Approach to Travel Medicine Counseling

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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 provide education to mitigate risks associated with international travel.

Epidemiology

Incidence
Illness and injury are common during travel. Specific incidence is difficult to ascertain. There were 1.2 billion international tourist travel arrivals in 2015 (CDC).

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)
      • Flying is contraindicated within 3 weeks of a myocardial infarction and within 10 days of a thoracic or abdominal surgery.
      • If preexisting eustachian tube dysfunction, use of a vasoconstricting nasal spray immediately before air travel may help lessen the likelihood of otitis or barotrauma (1).
    • Special conditions (pregnancy, breastfeeding, disability or handicap, immunocompromised state, older age)
      • Flying is not recommended after the 36th week of pregnancy. Many airlines require a provider letter if flying after this time.
    • Immunization history
    • Prior travel experience (previous malaria prophylaxis, experience with altitude, illnesses related to prior travel)
  • Trip details
    • Itinerary (countries/specific regions, rural or urban; side trips)
    • Timing (length, season, 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 (2).
    • 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.
    • Tick-borne 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 (2).
    • Yellow fever—highest risk in sub-Saharan Africa and the Amazon regions of South America. Vaccination is not considered valid until 10 days after administration (2).
  • Malaria prophylaxis
    • Based on destination, types of planned activities, and patient preferences. CDC has up-to-date recommendations.
    • Chloroquine-sensitive malaria (2,3)
      • Chloroquine—begin 1 to 2 weeks prior to travel, continue 4 weeks after leaving malaria-endemic area; may increase QTc interval (particularly if given with other QTc-prolonging drugs)
        • 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 (2,3)
      • 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: 1/4 tablet once weekly
          • >19 to 30 kg: 1/2 tablet once weekly
          • >30 to 45 kg: 3/4 tablet once weekly
          • >45 kg: 1 tablet once weekly
  • Protection against mosquitoes and ticks
    • Avoid areas of known outbreaks of communicable disease. Refer to the CDC travelers’ health Web site for updates.
    • Avoid peak exposure times and places.
      • Mosquitoes may bite at any time of the day.
      • Peak biting activity for vectors of some diseases (such as dengue, Zika, and chikungunya) is during daylight hours (1).
      • Peak biting activity for vectors of other diseases (such as malaria, West Nile, and Japanese encephalitis) are most active in twilight periods (dawn and dusk) or after dark.
    • Wear appropriate clothing: Minimize exposed skin.
    • Check for ticks.
    • Bed nets
    • Insecticides and repellants—reapply regularly.
      • DEET
      • Picaridin
      • Oil of lemon eucalyptus
      • IR3535
      • 2-Undecanone
  • Traveler’s diarrhea
    • Symptoms range from mild abdominal cramping and urgent loose stools to severe abdominal pain, fever, vomiting, and bloody diarrhea.
    • Approximately 80–90% bacterial, 5–8% viral, 10% protozoal (1)
    • 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 (2).
    • Intermediate-risk areas include countries in Eastern Europe, South Africa, and some of the Caribbean islands (2).
    • Strategies to minimize diarrhea (2)
      • 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 it 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) (2)
    • 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 (2)
    • High-altitude cerebral edema (HACE)—severe progression of AMS. Lethargy, drowsiness, confusion, ataxia; requires immediate descent (2)
    • 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 (2).
    • 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 (2).
      • 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 (2)
      • Dexamethasone—usually reserved for treatment; dose: 2 mg q6h or 4 mg q12h; should not be used for prophylaxis in pediatric patients (2)
      • Nifedipine—for prevention of HAPE only; dose: 30 mg SR q12h or 20 mg SR q8h (2)
      • Tadalafil—useful for prevention of HAPE only; dose: 10 mg BID (2)
  • 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.
    • Sedative hypnotics (nonbenzodiazepine), such as zolpidem, can be useful.
    • 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 (2).
      • ≥12 hours after surfacing from nondecompression dive
      • ≥18 hours after repetitive dives or multiple days of diving
      • 24 to 28 hours after a dive that required decompression stops
  • Other information
    • Avoid contact with animals because bites and scratches may transmit rabies.
    • Discuss risks such as traffic accidents, alcohol misuse, personal assault, robbery, and water safety.
    • Check hotels or other sleeping locations for bed bugs on bedding and furniture.
    • Consider travel insurance (including coverage for evacuation).
    • Hand carry medications and supplies.
    • Include medications to manage exacerbations or complications of existing chronic diseases.
    • Avoid areas with known outbreaks of communicable disease. Reference the CDC Travelers’ Health Web site before travel.
    • The Department of State’s Smart Traveler Enrollment Program provides destination-specific travel alerts.

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