Planning for Healthy Travel: Responsibilities & Resources
International travel encompasses a wide array of activities, including business travel, sightseeing, adventure travel, international adoption, and visiting friends and relatives. The process of planning these trips involves a relationship between the traveler, the clinicians, and the travel and tourism industry. This section outlines how these groups can work together so that travel may be safer, healthier, and more enjoyable.
RESPONSIBILITIES OF THE TRAVELER
Although studies have shown that most travelers from the United States and other countries do not seek pre-travel health advice, travelers need to understand the health risks that traveling internationally may pose and be actively involved in preparing for healthy travel.
Gathering Destination Information
Travelers should find out as many details as possible about their travel destinations, modes of travel, lodging, food, and activities during their trip. These details help the travel health provider tailor his or her advice in regard to immunizations, prophylaxis, and other health advice. Travelers can visit the CDC Travelers’ Health website (www.cdc.gov/travel) for the latest health information for international destinations, which includes disease outbreaks, natural disasters, and other events with health-related concerns.
Seeking and Following Pre-Travel Health Advice
Obtaining pre-travel health care and advice from a clinician familiar with travel is an important step in preparing to travel internationally. Ideally, this visit should take place 4–6 weeks before travel, but even getting a consultation in the week before travel can be of value. The pre-travel visit includes a discussion of immunizations, prophylactic medications (such as antimalaria drugs), and specific health advice for preventing and treating travelers’ diarrhea and other illnesses the traveler may encounter. Travelers who have chronic health issues or who take medications may also need to coordinate their pre-travel care with their regular doctors. CDC recommends that travelers prepare and carry a travel health kit (see Chapter 2, Travel Health Kits).
Avoiding Travel When Sick
Recently, more emphasis has been placed on advising people to avoid traveling while they are sick, if they may have a communicable disease that can be transmitted to other people. Postponing or canceling a trip can be inconvenient and may incur additional expenses, but these costs may be small compared with the public health costs of a disease outbreak, which may include a search for airline travelers who might have been exposed to the traveler’s disease.
RESPONSIBILITIES OF THE CLINICIAN
Regardless of their specialty, most clinicians will encounter a traveling patient at some point in their practice. Clinicians, especially those in primary care, should know basic travel health information to determine the extent of health advice their patients should access before traveling, and be able to recognize common post-travel health symptoms and syndromes.
Incorporating Pre-Travel Care into One’s Practice
At a minimum, clinicians can easily incorporate the topic of travel medicine into their practice by routinely asking patients if they are planning to travel internationally, particularly to a developing country. By doing so, clinicians can begin to raise awareness and emphasize the importance of a pre-travel consultation, and the fact that international travel can pose special health risks. Inquiring in advance also allows time for the patient to receive comprehensive pre-travel care, either at the current visit or by scheduling a pre-travel consult before the planned trip. Additionally, patients who have more complex medical histories, or who need to see a specialist in travel medicine, would have time to adequately address any special needs. Clinicians should be particularly aware of people who were born in or may be visiting friends or relatives in developing countries. For more information on this population, refer to Chapter 8, Immigrants Returning Home to Visit Friends and Relatives (VFRs).
Before evaluating a traveler for a pre-travel consultation, the clinician should determine what level of information he or she is comfortable giving to the patient. Some clinicians may base their comfort level on aspects of trips, such as location, length, and type, on the complexity of the patient’s medical history, or both. Common categories of service include the following:
- Referring all travelers to a travel clinic or a travel medicine specialist.
- Offering only basic pre-travel advice and common vaccinations for less complex situations, such as advising travelers who are going on a short vacation to a popular tourist destination such as Mexico or the Caribbean.
- Providing complex pre-travel consultations and making a commitment to the practice of travel medicine.
Even if clinicians have decided to offer only pre-travel care for less complex situations and itineraries, they should take the time to give a comprehensive pre-travel consultation, incorporating vaccines, medications, and behavioral preventive recommendations. For more information, see Chapter 2, The Pre-Travel Consultation.
Clinicians who wish to provide pre-travel care in more complex consultations can extend their knowledge and expertise in several ways:
- Refer to Appendix A for additional information about the practice of travel medicine, professional resources, and certifications offered through professional organizations.
- As travel medicine is dynamic, clinicians who regularly advise 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.
Incorporating Post-Travel Care into One’s Practice
Recognizing common travel-related disease symptoms and syndromes is important in the primary care and emergency care settings, as these settings are usually where an ill returned traveler will initially seek medical care. When assessing a patient for a possible infectious disease, it is of paramount importance to remember to obtain a travel history. Patients with influenzalike symptoms may not remember to volunteer the fact that they have recently traveled to Africa, for example, and could have malaria, which is potentially life-threatening. Further information about post-travel medical care can be found in Chapter 5.
Additionally, clinicians should have a plan as to when they will refer a patient to a specialist and who that specialist would be, before the patient comes into the office seeking medical care. 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).
RESPONSIBILITIES OF THE TRAVEL AND TOURISM INDUSTRY
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 travel and tourism industry professionals is not to provide personal medical consultations, mentioning that health risks exist and referring travelers to a clinic or to the International Society of Travel Medicine website are appropriate actions. In many cases, this may be the best opportunity to help someone who was not aware that pre-travel medical advice was important. The CDC Travelers’ Health website can be consulted to give a general idea of the health risks the client may encounter on a given trip (www.cdc.gov/travel).
CDC RESOURCES FOR TRAVEL HEALTH ADVICE
Travelers’ Health Website
CDC’s Travelers’ Health website features destination-specific pages with information on current CDC assessments of disease risk and recommendations for healthy travel (wwwnc. cdc.gov/travel/destinations/list.aspx).
The travel notice section of the website (wwwnc.cdc.gov/travel/notices.aspx) contains the latest information about international outbreaks or other health-related issues, including recommendations for travelers. CDC’s Travel Notices are presented in 4 levels: In the News, Outbreak, Travel Health Precaution, and Travel Health Warning (Table 1–01). Most notices posted on the website are in the first 2 categories. CDC rarely issues a travel health precaution or a travel health warning.
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 is incorporated at that time into the text of the online version of CDC Health Information for International Travel, and added to a running list of updates to the hardcopy edition at www.cdc.gov/yellowbook. Any related recommendation changes for specific destinations are also incorporated into the relevant destination pages.
Considerations for Instituting Travel Notices
The purpose of CDC Travel Notices is to inform travel health providers and travelers about situations occurring internationally that may present a health risk to US residents traveling internationally, and to provide recommendations for protecting the health of these travelers. These notices are not meant to catalog all disease outbreaks or health-related disasters. When deciding whether to post a travel notice and at what notice level, CDC considers several factors outlined below, in consultation with relevant subject-matter experts. These factors are used to guide the decisionmaking process, but do not limit the process from incorporating other factors necessary in making the best possible public health decision during an event.
Disease transmission: For specific disease outbreaks, the modes of transmission and patterns of spread, as well as the magnitude and scope of the outbreak in the area, affect the decision for the appropriate level of notice. Criteria include the presence or absence of transmission outside defined settings, as well as evidence that cases have spread to other areas.
Containment measures: The presence or absence of acceptable disease outbreak control measures in the affected area can influence decisions about travel notices, including the level of the notice. Outbreak-affected areas with poor or no containment measures in place may have the potential for a higher risk of transmission to exposed people and spread to other areas.
Quality of surveillance: Considerations include whether health authorities in the outbreak-affected area have the ability to accurately detect and report cases, and conduct contact tracing of exposed people. Areas where a disease is occurring that have poor surveillance systems may have higher risk of transmission than is apparent from local reporting.
Quality and accessibility of medical care: Affected areas with inadequate medical services and infection control procedures in place, as well as remote locations without access to medical evacuation, present a higher level of risk for the US traveler or resident living abroad.
Aftermath of a natural or nonnatural disaster: In the aftermath of a disaster, an assessment of the potential for illness and injury would be used to determine if a travel notice is warranted and at what level. Certain diseases may result due to circumstances such as flooding, congregation of displaced people into small areas, and the destruction of or limitation of food, water, and medical supplies. Resulting disease situations would situations would be assessed by using the categories above, as any disease outbreak would be assessed. Additionally, environmental risks, or risks related to injuries and safety, would be considered in disaster situations.
Considerations for Downgrading or Removing Notices
Factors used in considering the institution of a travel notice are also used in considering its removal or revision. As situations resolve, international health authorities may officially declare a formal end to a disease outbreak. However, in most instances, there is no formal end or resolution. In these cases, CDC must consider whether the disease outbreak has ceased or waned to levels that existed before the notice was posted. In disaster situations, a similar assessment would take place regarding the environmental risks to travelers’ health. “In the News Notices” and “Outbreak Notices” are reassessed at regular intervals, and are removed when they are no longer relevant or when the outbreak has resolved.
Since each disease is unique in characteristics such as incubation periods and transmission methods, the decision-making process for removing or downgrading notices is not an exact algorithm. For example, to downgrade a travel health warning to a travel health precaution, CDC would consider information such as the severity of the disease or event, surveillance data from the area, the extent of ongoing transmission, the public health response, and exported cases. In some situations, cases of the disease may cease, as happened during the SARS outbreak. However, in other situations, a travel health warning may no longer be needed because the disease has become endemic in affected areas, such as in the situation of 2009 pandemic influenza A (H1N1).
CDC’s Malaria website contains informational tools, educational materials, and cautionary tales of people who acquired malaria during or after travel without adequate prophylactic measures (www.cdc.gov/malaria/travelers/index.html). The CDC Malaria Map Application is an interactive map that provides location-specific information on current CDC assessments of malaria transmission, and recommendations for preventive malaria treatment (www.cdc.gov/malaria/map). Assessments are based largely on national surveillance reports; thus, the presence of malaria in most countries is dis-played only at the national and provincial level.
Table 1-01. CDC travel notice defiitions
|TYPE OF NOTICE||SCOPE2||RISK FOR TRAVELERS3||PREVENTIVE MEASURES||EXAMPLE OF NOTICE||
EXAMPLE OF RECOM-
|In the News||
Reports of an isolated event, sporadic cases, or the occurrence of a disease of public health signifi-
cance affecting a traveler or travel destination
No increased risk over baseline for travelers observing standard recommen-
Keeping travelers informed and reinforcing standard prevention recommen-
Report of increased cases of meningo-
coccal meningitis in several sub-Saharan African countries in 2009
Reinforced standard recommen-
dations for vaccination to the meningitis belt during the dry season (December - June)
|Outbreak||Event in a limited geographic area or setting||Increased risk, but definable and limited to specific settings||
Reminders about standard and enhanced recommen-
dations for the area, such as vaccination
|Outbreak of yellow fever in 2 states in Brazil outside the reported yellow fever risk areas in 2008–2009||
Reinforced yellow fever vaccine recommen-
dations for known yellow fever risk areas in Brazil and extended recommen-
dations for areas of the outbreak
Travel Health Precau-
|Event of greater scope affecting a larger geographic area||Increased risk in some settings or among travelers with specific risk factors, along with risk for spread to other areas||Specific precautions to reduce travelers' risk during the stay and what to do before, during, and after travel4, including what to do if ill; CDC may recommend that travelers in groups with high risks for complications consider delaying or canceling travel to certain areas||Outbreak of avian influenza among poultry and humans in several countries in Southeast Asia in early 2004||Recommended specific precautions, including avoiding areas with live poultry, such as live animal markets and poultry farms; ensuring poultry and eggs are thoroughly cooked; monitoring health|
|Travel Health Warning5||
Event with extremely serious health implica-
tions or evidence that a disease outbreak is expanding outside the area or populations initially affected
|Increased risk because of evidence of transmission outside defined settings or inadequate containment measures||In addition to the specific precautions cited above, CDC recommends travelers postpone nonessential travel4||Haiti earthquake in 2010, H1N1 influenza A in 2009, and severe acute respiratory syndrome (SARS) outbreak in Asia in 2003||Recommended travelers avoid nonessential travel to affected areas because of level of risk|
1The term "event" in the table is used for disease outbreaks and natural and nonnatural disasters with resulting health risks.
2The term "scope" incorporates the size, magnitude, and rapidity of spread of an event.
3Risk for travelers is dependent on several factors, including patterns of disease transmission, as well as severity of illness.
4 Preventive measures other than the standard advice for the region may be recommended, depending on the circumstances (for example, travelers may be advised to monitor their health for a certain period after their return, or arriving passengers may be screened at ports of entry).
5 The purpose of a travel health warning is to describe the situation and to reduce the volume of traffic to affected areas. For disease outbreaks, reducing the volume of travel aids in limiting the risk of spreading the disease to unaffected areas. For those who cannot avoid traveling to the affected area, the travel warning gives information about preventive measures to reduce travelers’ risk for illness or injury, and what they should do if they become ill or injured. Additional preventive measures may be recommended, depending on the circumstances (for example, travelers may be requested to monitor their health for a certain period after their return; arriving and returning passengers may be screened at airports of entry).
- Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004 Jan–Feb;11(1):23–6.
- Keystone JS, Kozarsky PE, Freedman DO. Internet and computer-based resources for travel medicine practitioners. Clin Infect Dis. 2001 Mar 1;32(5):757–65.
- Kozarsky PE, Keystone JS. Body of knowledge for the practice of travel medicine. J Travel Med. 2002 Mar–Apr;9(2):112–115.
- MacDougall LA, Gyorkos TW, Leffondre K, Abrahamowicz M, Tessier D, Ward BJ, et al. Increasing referral of at-risk travelers to travel health clinics: evaluation of a health promotion intervention targeted to travel agents. J Travel Med. 2001 Sep–Oct;8(5):232–42.
- Wolfe M, Wolfe Acosta R. Structure and organization of the pre-travel consultation and general advice for travelers. In: Keystone JS, Kozarsky PE, Freedman DO, Nothdurft HD, Connor BA, editors. Travel Medicine. 2nd ed. Philadelphia: Mosby; 2008. p. 35–45.