Approach to Travel Medicine Counseling

Approach to Travel Medicine Counseling is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Pretravel consultations assess trip plans to determine potential health hazards, discuss risks and methods for prevention, provide immunizations for vaccine-preventable disease and medications for prophylaxis and/or self-treatment, and educate the traveler to mitigate risks associated with international travel.

Epidemiology

Incidence
Illness and injury are common during travel.

Risk Factors

Risks vary by destination, length of the trip, planned activities, age, and health status of the traveler.

  • Traveler details
    • Past medical history (age, gender, medical conditions, allergies, medications)
    • Special conditions (pregnancy, breastfeeding, disability or handicap, immunocompromised state, older age)
    • Immunization history
    • Prior travel experience (previous malaria prophylaxis, experience with altitude, illnesses related to prior travel)
  • Trip details
    • Itinerary (countries and specific regions, rural or urban)
    • Timing (length of trip, season of travel, time until departure)
    • Reason for travel
    • Special activities (disaster relief, medical care, high altitude or climbing, diving, cruise ship, rafting, cycling, extreme sports)

General Prevention

  • Routine vaccinations
    • Haemophilus influenzae type b
    • Hepatitis B
    • Influenza
    • Measles, mumps, rubella—more common in countries without routine childhood immunizations
    • Meningococcal—outbreaks common in sub-Saharan Africa especially during the dry season (December through June). Saudi Arabia requires the quadrivalent vaccine for Hajj pilgrims (1).
    • Pneumococcal
    • Polio
    • Rotavirus—common in developing countries
    • Tetanus, diphtheria, pertussis
    • Varicella—more common in countries without routine childhood immunizations
    • Zoster—stress may trigger reactivation.
    • Human papillomavirus (HPV)—sexual activity during travel may lead to HPV infection.
  • Travel-specific vaccinations (destination dependent)
    • Cholera (not available in the United States)
    • Hepatitis A—often recommended regardless of destination
    • Japanese encephalitis
    • Rabies—if immunoglobulin would be difficult to obtain, consider vaccination to simplify postexposure prophylaxis.
    • Tickborne encephalitis (not available in United States)
    • Typhoid—highest risk in India, Pakistan, and Bangladesh. Do not give oral vaccine to immunocompromised patients or those who have taken antibiotics in the previous 72 hours (1).
    • Yellow fever—highest risk in sub-Saharan Africa and the Amazonian regions of South America. Vaccination is not considered valid until 10 days after administration (1).
  • Malaria prophylaxis
    • Based on destination, types of planned activities, and patient preferences. CDC has up-to-date recommendations.
    • Personal protective measures
      • Wear appropriate clothing.
      • Bed nets
      • Insecticides and repellants
        • DEET
        • Picaridin
        • Oil of lemon eucalyptus
        • IR3535
    • Chloroquine-sensitive malaria (1,2)
      • Chloroquine—begin 1 to 2 weeks prior to travel, continue for 4 weeks after leaving malaria-endemic area; may increase QTc interval (particularly if given with other QTc-prolonging agents)
        • Adult dose: 300 mg base (500 mg salt) orally once weekly
        • Pediatric dose: 5 mg/kg base (8.3 mg/kg salt) orally once weekly (up to 300 mg base per dose)
      • Hydroxychloroquine—begin 1 to 2 weeks prior to travel, continue for 4 weeks after leaving malaria-endemic area; dosed weekly
        • Adult dose: 310 mg base (400 mg salt) orally once weekly
        • Pediatric dose: 5 mg/kg base (6.5 mg/kg salt) orally once weekly (up to 310 mg base per dose)
    • Chloroquine-resistant malaria (1,2)
      • Atovaquone/proguanil—begin 1 to 2 days before travel and continue for 1 week after leaving malaria-endemic area.
        • Adult dose: 250 mg/100 mg atovaquone/proguanil PO daily
        • Pediatric dose: Tablets contain 62.5 mg/25 mg atovaquone/proguanil hydrochloride.
          • 5 to 8 kg: 1/2 pediatric tablet daily
          • 8 to 10 kg: 3/4 pediatric tablet daily
          • 10 to 20 kg: 1 pediatric tablet daily
          • 20 to 30 kg: 2 pediatric tablets daily
          • 30 to 40 kg: 3 pediatric tablets daily
          • >40 kg: 1 adult tablet daily
      • Doxycycline—begin 1 to 2 days before travel and continue for 4 weeks after leaving malaria-endemic area.
        • Adult dose: 100 mg orally daily
        • Pediatric dose: ≥8 years old 2.2 mg/kg up to adult dose of 100 mg daily
      • Mefloquine—begin ≥2 weeks before travel and continue for 4 weeks after leaving malaria-endemic area; has a number of drug interactions
        • Adult dose: 228 mg base (250 mg salt) orally once weekly
        • Pediatric dose
          • ≤9 kg: 4.6 mg/kg base (5 mg/kg salt) orally once weekly
          • >9 to 19 kg: ¼ tablet once weekly
          • >19 to 30 kg: ½ tablet once weekly
          • >30 to 45 kg: ¾ tablet once weekly
          • >45 kg: 1 tablet once weekly
  • Traveler’s diarrhea
    • Symptoms range from mild abdominal cramping and urgent loose stools to severe abdominal pain, fever, vomiting, and bloody diarrhea.
    • Length—bacterial causes last 3 to 7 days if untreated. Viral lasts 2 to 3 days. Protozoal can last weeks to months if not treated.
    • High-risk areas include Asia, Middle East, Africa, Mexico, and Central and South America (1).
    • Intermediate-risk areas include countries in Eastern Europe, South Africa, and some of the Caribbean islands (1).
    • Strategies to minimize diarrhea (1)
      • Wash hands or use sanitizer prior to eating.
      • Avoid raw or undercooked meat, fish, or shellfish, salads, uncooked vegetables, unpasteurized fruit juices, or unpasteurized milk or milk products.
      • Avoid unpeeled raw fruit. Peel fruit yourself if possible.
      • Tap water may be unsafe for drinking, making ice, preparing food, washing dishes, or brushing teeth; use sealed bottled water if possible.
    • For high-risk patients—bismuth subsalicylate reduces incidence of travelers’ diarrhea by 50%; 2 oz of liquid or two chewable tablets 4 times per day (not recommended for children <3 years) (1)
    • Antibiotic options for diarrhea self-treatment
      • Ciprofloxacin 500 mg q12h × 2 doses
      • Azithromycin 500 mg daily for 1 to 3 days
    • Adjunct medications
      • Loperamide
        • 4 mg initially followed by 2 mg after each loose stool (max 16 mg/day)
        • Pediatric dose
        • Not recommended for children <6 years
        • 6 to 8 years—2 mg initial dose, followed by 1 mg after each loose stool (max 4 mg/day)
        • 9 to 11 years—2 mg after initial dose, followed by 1 mg after each loose stool (max 6 mg/day)
        • ≥12 years: Refer to adult dosing.
      • Diphenoxylate
        • 5 mg (2 tablets) 3 or 4 times per day until control achieved (max 20 mg/day)
        • Pediatric dose: not recommended for children <2 years; 0.3 to 0.4 mg/kg/day in 4 divided doses
  • Altitude illness
    • Acute mountain sickness (AMS)—most common. Typically presents with headache starting 2 to 12 hours after arrival. Other symptoms include fatigue, loss of appetite, nausea, and vomiting. Usually resolves within 24 to 48 hours of acclimatization (1).
    • High-altitude cerebral edema (HACE)—severe progression of AMS. Lethargy, drowsiness, confusion, and ataxia; requires immediate descent (1)
    • High-altitude pulmonary edema (HAPE)—can occur by itself or with AMS and HACE. Symptoms begin with shortness of breath on exertion and progress to shortness of breath at rest, weakness, and cough. Supplemental oxygen and immediate descent. HACE and HAPE can be fatal (1).
    • Preventive measures
      • Ascend gradually—from low altitude to <9,000 feet in 1 day. >9,000 feet, don’t climb >1,600 feet per day. Plan an extra day for acclimatization every 3,300 feet (1).
      • In first 48 hours, avoid alcohol and only perform mild exercise.
    • Preventive medications
      • Recommended for those at high risk for AMS (based on rate of ascent or history of HACE or HAPE): Consider for those at moderate risk.
      • Acetazolamide—dose: 125 mg BID (250 mg BID if >100 kg); pediatric dose: 2.5 mg/kg q12h (1)
      • Dexamethasone—can be used for prevention although usually reserved for treatment; dose: 2 mg q6h or 4 mg q12h; should not be used for prophylaxis in pediatric patients (1)
      • Nifedipine—useful for prevention of HAPE only; dose: 30 mg SR version q12h or 20 mg SR version q8h (1)
      • Tadalafil—useful for prevention of HAPE only; dose: 10 mg BID (1)
  • Jet lag
    • Before travel, adjust sleep cycle (and possibly meal times) 1 to 2 hours earlier or later (depending on direction of travel) for several days prior to departure.
    • Drink plenty of water to remain hydrated.
    • Optimize sunlight exposure to destination.
    • Nonaddictive sedative hypnotics (non-benzodiazepine), such as zolpidem, can be useful to increase sleep.
    • If using benzodiazepines, use short-acting agents, such as temazepam.
  • Motion sickness
    • High-risk individuals
      • Children ages 2 to 12 years
      • Women, especially when pregnant, menstruating, or on hormones
      • People who get migraines, especially during a migraine
      • Some medications
    • Prevention strategies
      • Avoidance of known triggers
      • Strategic positioning (front of car, overwing of aircraft)
      • Treatment
        • Dimenhydrinate dose: pediatric dose: 1.0 to 1.5 mg/kg 1 hour before travel and every 6 hours during the trip
        • Diphenhydramine: pediatric dose: 0.5 to 1.0 mg/kg per dose up to 25 mg 1 hour before travel and every 6 hours during the trip
        • Scopolamine—transdermal patch to hairless area behind ear at least 4 hours prior to exposure and every 3 days as needed
  • Environmental hazards
    • Avoid walking barefoot (parasites can enter skin).
    • Avoid swimming in freshwater where there is a risk for schistosomiasis or leptospirosis.
    • Use sunscreen.
    • If scuba diving, avoid flying or altitude exposure >2,000 feet (1).
      • ≥12 hours after surfacing from no-depression dive
      • ≥18 hours after repetitive dives or multiple days of diving
      • 24 to 28 hours after a dive that required decompression stops
  • Other information
    • Consider travel insurance (including coverage for evacuation).
    • Hand carry medications and supplies.
    • Include medications to manage exacerbations or complications of existing chronic diseases.
    • The Department of State’s Smart Traveler Enrollment Program provides destination-specific travel alerts.

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Citation

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TY - ELEC T1 - Approach to Travel Medicine Counseling ID - 816878 Y1 - 2019 PB - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816878/all/Approach_to_Travel_Medicine_Counseling ER -