Chapter 2The Pre-Travel Consultation
The Pre-Travel Consultation
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.
QUALIFICATIONS FOR PROVIDING A PRE-TRAVEL CONSULTATION
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.
COMPONENTS OF A PRE-TRAVEL CONSULTATION
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.
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
|Past medical history||
|Prior travel experience||
|Reason for travel||
In the United States, 66% of imported typhoid cases are in VFRs, primarily those returning from South America and Southeast Asia. Stress food and water precautions and handwashing. Discuss food preparation with travelers, since the source of foodborne illness is often a meal served in someone’s home.
Do not assume that immigrants are immune to hepatitis A. Many young adults and adolescents from developing countries are susceptible. Children aged <15 years are at highest risk.