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Chapter 2 The Pre-Travel Consultation

The Pre-Travel Consultation

Lin H. Chen

The pre-travel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pre-travel consultation are to assess the traveler’s trip plans and determine potential health hazards; to educate the traveler regarding the anticipated risks and methods for prevention; to provide immunizations for vaccine-preventable diseases and medications for prophylaxis, self-treatment, or both; and to empower the traveler to manage his or her health throughout the trip.


Much evidence has accumulated relevant to travelers’ health and forms the basis of pre-travel advice. Providers of pre-travel consultations should possess a general knowledge of the evidence base, understand disease epidemiology as well as routes of transmission and preventive measures, and be able to explore and discuss the risks clearly with travelers.

The outcome of a pre-travel consultation likely depends on the expertise and communication skills of the provider, as well as the health beliefs of the traveler. In-person counseling by trained staff can effectively deliver some messages, in particular with regard to malaria risk and prevention. Familiarity with the traveler’s destination, its culture, infrastructure, and disease patterns generates credibility for the advisor. An advisor with a passion for travel and personal travel experience may ably infuse vitality into the consultation and impart sound and memorable information.

Various disciplines of medicine provide pre-travel consultation, including primary care physicians, infectious diseases specialists, and travel medicine specialists. Primary care clinicians may have access to the traveler’s medical history but may not have detailed knowledge of travel medicine. Travel medicine specialists have in-depth knowledge regarding immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for any traveler with a complicated health history, special risks, or exotic or complicated itineraries.


Effective pre-travel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel style, and activities, all of which determine health risks (Table 2-01). Advice should be personalized, highlighting the likely exposures, and also reminding the traveler of ubiquitous risks such as injury, foodborne and waterborne infections, respiratory tract infections, and bloodborne and sexually transmitted infections. Written information is essential to supplement the oral advice and enable travelers to review the abundant instructions from their clinic visits. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pre-travel consultation.

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks. These factors can be incorporated into a paper intake form or electronic module to document the consultation (Table 2-01). Certain travelers may confront special risks. Recent hospitalization for serious problems may even lead the advisor to recommend delaying travel. Air travel is contraindicated for certain conditions. Other traveler characteristics that are associated with specific risks include travelers who are visiting friends or relatives, long-term travelers, travelers with chronic illnesses, immunocompromised travelers, pregnant travelers, and travelers with small children. More comprehensive discussion on advising travelers with specific needs is available in Chapter 8.

Manage Risk

Immunizations are a crucial component of pre-travel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. At the same time, the pre-travel consultation presents an opportunity to update routine vaccines (Table 2-02).

The scope of pre-travel consultations includes preventive and self-treatment medications, such as malaria chemoprophylaxis, self-management of travelers’ diarrhea, and prophylaxis or treatment for acute mountain sickness. Along with immunizations, prevention of malaria and travelers’ diarrhea are key topics. If a traveler anticipates the need to treat motion sickness, jet lag, or severe allergic reactions, consider medications for self-management, such as motion sickness therapy, a sleep aid, and epinephrine. Prescribing multiple medications, particularly for travelers already taking medications, warrants a review for possible drug interactions.

The pre-travel consultation also provides the ideal setting to review wellness strategies with travelers and to remind them of healthy practices during travel (Table 2-03). For travelers going to malaria-endemic countries, discuss malaria transmission, ways to reduce risk, and recommendations for chemoprophylaxis. Because of the frequent occurrence of travelers’ diarrhea, advise travelers regarding food and water precautions and discuss a strategy to treat diarrhea if it occurs. Other topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues. General issues such as preventing injury and sunburn also deserve mention. Concise, written handouts can effectively summarize the salient issues.

Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. For example, a traveler with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma may flare in a traveler visiting a polluted city or from physical exertion during a hike; planning for treatment in case of asthma exacerbation can be lifesaving. Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, the exposures related to special activities also merit discussion. For example, river rafting in Africa could expose a traveler to schistosomiasis, and spelunking in Central America could put the traveler at risk of histoplasmosis.

Many medical issues that arise during travel can be self-managed. Therefore, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. More detailed information for providers and travelers is given in Chapter 2, Travel Health Kits; Chapter 8, Travelers with Chronic Illnesses; Chapter 8, Humanitarian Aid Workers; and Appendix B.

Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the indicated vaccines and medications, a situation that requires prioritization of interventions. (See Perspectives: Prioritizing for the Resource-Limited Traveler section later in this chapter.) Finally, a comprehensive pre-travel consultation should include providing the traveler with a record of immunizations administered.

Table 2-01. Information necessary for a risk assessment during pre-travel consultations

Health Background
Past medical history
  • Age
  • Sex
  • Underlying conditions
  • Allergies (especially any pertaining to vaccines, egg, or latex)
  • Medications
Special conditions
  • Pregnancy
  • Breastfeeding
  • Disability or handicap
  • Immunocompromised
  • Older age
  • Psychiatric condition
  • Seizure disorder
  • Recent surgery
  • Recent cardiopulmonary event
  • Recent cerebrovascular event
Immunization history
  • Routine vaccines
  • Travel vaccines
Prior travel experience
  • Experience with malaria chemoprophylaxis
  • Experience with altitude
  • Illnesses related to prior travel
Trip Details
  • Countries and specific regions, including order of countries if >1 country
  • Rural or urban
  • Trip duration
  • Season of travel
  • Time to departure
Reason for travel
  • Tourism
  • Business
  • Visiting friends and relatives (VFR)
  • Volunteer, missionary, or aid work
  • Research or education
  • Adventure
  • Pilgrimage
  • Adoption
  • Health care–seeking (medical tourism)
Travel style
  • Independent travel or package tour
  • General hygiene standards at destination
  • Modes of transportation
  • Accommodations (such as tourist or luxury hotel, guest house, hostel or budget hotel, dormitory, local home or host family, or tent)
Special activities
  • Disaster relief
  • High altitude or climbing
  • Diving
  • Cruise ship
  • Rafting
  • Cycling
  • Extreme sports

Table 2-02. Vaccines to update or consider during pre-travel consultations

Routine Vaccines
Haemophilus influenzae type b No report of travel-related infection, although organism is ubiquitous.
Hepatitis B Recommended for travelers visiting countries where HBsAg prevalence is ≥2% (see Map 3-04). Vaccination may be considered for all international travelers, regardless of destination, depending upon the traveler’s behavioral risk as determined by the provider and traveler.
Human papillomavirus No report of travel-acquired infection, although causal relationship is difficult to establish.
Influenza Outbreaks have occurred on cruise ships, and 2009 influenza A(H1N1) illustrated the rapidity of spread via travel.
Measles, mumps, rubella Infections are common in countries that do not immunize children routinely, including Europe. Outbreaks have occurred in the United States as a result of travel.
Meningococcal Outbreaks occurred with Hajj pilgrimage, and the Kingdom of Saudi Arabia requires the quadrivalent vaccine for pilgrims.
Pneumococcal Organism is ubiquitous and causal relationship to travel is difficult to establish.
Polio Unimmunized or underimmunized travelers can acquire poliovirus, as occurred in a case reported in association with a stay with a host family in Latin America that had been declared polio-free.
Rotavirus Common in developing countries, although not a common cause of travelers’ diarrhea in adults. The vaccine is only recommended in young children.
Tetanus, diphtheria, pertussis Rare cases of diphtheria have been attributed to travel. Pertussis has occurred in travelers, recently in adults whose immunity has waned.
Varicella Infections are common in countries that do not immunize children routinely, as in most developing countries. Naturally occurring disease also occurs later in tropical countries.
Zoster Travel (a form of stress) may trigger herpes zoster, but causal relationship is difficult to establish.
Travel Vaccines
Cholera (not available in the United States) Cases in travelers have occurred recently in association with travel to the Dominican Republic and Haiti.
Hepatitis A Prevaccination incidence was 3–20 cases/1,000 person-months of travel, but recent surveillance indicated a decline to 3–11 cases/100,000 person-months of travel. Prevalence patterns of HAV infection may vary among regions within a country, and missing or obsolete data present a challenge. Some expert travel clinicians advise people traveling outside the United States to consider hepatitis A vaccination regardless of their country of destination.
Japanese encephalitis Rare cases have occurred, estimated at <1 case/1 million travelers to endemic countries.
Rabies Rabies preexposure immunization simplifies postexposure immunoprophylaxis.
Tickborne encephalitis (not available in the United States) Cases have been identified in travelers with an estimated risk of 1/10,000 person-months in travelers. Endemic areas are expanding in Europe.
Typhoid UK surveillance found the highest risk to be travel to India (6 cases/100,000 visits), Pakistan (9 cases/100,000 visits), and Bangladesh (21 cases/100,000 visits).
Yellow fever Risk occurs mainly in defined areas of sub-Saharan Africa and the Amazon drainage of South America. Some countries require proof of vaccination for entry. For travelers visiting multiple countries, order of travel may make a difference in the requirements.

Abbreviation: HBsAg, hepatitis B surface antigen.

Table 2-03. Major topics for discussion during pre-travel consultations

  • Review routine immunizations and those indicated for the specific itinerary.
Malaria chemoprophylaxis
  • Determine if there is a risk of malaria.
  • Discuss personal protective measures.
  • Discuss risks and benefits of chemoprophylaxis, and recommended choices of chemoprophylaxis for the itinerary.
Travelers’ diarrhea
  • Recommend strategies to minimize diarrhea.
  • Discuss antibiotics for self-treatment and adjunct medications such as loperamide.
Other vectorborne diseases
  • Define risk of disease in specific itinerary and insect precautions needed.
Altitude illness
  • Determine if the itinerary puts the traveler at risk of altitude illness.
  • Discuss preventive measures such as gradual ascent, adequate hydration, and medications to prevent and treat.
Other environmental hazards
  • Caution the traveler to avoid contact with animals to reduce the potential for bites and scratches that can transmit rabies.
  • Advise to avoid walking barefoot as parasites can enter intact or damaged skin.
  • Advise to avoid wading or swimming in freshwater where there is risk for schistosomiasis or leptospirosis.
  • Remind travelers to apply sunscreen to skin exposed to the sun.
Personal safety
  • Discuss precautions the traveler can take to minimize risks specific to the trip, such as traffic accidents, alcohol excess, personal assault, robbery, or drowning.
  • Provide information on travel health and medical evacuation insurance.
Sexual health and bloodborne pathogens
  • Caution the traveler to avoid activities that can lead to sexually transmitted infections, unwanted pregnancy, or bloodborne infections.
  • Remind travelers to use condoms if they do have sex.


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