Amanda D. Whatley, Nina Marano, Phyllis E. Kozarsky

In 2007, approximately 14% of adult U.S. residents spent at least one night outside the United States. Additionally, there were over 64 million trips outside the country, a 21% increase since 1997. As international travel has increased dramatically over the past decades and as travelers choose more varied destinations and activities, the responsibilities of the traveler, clinician, and travel industry become more complex and interdependent. This section outlines how these groups can work together so that travel may be safer and healthier, and more enjoyable.

Responsibilities of the Traveler

Although studies have shown that the majority of travelers from the United States and other countries do not seek pre-travel health advice, travelers do need to understand the health risks that traveling internationally may pose and take an active part in health preparation. Whether a person is a frequent international traveler or on the trip of a lifetime, he or she can take steps to plan for healthy and safe travel.

• Gather information about the travel destination(s) and possible activities.
  • Regardless of whether travelers are planning their own trips or joining a tour group, travelers should find out as many details as possible about their travel destinations, modes of travel, lodging, food, and activities during the trip.
  • These details are important to tailoring the travel health advice individually for each person. For example, two travelers to the same country but who have different itineraries and planned activities may be provided different vaccines, medications, and detailed advice in preparation for their trips.
• Visit the CDC Travelers’ Health website for health information.
  • The website (www.cdc.gov/travel) is kept current with latest recommendations concerning endemic diseases, as well as outbreaks around the world and other health-related situations, such as effects of natural disasters.
  • Of particular interest are the destination pages with country-specific health information.
  • The information provided on the website, along with that from a health-care provider, will equip travelers with what they need to know to remain as healthy as possible.
• Seek pre-travel health advice from a health-care provider familiar with travel.
  • Travelers should make certain that there is enough time (ideally 4–6 weeks) to see a health-care provider and obtain any necessary vaccinations before they travel. Those with imminent travel, such as business travelers, should still seek travel health advice from an expert.
  • Even healthy young adults going to developed areas should be up-to-date on their routine vaccinations. Vaccination practices in other parts of the world vary. Travel anywhere outside the United States, even to industrialized regions, such as Western Europe, presents a risk for exposure to measles and other vaccine-preventable conditions, such as influenza and hepatitis A.
  • One of the most important ways that travelers can prepare for their visit with a health-care provider is to come to the clinic with helpful details that will facilitate a pre-travel consultation (Box 1-1).
  • The CDC Travelers’ Health website provides help in locating a clinic for pre-travel consultation. The site provides links to directories of travel medicine clinicians who are members of the International Society of Travel Medicine and the American Society of Tropical Medicine and Hygiene. The site also provides links to state health departments and the Yellow Fever Vaccination Clinic Registry that lists facilities approved to provide yellow fever vaccinations (wwwn.cdc.gov/travel/contentTravelClinics.aspx).
• Prevent illness during travel.
  • Even with travel advice, vaccines, and medications, a person is not 100% protected against all diseases or injuries. Healthy behaviors, such as being careful about food and water, protecting against insect and mosquito bites, and washing hands frequently, are important ways of preventing many common travel illnesses.
  • Travelers should prepare and carry a travel health kit (see the Travel Health Kits section in Chapter 2), equipped with many items that can help prevent and treat common travel-related illnesses and injuries.
  • Increased awareness of cough hygiene or respiratory etiquette (such as covering one’s mouth when coughing) is not only a courtesy, but if generally practiced, would help reduce transmission of respiratory and influenza-like illnesses. Travelers should exercise appropriate precautions and try not to travel if they are ill with a communicable disease that is spread easily to other people (see the Obtaining Health Care Abroad for the Ill Traveler section in Chapter 2).

Responsibilities of the Clinician

Regardless of their specialty, most clinicians will encounter a traveling patient at some point in their practice. It is important for clinicians, especially those in primary care, to know some basic travel health information to determine the extent of health advice their patients should access prior to traveling and to recognize common post-travel health symptoms and syndromes.

• Incorporate the subject of travel medicine into one’s practice.
  • This might be as basic as asking patients if they are planning to travel internationally, particularly to a developing country destination, and referring them to a travel medicine clinic.
  • Clinicians should emphasize the importance of a pre-travel consultation and the fact that international travel can pose special health risks that should be addressed.
  • Health-care providers should be particularly aware of individuals who have migrated to the United States from another country or who may be visiting friends or relatives in developing countries. The goal of inquiring well in advance would either allow the time for the individual to access a specialist in travel medicine or allow the health-care provider the opportunity to convey risk information over time, provide vaccine immunity by administering needed vaccines well in advance, and provide the patient the opportunity to consider possible costs over several months rather than require the patient to make a decision based on a single interaction.
• Determine one’s own limitations in giving pre-travel advice.
  • Before evaluating an individual for a pre-travel consultation, the clinician should determine what level of information he or she is comfortable in giving to the patient regarding their travel plans. Choices are—
    • Referring all travelers to a travel clinic or a travel medicine specialist.
    • Offering basic pre-travel advice for less complex situations, such as advising travelers who are going on a short vacation to a popular tourist destination, like Mexico or the Caribbean. In such cases, updating routine vaccinations, providing hepatitis A and B vaccines, and providing education about healthy behaviors to prevent diseases and injuries may be all that is necessary.
    • Providing complex pre-travel consultations and making a commitment to the practice of travel medicine.
• Give a comprehensive pre-travel consultation.
  • For more information, see The Pre-Travel Consultation in Chapter 2. Basic components of a pre-travel consultation will include a risk assessment, providing health counseling and advice, and selection and administration of appropriate vaccinations and medications. There are several ways clinicians can extend their knowledge to provide comprehensive pre-travel care and more complex consultations.
  • The International Society of Travel Medicine (ISTM) provides educational resources, including the Journal of Travel Medicine, an active listserv, and a Certificate of Knowledge in Travel Health (CTH), awarded upon completion of an exam.
  • Numerous conferences are held throughout the year, both nationally and internationally, on the subject of travel medicine.
  • The Body of Knowledge for the Practice of Travel Medicine, which is the scope of the specialty of travel medicine, has been published, recently updated, and is available on the ISTM website (www.istm.org).
  • As the subject matter of travel medicine is quite dynamic, clinicians who will be regularly advising travelers in pre-travel consultations need to maintain a current base of knowledge. Many different internet resources and databases, although sometimes incomplete or in conflict with one another, are available for clinicians to use to keep abreast of the health issues in international travel (see Appendix B).
  • In addition to general pre-travel consultations, some clinicians may also wish to become registered yellow fever vaccine providers. This process is initiated with one’s state health department.
• Recognize common disease symptoms and syndromes of international travelers.
  • When assessing a patient who is ill, simply asking about their recent travel history is the first step in providing post-travel medical care. This can be a major clue in determining the cause of the ailment. For example, a patient who returns from sub-Saharan Africa with a fever and flu-like symptoms needs emergency attention to rule out malaria.
  • The extent of the care given by each clinician is personally determined. Knowing when one will refer a patient to a specialist and who that specialist would be are important decisions to make before patients come into the office seeking medical care, or even pre-travel health advice.
  • Patients needing more extensive post-travel care can be referred to a clinician in infectious diseases or clinical tropical medicine. The American Society of Tropical Medicine and Hygiene provides a listing of such clinicians on its website (www.astmh.org).
  • Further information about post-travel medical care can be found in Chapter 4.

Responsibilities of the Travel Industry

The responsibilities of the travel industry, including travel agencies, tour operators, and air and cruise lines, do not culminate with the final booking of the tickets or hotel rooms. These members of the travel industry, too, should learn about the basics of travel medicine as it affects the areas of the world where their customers are traveling.

• Learn about health risks around the world.
  • Access the CDC Travelers’ Health website for information about many travel destinations (www.cdc.gov/travel).
• Acknowledge travel health risks and provide resources for education for travelers.
  • Studies have shown that customers often look to their travel agents to advise them on all aspects of their trip, including health risks and preventive actions they should take.
  • Although the role of the travel industry is not to provide personal medical consultations, mentioning that health risks exist and referring travelers to a clinic or to the ISTM website are appropriate actions.
  • Most travelers will likely travel regardless of possible health risks if they know that they can take actions to help prevent getting sick. A healthy trip and a positive experience, as a result of proper preventive health behaviors, will be motivation to travel again in the future.

Resources for Travel Health Advice: CDC Website

Travelers' Health Website

Destination Pages

CDC’s Travelers’ Health website now features destination-specific pages with information on current CDC assessments of disease risk and recommendations for healthy travel (wwwn.cdc.gov/travel/destinationList.aspx).

Travel Notices

Prior to embarking on a trip, travelers and their health-care providers should consult sources such as the Travel Notice section of the website (wwwn.cdc.gov/travel/notices.aspx) for the latest information on outbreaks or other health-related issues.

CDC’s Travel Notices are presented in the following four levels of increasing precautionary guidance to assist the traveler (Table 1-1). Most notices posted on the website appear under “In the News” or “Outbreak.” In only one instance, during the outbreak of SARS in 2003, has postponement of nonessential travel to affected areas been recommended in a Travel Health Warning.

1. In The News provides information about sporadic cases of disease or an occurrence of a disease of public health significance affecting a traveler or travel destination. The risk for an individual traveler does not differ from the usual risk in that area.
2. Outbreak Notice provides information about a disease outbreak in a limited geographic area or setting. The risk to travelers is defined and limited, and the notice will remind travelers about standard or enhanced travel recommendations, such as vaccinations.
3. Travel Health Precaution provides specific information about a disease outbreak of greater scope and over a larger geographic area so travelers can take measures to reduce the risk of infection. CDC does not recommend against travel to a specific area but may recommend limiting exposure to a defined setting, such as poultry farms or health-care settings.
4. Travel Health Warning recommends against nonessential travel to an area because a disease of public health concern is expanding outside the areas or populations that were initially affected. The purpose of a travel warning is to reduce the volume of traffic to affected areas, thus limiting the risk of spreading the disease to unaffected areas.

Occasionally, travel notices may feature changes to existing recommendations, such as adding antimalarial prophylaxis for an area previously thought to be malaria free. If the outbreak resolves, the recommendation may be withdrawn. If the new recommendation becomes permanent, it will be highlighted and incorporated into the text of the online version of CDC Health Information for International Travel 2010 at www.cdc.gov/yellowbook. A complete description of the definitions and criteria for issuing and removing travel notices can also be found in Table 1-1 and at wwwn.cdc.gov/travel/notices.aspx.

Malaria Website

CDC’s Malaria website contains informational tools, educational materials, and cautionary tales of real people who acquired malaria after travel without adequate prophylactic measures (www.cdc.gov/malaria/travel/index.htm).

CDC’s Malaria Risk Map is an interactive map that provides location-specific information on current CDC assessments of malaria risk and recommendations for preventive malaria treatment (www.cdc.gov/malaria/risk_map).

References

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