Chapter 2The Pre-Travel Consultation
The Pre-Travel Consultation
The risk assessment is the foundation of the pre-travel consultation and allows the health care provider to customize care for each traveler based on the itinerary, health and medical history, and the traveler’s concerns and needs. The goal of the pre-travel consultation is to prepare the traveler through counseling, education, vaccinations, and medications to help reduce and manage their risk of illness and injury during travel.
The well-organized and well-executed pre-travel consultation supports consistent, appropriate, and efficient pre-travel health preparation with the following 3 essential elements: risk assessment, risk communication, and risk management.
The pre-travel health risk assessment involves gathering pertinent information about the itinerary (“where, when, and what”) and the traveler (“who, why, and how”) to highlight the potential hazards of the trip, and alert the travel health provider to any contraindications and precautions to vaccinations or medications that may be indicated. A questionnaire designed to collect and organize the itinerary and traveler data is an essential tool to help support the risk assessment process and facilitate consistent practice.
The most important information to gather is the following:
- Countries and regions to be visited, in the order of travel
- Visits to urban versus rural areas
- Dates and length of travel in each area
- Purpose of travel (such as business, vacation, visiting friends and relatives)
- Modes of transportation
- Planned and possible activities (such as hiking, scuba diving, camping)
- Types of accommodations in each area (such as air-conditioned, screened, tents)
Traveler demographics and health/medical history
- Age, sex
- Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events
- Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system
- Medications (current or taken in the past 3 months)
- Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal)
- Pregnancy and breastfeeding (current status and plans)
- Any planned surgeries or other medical care during travel (medical tourism)
An example of using the itinerary and traveler data includes determining if there will be a risk of yellow fever disease or a country requirement for proof of yellow fever vaccination based on the planned destinations, and if there is a contraindication (such as egg allergy) or a precaution (such as age >60 years) to the traveler’s receiving the vaccine. Malaria risk is another example. It is important to assess whether the traveler will be going to a region endemic for malaria, and what the appropriate measures are to help prevent malaria based on the details of the traveler’s itinerary, activities, and medical history. See the respective disease sections in Chapter 3 for detailed information on yellow fever and malaria prevention.
During the risk assessment, the provider must remain alert to other factors about “who” will be traveling. Such factors include the traveler’s previous travel experience, perception of risk, cultural background, peer groups, and possible barriers to care, such as economic issues, attitudes regarding vaccine safety, and language limitations. These factors may affect the traveler’s ability and willingness to accept and adhere to recommendations.
Certain travelers are considered high risk, as their preexisting health and medical conditions may be uniquely impacted by travel and related activities. In some cases, risk-reduction measures may be more complicated because of increased precautions and contraindications. It is important to anticipate the special needs of the following high-risk travelers:
- People with weakened immune systems
- Women who are pregnant or breastfeeding
- People with certain preexisting medical issues such as diabetes, and certain pulmonary and cardiac conditions
- People visiting friends and relatives (VFRs). These travelers have typically migrated from a less-developed area to a developed area, and are now returning to the region of their birth. The traveler returning to his or her country of origin may not appreciate the dynamics of risk and waning immunity, especially for diseases such as malaria. Of special importance are new family members or children who are visiting the area for the first time (see Chapter 8, Immigrants Returning Home to Visit Friends and Relatives [VFRs]).
- Families with young children
- People traveling to adopt children abroad (see Chapter 7, International Adoption)
- The older traveler (aged >60 years)
The importance of the risk assessment may be illustrated by 3 travelers going to the same country: one for a week-long, urban-based business trip; the next on an adventure-seeking, backpack vacation to rural areas over several months; and the third a pregnant VFR traveler. The recommendations and preparation for each of these travelers will vary based on their unique needs and itinerary details.
Risk communication is an integral part of the pre-travel consultation process and relates directly to “who” will be traveling. Risk communication includes the presentation of reliable, evidence-based information in a context appropriate for the individual traveler. Information gathered during the risk assessment interview, including the traveler’s baseline knowledge and beliefs about the risks, and his or her understanding and opinions about risk reduction measures, are important to guiding discussions. For risk communication to be effective, adequate time must be allocated for these discussions.
Giving the traveler both verbal and written information helps to guide and focus the discussions and reinforces important traveler-specific issues. Examples include vaccine information statements, disease information pamphlets, and malaria risk maps. During a careful risk assessment and thoughtful risk communication, a risk management plan takes shape (vaccinations, medications, and targeted risk-avoidance education).
The essential elements of risk management include the following:
- Vaccines: selection, administration, and documentation of vaccinations (see Box 2-01)
- Consider required, recommended, and routine vaccinations (see below)
- Discuss vaccine indications, contraindications, precautions, and timing of doses
- Offer and discuss vaccine information before vaccines are administered
- Recommendations and prescriptions as appropriate according to risk, such as antimalarial chemoprophylaxis, travelers’ diarrhea self-treatment, and medications for altitude sickness
- Malaria prevention and adherence to chemoprophylaxis (if indicated by the risk assessment)
- Risk and prevention of other insectborne diseases
- Methods to reduce foodborne and waterborne illness
- Self-management of travelers’ diarrhea
- Animal avoidance and rabies prevention
- Reducing the negative effect of other itinerary risks (such as altitude or pollution)
- Activity-specific risks (such as road safety, diving, rafting, and rural road travel)
- Personal behavior risks (such as sexually transmitted diseases and illegal drug use)
- General guidance:
- Symptoms that may require medical attention during or after travel (such as fever, gastrointestinal symptoms, or dermatologic symptoms)
- Preparing a travel health kit (see the Travel Health Kits section later in this chapter)
- Accessing medical care abroad and obtaining medical/evacuation insurance (see the Obtaining Health Care Abroad for the Ill Traveler and Travel Health Insurance and Evacuation Insurance sections later in this chapter)
When considering vaccinations, common terms used include “required,” “recommended,” and “routine.” A required vaccine is one a traveler needs to enter a particular destination country for which either proof of vaccination or a medical waiver is mandatory. Recommended vaccines are those vaccines that are medically advised based on the actual disease risks of the itinerary, regardless of the presence or absence of country entry requirements. Routine vaccines refer to those vaccines that are recommended in the United States, regardless of travel. These routine vaccines are an important part of pre-travel care because many of the diseases they protect against are more common in countries outside the United States. In addition, diseases such as measles and mumps continue to cause localized outbreaks even in developed countries.
Box 2-01. Vaccinations for consideration in the pre-travel consultation
A list of vaccines used in the United States (including the manufacturer’s vaccine name) can be found on CDC’s website at www.cdc.gov/vaccines/vpd-vac/vaccines-list.htm.
The pre-travel consultation is a good opportunity to make sure travelers are up-to-date on their routine vaccines. Clinicians should refer to the age-appropriate immunization schedule published each year by the Advisory Committee for Immunization Practices (ACIP). Current schedules are posted on the CDC website at www.cdc.gov/vaccines/recs/schedules/default.htm. Depending on the age and risk factors of the patient, the following vaccines may be routinely recommended, regardless of travel:
- Hepatitis A
- Hepatitis B
- Haemophilus influenzae type b (Hib)
- Herpes zoster (shingles)
- Human papillomavirus (HPV)
- Measles (rubeola)
- Varicella (chickenpox)
Recommendations for these vaccines are dependent on many factors, including the travel destination. Refer to the destination-specific web pages on the CDC Travelers’ Health website at www.cdc.gov/travel.
The most common vaccines considered for travelers include the following:
- Hepatitis A*
- Hepatitis B*
- Japanese encephalitis (JE)
- Polio (adult booster)
- Typhoid fever
- Yellow fever
Some countries require that travelers carry proof of vaccination on an International Certificate of Vaccination or Prophylaxis (ICVP) to enter the country. Requirements can change at any time, so it is important to check the CDC Travelers’ Health website and the US Department of State (embassy or consulate) websites for information about requirements.
- Yellow fever vaccine (see the country-specific requirements in Chapter 3)
- Meningococcal vaccine (for pilgrims entering Saudi Arabia for the Hajj)
DOCUMENTATION AND WRITTEN RECORDS
Careful documentation of all vaccinations, medications, and specific recommendations given to the traveler helps to complete the care plan record. Using an electronic record or standardized form facilitates documentation and helps ensure consistency of practice. Travelers should be encouraged to keep a record of their vaccinations and medications, and update it with their health care provider at each visit.
Clinicians who are registered to give yellow fever vaccine must know how to complete the International Certificate of Vaccination or Prophylaxis (ICVP) to ensure that this documentation will be accepted at the borders of destination countries (see Chapter 3, Yellow Fever).
The Immunization Action Coalition (www.immunize.org) gathers essential information on the safety, efficacy, and use of vaccines, including a listing of all the most current vaccine information statements, sample standing orders, forms, storage and handling guidelines, and links to other resources related to vaccines. These may be helpful in developing practice-specific policies and procedures to support the pre-travel consultation process and best practice.
Clinicians should plan to spend an average of 30–45 minutes conducting a complete pre-travel consultation, given the potential complexities in preparing the traveler. Clinicians with limited knowledge and expertise in travel medicine and the pre-travel consultation should consider referring travelers with complex itineraries or special needs (see Chapters 7 and 8) to a travel medicine clinic or travel medicine specialist.
The references for this section will help providers gain a more in-depth perspective on the expectations for providing pre-travel health care, and offer further guidance on the pre-travel consultation process.
- Bauer IL. Educational issues and concerns in travel health advice: is all the effort a waste of time? J Travel Med. 2005 Jan–Feb;12(1):45–52.
- Crockett M, Keystone J. “I hate needles” and other factors impacting on travel vaccine uptake. J Travel Med. 2005 Apr;12 Suppl 1:S41–6.
- Evans G, Bostrom A, Johnston RB, Fisher BL, Stoto MA, editors. Risk Communication and Vaccination. Washington, DC: National Academies Press; 1997.
- Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
- Immunization Action Coalition. Vaccination information for healthcare professionals. Saint Paul, MN: Immunization Action Coalition; 2010 [cited 2010 Nov 8]. Available from: www.immunize.org.
- Kozarsky P. The body of knowledge for the practice of travel medicine—2006. J Travel Med. 2006 Sep–Oct;13(5):251–4.
- Spira A. Setting the standard. J Travel Med. 2003 Jan–Feb;10(1):1–3.
- Thomson R, Edwards A, Grey J. Risk communication in the clinical consultation. Clin Med. 2005 Sep–Oct;5(5):465–69.
- 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.