Chapter 2The Pre-Travel ConsultationSelf-Treatable Conditions
Despite providers’ best efforts, some travelers will become ill while traveling. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pre-travel counseling may actually result in a more accurate self-diagnosis and treatment than relying on local medical care in some developing countries. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in the developing world (as many as 50% of the drugs on the shelves) makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Perspectives: Pharmaceutical Quality & Counterfeit Drugs later in this chapter).
Providing education and prescriptions is part of the pre-travel consultation. The key aspect of this strategy is to recognize the conditions for which the traveler may be at risk, given the travel itinerary, and to educate the traveler about the diagnosis and treatment of those particular conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing one choice of treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:
- “Travelers’ diarrhea” is the sudden onset of abnormally loose, frequent stools.
- The treatment is ciprofloxacin 500 mg, every 12 hours, for 1 day (2 doses).
- The traveler should feel better within 6–24 hours.
- If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.
To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:
- Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.
- A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.
- Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.
The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the particular destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book.
Travelers’ diarrhea (TD) is perhaps the most frequent indication for self-treatment. The success of this strategy is based on the epidemiologic evidence that bacterial pathogens account for >90% of TD in short-term travelers. The recognition of antibiotic resistance for certain organisms in specific destinations has made the empiric choice of treatment somewhat more problematic in recent years (see the Travelers’ Diarrhea section next in this chapter).
Altitude illness or acute mountain sickness (AMS) is a risk for travelers who ascend rapidly to altitudes >8,000 ft (2,440 m). Certain common travel destinations, such as Cuzco, Peru, or Lhasa, Tibet, involve flying to altitudes of 11,150 ft (3,400 m) or 12,000 ft (3,660 m), respectively. The symptoms of headache, anorexia, nausea, fatigue, lassitude, and poor sleep can largely be prevented or treated with acetazolamide (see the Altitude Illness section later in this chapter).
Jet lag affects almost everyone who crosses 3 or more time zones. There is no consensus on the optimal pharmacologic treatment or prevention of the symptoms of jet lag, but sleeping medication taken at the destination may help regularize sleep patterns (see the Jet Lag section later in this chapter).
Motion sickness can be a major deterrent to enjoyment for any susceptible person on a boat or a winding road. Premedication may help alleviate or ameliorate this bothersome syndrome (see the Motion Sickness section later in this chapter).
The self-treatment of suspected respiratory infections with empiric antibiotics is controversial. Almost all upper respiratory tract infections are initially caused by viruses. However, these viral infections, under the stress of travel, can lead to bacterial sinusitis, bronchitis, or pneumonia. Respiratory infections that last longer than a week without signs of improvement may require empiric antibiotics for recovery. Prolonged respiratory infections may have more of a negative effect on a trip than diarrheal disease (see the Respiratory Infections section later in this chapter).
Bacterial skin infections are not common among travelers, but when they occur, they can be particularly distressing. Bacterial abscesses or cellulitis can worsen rapidly and be very painful. If the traveler is in a remote area, or even more than a day’s travel from medical care, the use of empiric antibiotic treatment can be beneficial (see Chapter 5, Skin and Soft Tissue Infections in Returned Travelers).
Urinary tract infections are common among many women, and carrying an antibiotic for empiric treatment of this condition may be valuable in many circumstances.
Vaginal yeast infections in women can be an annoying and debilitating problem. For women who know they are prone to infections, all sexually active women, and those who may be receiving antibiotics for other reasons, including doxycycline for malaria chemoprophylaxis, a self-treatment course of their preferred antifungal medication can be prescribed.
Occupational exposure to HIV is a particular risk to those participating in medical-related activities. Thousands of such people work in areas of sub-Saharan Africa, where the HIV prevalence may be higher than 15%–20%. A needlestick in this setting should prompt immediate wound care and the possible use of antiretroviral medications (see the Occupational Exposure to HIV section later in this chapter).
Malaria self-treatment is often referred to as standby emergency treatment (SBET). This strategy asks the traveler to use a therapeutic dose of a prescribed antimalarial drug when the traveler has a fever accompanied by systemic illness, and then proceed to reliable medical care within 24 hours. The goal is to prevent death or severe malaria. Since most travelers at risk of malaria should be advised to use prophylactic medication, this strategy is usually discouraged and reserved for a specific type of traveler under certain defined circumstances (see Chapter 3, Malaria).