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 relationships between the traveler, the clinicians, and the travel and tourism industry. This section outlines how these groups can work together to make travel safer, healthier, and more enjoyable.
RESPONSIBILITIES OF THE TRAVELER
Travelers need to understand the health risks that traveling internationally may pose and be actively involved in preparing for healthy travel. Unfortunately, studies have shown that most travelers from the United States and other countries do not seek pre-travel health advice.
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 antimalarial drugs), and specific health advice for preventing and treating travelers’ diarrhea and other illnesses the traveler may experience. 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 spread easily to other people. Postponing or canceling a trip can be inconvenient and 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 passengers 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 & 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 (www.istm.org) 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).
TRAVELERS’ HEALTH WEBSITE FOR TRAVEL HEALTH ADVICE
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). Destination pages contain information about endemic diseases and health risks with links to travel notices.
Travel notices are a key feature of the website information. Notices are assigned different levels based on various factors relating to the disease, destination, and situation (see Box 1-01). Travel notices and more detailed information about the various levels of notices can be found at wwwnc.cdc.gov/travel/notices.htm.
The purpose of a travel notice is to inform and educate travelers and clinicians with health information and prevention recommendations regarding diseases, conditions, and disasters that they may encounter while abroad. Notices are destination-specific and are usually posted for unexpected disease outbreaks or disasters. Travel notices also inform public health scientists to be aware of possible importation of disease into the United States.
CDC posts only confirmed events from official sources. Serious consideration is given to the impact, both positive and negative, before posting a notice. Notices are posted for the awareness and protection of travelers. Once posted, both outbreak and event notices are reviewed periodically (at least monthly) and updated or removed as indicated.
Box 1-01. Factors that influence travel notice levels
- Case-fatality ratio
- Incubation period
- Period of communicability
- Susceptibility: resistance, risk, immunity, healthy carriers, vulnerable populations
- Transmission: airborne, vectorborne, waterborne, foodborne, bloodborne, multiple transmission routes
- Prevention: vaccine, prophylaxis, behaviors, efficacy of vaccine or drug
- Treatment: postexposure prophylaxis, medication, treatment failures, antibiotic resistance
- Sequelae: injury, disability
- Occurrence: endemicity, past outbreaks
- Containment measures: public health infrastructure, political stability, access to potable water and sanitation, vector control methods, percent gross domestic product spent on health care, international interventions, ministry of health activities, importation
- Accessibility of medical care: clinics or hospitals in the area, internationally recognized clinics, availability of treatment or prophylaxis, available medical evacuation
- Frequency of visits by US travelers
- New situation: appearance in a new area, expansion of an existing area, out of season, different population
- Scope: confirmed case count, probable case count, cases in health care staff or travelers, important event (even if small case numbers), population affected where event is occurring
- Quality of surveillance: credibility of surveillance, in-country CDC or World Health Organization staff, ministry of health reporting, public health surveillance systems
- Aftermath of disaster: people affected, water supply, environmental hazard, homelessness, risk of potential for illness and injury, diseases as a result of disaster, destruction of food and water sources, lack of medical supplies, environmental risks, risk of toxic spread
- Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004 Jan–Feb;11(1):23–6.
- Hatz CFR, Chen LH. Pre-travel consultation. In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. p. 31–6.
- 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.