they are not standard equipment in all countries. Moreover, taking safety precautions while driving limits the risk of a significant accident with trauma that may require a blood transfusion in a setting where the blood supply is not necessarily safe.

Traveler's Diarrhea:

Traveler's diarrhea is a clinical entity defined as three or more loose or watery stools within 24 hours, associated with one or more additional constitutional symptoms, including crampy abdominal pain and/or nausea.⁶ Most cases are acute, watery, and self-limited, without dysenteric or chronic symptoms. Causes of watery diarrhea include bacteria (more than 80% of cases), viruses, and parasites. Enterotoxigenic Escherichia coli is the leading bacterial pathogen (Table 3). Other causes vary by geographic location and time of year. Chronic diarrhea is usually non-bloody, without fever, and persists over a few weeks. Dysentery or bloody diarrhea accounts for up to 15% of cases of traveler's diarrhea. Bloody stools indicate a more invasive process referred to as dysentery, which has an overlapping but slightly different list of causative organisms. Fever more often accompanies dysentery.

Avoiding Food and Waterborne Illnesses
Some precautions can make eating overseas much safer. Travelers should be counseled to:

• Choose foods that are thoroughly and recently cooked, not reheated.
• Wash all fruits and vegetable with clean water before slicing them, to avoid carrying bacteria into the otherwise-clean inside layers. Raw fruits and vegetables peeled by travelers are usually safe.
• When dining out (where one has less control over food preparation), avoid raw meat, fish and vegetables, especially salads. Street vendor food is risky unless properly prepared in front of you. Caution must even be exercised regarding airline food prepared in lesser-developed countries.
• Avoid drinking tap water—even hotel tap water used for brushing teeth can be a source of infection. Ice should be considered contaminated, especially ice cubes on flights that originate in developing countries. Commercially prepared bottled or canned beverages are usually safe alternatives to water.
• Purify drinking water by boiling it, treating it with halogens (chlorine or iodine), or filtering it when reliably clean water is not available. Water brought just to a boil before cooling is generally as safe as water boiled for several minutes.⁶ Compared with boiling, halogen treatment is less likely to remove parasites. Because halogens are most effective in clear water, cloudy water should first be allowed to settle until clear. Filters are somewhat expensive, but effective. The combination of halogen treatment and filtering is nearly as good as boiling.

In summary, regarding food and water precautions, the CDC has developed a simple rule of thumb: "Boil it, cook it, peel it, or forget it."

Prophylaxis for Traveler's Diarrhea
Prophylactic antibiotic use is generally discouraged.¹² Widespread medication use increases the likelihood of side effects, including photosensitivity, vaginal and superficial fungal infections, and severe drug reactions such as Stevens-Johnson syndrome. It is a nuisance to take a medication every day for a condition that may not develop. Prophylactic medication use may also lead to a false sense of security, resulting in decreased compliance with the more important and effective general recommendations on food and water precautions. Finally, antibiotic resistance is a growing problem, with well-documented examples among diarrheal pathogens. Prophylactic antibiotic use is more likely to induce resistance than the occasional treatment regimens outlined below.

Diagnosis of Traveler's Diarrhea
The diagnosis is clinical; and the categorization of routine traveler's diarrhea vs. dysentery vs. chronic diarrhea is noted above.

Treatment of Traveler's Diarrhea
Dehydration is the major health risk. Oral rehydration solutions containing both carbohydrate/sugar and salt are optimal as fluid replacement.

Patients can prepare their own inexpensive solutions, using simple available ingredients (Figure 1). The cereal-based formula provides four times as many calories as the glucose-based recipe, and may help decrease the stool volume and duration of diarrhea.⁶ Ricelyte, a fully prepared cereal-based oral rehydration solution, can be purchased over the counter.

The principle behind oral rehydration is that glucose facilitates water absorption, and sodium absorption is coupled with glucose absorption. Too much sugar inhibits water absorption and can actually cause water loss via osmotic diarrhea. An ideal glucose concentration for water absorption is about 2.5%. Many drinks such as apple juice, cola drinks, sport drinks, and flavored gelatin contain about 6% glucose. These drinks can be diluted by adding approximately 1-1/2 volumes of water. It is important to dilute with clean (bottled, boiled, or chemically treated) or sterile water to avoid an increased infectious burden or secondary infection.

Untreated, traveler's diarrhea (TD) usually remits spontaneously in 3 to 5 days. Antibiotics often diminish the symptoms of traveler's diarrhea to approximately 1 day, and the addition of loperamide (Imodium) may further reduce the duration of symptoms to less than 1 day.¹² However, loperamide therapy should be avoided if the diarrhea is bloody or fever is present (dysentery). These symptoms should also be used as indicators to seek local medical attention, as they may indicate a more serious medical condition. Symptom-initiated antibiotic treatment is usually effective when taken for 1 to 5 days.⁶

Several options for therapy exist, including bismuth subsalicylate, ciprofloxacin, azithromycin, furazolidone (Furoxone), and rifaximin (XIFAXAN). While bismuth subsalicylate can be effective as prophylaxis and treatment, the large doses required make it less practical. It also binds to antibiotics and limits their effectiveness. The quinolones are rapidly effective for the common causes of traveler's diarrhea. Furazolidone is not as rapidly effective as the quinolones, but it can be given to children and has anti-Giardia activity (when given for 7 to 10 days) not seen with the other antibiotics. New data make azithromycin an attractive option for children and quinolone allergic adults. Rifaximin is a newly approved non-absorbable antibiotic. It is indicated for persons >12 years of age with TD caused by noninvasive strains of E. coli. The narrow spectrum of rifaximin and recent availability of generic ciprofloxacin continue to make quinolones my preference for episodic self-treatment of TD.

Recommendations
I currently recommend ciprofloxacin, twice a day for 3 days, as symptom-initiated treatment for traveler's diarrhea in adults.^6,12 The newer fluoroquinolones sparfloxacin (Sparflox) and levofloxacin (Levaquin) may induce more photosensitivity, making them less attractive for travelers. Furazolidone is an alternative for children or for persons unable to tolerate fluoroquinolones (Table 4). Azithromycin (Zithromax) can also be considered as an alternative in fluoroquinolone allergic travelers.

Chronic diarrhea
Rarely, travelers experience chronic diarrhea, often with weight loss and malabsorption.¹³ Because the pathogens responsible are often not self-limited and not sensitive to quinolone antibiotics (Table 5), further medical care is necessary. These patients typically present to their primary care physician after returning home. Physicians should identify the etiologic agent and give pathogen-specific therapy in this situation. Dysentery is a serious medical condition. It is imperative to make a specific diagnosis. Dysentery should be managed under the direct supervision of a physician.

Malaria:

This review of travel medicine will not review classic malaria disease issues, but rather will focus on preventing this disease in international travelers.

Each year more than 7 million Americans travel to countries in which malaria is common.⁶ There are 1000-1500 reported cases (under-reporting common) of malaria each year, with the greatest number (up to 83%) coming after travel to East Africa.⁶ Most mosquitoes that transmit malaria are found in rural areas (in contrast to those that transmit yellow fever). Hence, travel to major urban areas usually does not pose a risk for malaria, but even short trips to rural areas may place patients at risk.

Avoiding mosquitoes is the first objective. Travelers should use repellents and mosquito nets and stay indoors in the evening, which is the peak biting time for malaria-carrying mosquitoes. Soaking bed-nets and clothing in permethrin can significantly reduce mosquito bites. Permethrin is colorless and odorless and remains active even after washing. Diethyltoluamide (DEET) is one of the most widely recommended repellents. The product should contain 30% to 50% DEET. Products with higher concentrations (up to 100% DEET) are not recommended, and could rarely cause serious side effects, especially in young children. Microencapsulated preparations are still effective with the least systemic absorption. Note that dark clothing, cologne, and perfume attract mosquitoes. Early enthusiasm for Skin-So-Soft, a moisturizing bath oil, as an insect repellent has not been borne out.

Given the potential severity of malaria, additional measures are prudent, including prophylaxis.

Prophylactic Drugs for Malaria
No effective vaccines against malaria are currently available, but prophylactic medications dramatically reduce the risk. To select these medications, physicians need up-to-date data on the resistance patterns and relative risk of malaria in the country of destination, and knowledge of side effects and contraindications. The complexity of these considerations mandates referral to a traveler's clinic. Drug resistance is the major reason to choose one medication over another.

Chloroquine (Aralen) is the oldest, safest, and best tolerated of the available medications. It is safe throughout pregnancy (although pregnant women should avoid malaria-infested areas, if at all possible). Unfortunately, chloroquine-resistant strains of malaria are increasing, nearly all of them in Plasmodium falciparum, the most deadly of the parasites that cause malaria. Consequently, the areas of the world where chloroquine is still useful are continually shrinking.

Mefloquine (Larium) is an alternative choice in areas of chloroquine resistance. Mefloquine can have unpleasant side effects of dizziness, anxiety, insomnia, and nightmares, which have been much publicized in recent travel literature.¹⁴ However, a similar incidence of central nervous system reactions was noted among Peace Corps volunteers who took chloroquine.¹⁵ Mefloquine reactions are more common in young adults than in older adults and children, and are potentiated by alcohol. The drug should be avoided in patients with a history of seizures or psychiatric disorders. Fairly extensive worldwide use has documented that mefloquine is safe to use in the second and third trimesters of pregnancy. Since mefloquine works against the blood stage of malaria, which may take up to 4 weeks to appear after a bite, mefloquine must be continued for 4 weeks after leaving a malarious area.

Doxycycline (Vibramycin) is a common alternative for patients traveling to areas with chloroquine resistance who are unable or unwilling to take mefloquine.^6,9 However, it must be taken every day, compared with once a week for mefloquine, making it less convenient. Like mefloquine, doxycycline must be taken for 4 weeks after travel. In addition, doxycycline causes a higher incidence of photosensitization reactions, which can be particularly troublesome in sunny tropical countries. It also causes a slightly higher incidence of vaginal yeast infections. On the other hand, it may prevent traveler's diarrhea. Of note, doxycycline is contraindicated throughout pregnancy.

Combined atovaquone/proguanil (Malarone) is the newest antimalarial drug on the market as an alternative to mefloquine and doxycycline. It is active against chloroquine-resistant malarial organisms. Daily dosing ensures that a therapeutic level is reached quickly. If an extended trip has a very short segment with malaria exposure, Malarone enables focused preventive treatment. Because it works in the liver, it needs to be taken for only 1 week after leaving a malarious area. It is good for last-minute travel or brief stays in areas where malaria is prevalent while on a longer, mostly malaria free trip. It should not be used as prophylaxis during pregnancy.

To ensure the best effect, and because this drug can cause gastrointestinal upset, it should be taken with food or a milky drink (milk, milkshake, yogurt, and so forth), according to the package insert. It is key to recall the caveat that all such dairy products need to be pasteurized to be safe.

Signs and Symptoms
The onset of malaria can resemble a viral infection with a fever persisting for several days and possibly weeks. The classic picture consists of periodic shaking chills with a very high fever and profuse sweating. The patient may also experience joint pain, nausea, vomiting, loss of energy, and headaches. After the acute malarial attack has passed, the disease may become chronic with occasional relapses if the infection is due to a form with a relapsing liver stage (P vivax or P malariae, but not P falciparum). An attack is sometimes difficult to recognize in infants and small children with no symptoms other than loss of appetite, extreme fatigue, and agitation. If a parent believes he or she or their child is suffering an attack of malaria, they should seek expert medical assistance.

It is also important to note that the initial symptoms of malaria may occur up to 1 year after exposure with or without preventive measures. For this reason, it is necessary to emphasize the importance of patients' reminding their doctor that they have traveled to an area with malaria when they are evaluated for a fever.

Upper Respiratory Tract Infections:

Upper respiratory infections (URI) are common throughout the world. Traveling brings one in contact with a large number of people probably accounting for the perception of increased respiratory illness when traveling. Though air is recirculated on commercial airliners, it is highly filtered making it very unlikely to acquire a respiratory infection from another passenger. The few documenting cases of severe respiratory infection acquired on airplanes are from people sitting in very close proximity to the index patient on long flights.¹⁶ It is often wise to bring favorite over-the-counter URI medication as selection and availability is unpredictable in travel situations.

Severe Acute Respiratory Syndrome (SARS) is an emerging infectious disease caused by a variant of Coronavirus (a common cold virus).¹⁷ Its clinical manifestations are highly consistent with upper respiratory viral infections including fever, cough, shortness of breath, and a short incubation period—typically less then 10 days. Unfortunately, SARS appears to have a much higher mortality rate making it especially concerning. Proper attention to routine public health measures (hand washing and general hygiene) can significantly minimize one's risk of infection. Additional use of facemasks, especially NIOSH-certified N95 fitted masks, can further reduce exposure when contact with a potentially infectious person is more likely. Regular surgical masks may provide some measure of protection, but the exact amount is uncertain. The current epidemic is evolving, and it is impossible to determine the full extent of this disease, although it has had a chilling affect on international travel to Asia recently. In many ways, this very changing nature of human health and its impact in our global world only reinforce the benefit of consultation with specialized international travelers' health clinics prior to trips abroad. Itinerary review and updates on the latest information help maximize the likelihood of a healthy, productive, and enjoyable travel experience.

Influenza has been an occasional problem at some travel destinations or rarely on some cruise lines. The issue is usually seasonal, yet international travel can alter typical timing. Older and immune compromized travelers might consider adding prescription oral anti-influenza medication to take in the event of exposure. This can be discussed with your travel health advisor.

Sexually Transmitted Diseases:

With gonorrhea among the top five diseases of international travelers and with HIV infection on the rise,¹⁸ physicians should counsel their patients about the risks and available prophylactic measures for sexually transmitted diseases.

However, not all patients will follow your advice. A recent survey of more than 3,000 Swiss travelers to developing counties found that 87% complied with recommended malaria chemoprophylaxis but, remarkably, 50% of the same travelers engaged in casual sex abroad, usually with a partner from the host country.¹⁷ Of the sexual encounters, 38% were unprotected, even though the travelers shared a similar knowledge about the risks of HIV virus and other sexually transmitted diseases compared with malaria. Of note, those who engaged in high-risk sexual practices were not the same group who were noncompliant with malaria protective measures.

If a patient with a preexisting medical condition is planning an international trip, the physician should ask about the destination and type of trip to decide whether special considerations are necessary. Examples include high-altitude destinations and adventure travel. In addition, some patients, such as those with diabetes mellitus need special diets.⁶ (The RESOURCES FOR TRAVELERS section includes helpful references for travelers with special medical needs, including where to find dialysis centers abroad.)

Traveler's with disabilities have special needs, yet an increasing series of resources to facilitate enjoyable travel. The U.S. Government Architectural and Transportation Barriers Compliance Board (Access-Board) produces and distributes a variety of publications for travelers with disabilities. Information can be obtained via telephone 1-800-872-2253 (voice), or 1-800-993-2822 (TTY). Information may also be obtained over the Internet at http://www.access-board.gov. Overall, the Internet provides many resources to investigate the range of possibilities for travelers with disabilities. I strongly encourage independent research to ensure patients with disabilities plan ahead for their unique needs. See the RESOURCES FOR TRAVELERS section for a sampling of web sites (note: no endorsement is implied from listing in this chapter).

In general, patients with medical conditions should:

• Keep their medications in their original containers to avoid customs delays
• Take along an epinephrine injection kit if they have severe allergies to insect stings, unless this is otherwise contraindicated
• Consider taking a copy of their electrocardiogram, a recent medical summary, and the phone number of their primary care physician in case a treating physician abroad needs to contact them. (A list of English-speaking physicians around the world is available from the International Association for Medical Assistance to Travelers, 417 Center St., Lewiston, NY 14092; 716-754-4883).
• Investigate exactly what their insurance policies cover during travel overseas: Medicare, for example, does not cover medical expenses outside the United States. Supplemental insurance is usually available and is wise to consider. Most pre-travel medical evaluations and vaccinations are not covered by medical insurance plans. However, updating patients on routine immunizations, which further protect them overseas, may be covered.

Special Considerations for Coronary Artery Bypass Surgery Patients:

Of note, a growing number of international travelers have previously undergone coronary artery bypass grafting (CABG). A survey of 10,000 post-CABG patients found that 40% had traveled recently to either a domestic or a foreign location.¹⁸ There was a very low incidence of myocardial infarction or hospitalization during the trip. The only identified health concern was that older post-CABG patients had slightly more shortness of breath when they traveled to Mexico and South America compared with other destinations. The higher altitude of many of the destinations in Central and South America probably explains this finding.¹⁸

The goal of travel medicine is to allow the patient to enjoy a long-awaited vacation or perform productively on an important business trip overseas. The needs of international travelers to developing worlds are unique. To ensure a safe and enjoyable trip, special pre-travel counseling and vaccines are usually necessary. Primary care physicians are often the first to be apprised of plans for international travel. Therefore, they can initiate care and select those patients needing referral to a travel medicine clinic. Understanding the background issues related to the international traveler will facilitate patient care and the referral process. Bon voyage.

Books About Travel Medicine

Rose SR. International Travel Health Guide. 15th ed. Northampton, MA: Travel Medicine Inc, 2004.

Jong EC, McMullen R, eds. The Travel and Tropical Medicine Manual 3rd ed. Philadelphia: WB Saunders Co, 2003.

Bia FJ, editor. Travel Medicine Advisor. Atlanta, GA: American Health Consultants, 2002.

Dawood R, ed. Travelers' Health: How to Stay Healthy Abroad. New York: Random House, 2002.

Forgey WW. Travelers' Medical Resource: a Guide to Health and Safety Worldwide. Merrillville, IN: ICS Books, 1990.

Electronic Resources

Centers for Disease Control and prevention. Toll-free telephone: 877-FYI-TRIP; toll-free fax is 888-232-3299. Internet web site www.cdc.gov/travel/

World Health Organization: Internet web site: www.who.ch/programmes/ctd.

Newsletters and Periodicals

The Diabetic Traveler Newsletter. Box 8223 RW, Stamford, CT 06905; 203-327-5832.

Consumer Reports Travel Letter. Consumers Union, 101 Truman Ave, Yonkers, NY 10703; 914-378-2000 or 800-234-1645.

Kidney Dialysis Abroad

International Directory of Dialysis Centers. Creative Age Publications, 7628 Densmore Ave, Van Nuys, CA 91406; 800-442-5667 or 818-782-7328.

Disability Travel Sites

General access information for disabled:
http://www.access-able.com

Wheelchair travel oriented website:
http://www.disabilitytravel.com

Travel for hearing impaired people:
http://www.sinuscarecenter.com/herimaao.html

United Kingdom based broad listing of information for disabled travelers: http://www.turnaround.cdis.co.uk/
disability%20info/Holidays.html

Business Travel

World Business Travel Guide. Toronto: SP Travel Books, 1987.

Personal Safety

Worring RW, Hibbard WS, Schroeder S. Travel Safely At Home and Abroad: Don't Be a Target! Helena, MT: Uniquest Publications, 1996.

Savage PV. The Safe Travel book. New York, Lexington Books, 1993.

Scotti AJ. Executive Safety and International Terrorism: A Guide for Travellers. Englewood Cliffs, NJ: Prentice-Hall, 1986.

Wilderness Medicine

Auerbach PS, ed. Wilderness Medicine. 4th ed. St. Louis, MO: CM Mosby, Inc. 2001.

Kennedy B. Caring for Children in the Outdoors. Oakland, CA: Adventure Medical Kits, 1994.

Auerbach PS, ed. Medicine For the Outdoors. New York, NY. The Lyons Press. 1999.

Houston CS. Going Higher: The Story of Man and Altitude. Boston: Little, Brown, 1987.

SOURCE: Adapted from Rose, reference 6.

Return to Medicine Index

1. Mardh PA. What is travel medicine? Content, current position, tools, and tasks. J Travel Med. 2002; 9:34-47.
2. Keystone JS. Dismukes R. Sawyer L. Kozarsky PE. Inadequacies in Health Recommendations Provided for International Travelers by North American Travel Health Advisors. J Travel Med. 1994;1(2):72-78.
3. Steffen R. The epidemiologic basis for the practice of travel medicine. In: Lobel HO, Steffen R, Kozarsky PE, eds. Travel medicine 2. Proceedings of the Second Conference on International Travel Medicine. Atlanta GA: International Society of Travel Medicine, 1992:11-14.
4. Lustenberger I. Todesfalle von Schweizern In Ausland (thesis). University of Zurich, 1991.
5. North American Charter for Travel Health. A consensus statement on providing travel health advice. October 22, 1996. Internet Web site: (www.istm.org/consensus.html). Accessed March 20, 2002.
6. Rose SR. International travel health guide, 13th Edition. Northampton, MA: Travel Medicine, Inc., 2002.
7. Paulson E. Travel statement on jet lag. Can Med Assoc J. 1996; 155:61-66.
8. Lamberg L. Melatonin potentially useful but safety, efficacy remain uncertain. JAMA. 1996;276:1011-1014
9. CDC Health Information for International Travel, 2001-2002. US Department of Health and Human Services, US Government Printing Office, Washington, D.C., 2001.
10. Innis BL, Snitbhan R, Kunasol P, et al. Protection against hepatitis A by an inactivated vaccine. JAMA. 1994;271:1328-1334.
11. Peter G, LePow ML, McCracken GH Jr., Phillips CF, editors. 2001 Redbook BReport of the Committee on Infectious Diseases. American Academy of Pediatrics, 2001.
12. Taylor DN, Sanchez JL, Candler W, Thornton S, McQueen C, Echeverria P. Treatment of travelers' diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med. 1991;114:731-734.
13. DuPont HL, Capsuto EG. Persistent diarrhea in travelers. Clin Infect Dis. 1996;22:124-128.
14. Dawood R. Are these pills safe? Condé Nast Traveler. 1996;31:37-41.
15. Lobel Ho, Bernard KW, Williams SL, Hightower AW, Patchen LC, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine. JAMA. 1991;265:361-64.
16. Olsen SJ, Chang HL, Cheung TY, et al. Transmission of the Severe Acute Respiratory Syndrome on Aircraft. N Engl J Med. 2003;349:2416-2422.
17. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The Severe Acute Respiratory Syndrome. N Engl J Med. 2003;349:2431-2441.
18. Bonneux L, Van der Stuyft P, Taelman H, et al. Risk factors for infections with human immunodeficiency virus among European expatriates in Africa. BMJ. 1988;297:581-584.
19. Gagneux OP, Blochlinger CU, Tanner M, Hatz CF. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;3:14-21.
20. Hargarten SW, Anderson AJ, Walker J, Barboriak JJ. Travel of U.S. citizens after coronary artery bypass surgery. J Travel Med. 1996;3:7-10.

Disclaimer