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||
Table 2-02. Vaccines to update or consider during pre-travel consultations
|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.|
|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
|Other vectorborne diseases||
|Other environmental hazards||
|Sexual health and bloodborne pathogens||
- Angell SY, Behrens RH. Risk assessment and disease prevention in travelers visiting friends and relatives. Infect Dis Clin North Am. 2005 Mar;19(1):49–65.
- Askling HH, Rombo L, Andersson Y, Martin S, Ekdahl K. Hepatitis A risk in travelers. J Travel Med. 2009 Jul–Aug;16(4):233–8.
- CDC. Tick-borne encephalitis among US travelers to Europe and Asia—2000–2009. MMWR Morb Mortal Wkly Rep. 2010 Mar 26;59(11):335–8.
- Chen LH, Hill DR. PIER Module: Travel immunizations. Philadelphia, PA: American College of Physicians [cited 2012 Feb 12]. Available from: http://pier.acponline.org/physicians/procedures/physpro272/physpro272-wn.html (requires ACP membership for access).
- Chen LH, Wilson ME, Davis X, Loutan L, Schwartz E, Keystone J, et al. Illness in long-term travelers visiting GeoSentinel clinics. Emerg Infect Dis. 2009 Nov;15(11):1773–82.
- Christenson JC. Preparing families with children traveling to developing countries. Pediatr Ann. 2008 Dec;37(12):806–13.
- DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, et al. Expert review of the evidence base for self-therapy of travelers’ diarrhea. J Travel Med. 2009 May–Jun;16(3):161–71.
- Freedman DO. Clinical practice. Malaria prevention in short-term travelers. N Engl J Med. 2008 Aug 7;359(6):603–12.
- Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006 Jan 12;354(2):119–30.
- Hartjes LB, Baumann LC, Henriques JB. Travel health risk perceptions and prevention behaviors of US study abroad students. J Travel Med. 2009 Sep–Oct;16(5):338–43.
- 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.
- 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.
- Hills SL, Griggs AC, Fischer M. Japanese encephalitis in travelers from non-endemic countries, 1973–2008. Am J Trop Med Hyg. 2010 May;82(5):930–6.
- International Society of Travel Medicine. The body of knowledge for the practice of travel medicine. Atlanta: International Society of Travel Medicine; 2006 [cited 2012 Sep 18]. Available from: https://www.istm.org/WebForms/Members/MemberResources/Cert_Travhlth/Body.aspx.
- LaRocque RC, Rao SR, Tsibris A, Lawton T, Barry MA, Marano N, et al. Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport. J Travel Med. 2010 Nov–Dec;17(6):387–91.
- Mackell S. Traveler’s diarrhea in the pediatric population: etiology and impact. Clin Infect Dis. 2005 Dec 1;41 Suppl 8:S547–52.
- Mali S, Kachur SP, Arguin PM, Division of Parasitic Diseases and Malaria (CDC). Malaria surveillance—United States, 2010. MMWR Surveill Summ. 2012 Mar 2;61(2):1–17.
- McCarthy AE, Mileno MD. Prevention and treatment of travel-related infections in compromised hosts. Curr Opin Infect Dis. 2006 Oct;19(5):450–5.
- Patel TA, Armstrong M, Morris-Jones SD, Wright SG, Doherty T. Imported enteric fever: case series from the hospital for tropical diseases, London, United Kingdom. Am J Trop Med Hyg. 2010 Jun;82(6):1121–6.
- Pitzurra R, Steffen R, Tschopp A, Mutsch M. Diarrhoea in a large prospective cohort of European travellers to resource-limited destinations. BMC Infect Dis. 2010;10:231.
- Schlagenhauf P, Petersen E. Malaria chemoprophylaxis: strategies for risk groups. Clin Microbiol Rev. 2008 Jul;21(3):466–72.
- Steffen R, Amitirigala I, Mutsch M. Health risks among travelers—need for regular updates. J Travel Med. 2008 May–Jun;15(3):145–6.
- Talbot EA, Chen LH, Sanford C, McCarthy A, Leder K, Research Committee of the International Society of Travel Medicine. Travel medicine research priorities: establishing an evidence base. J Travel Med. 2010 Nov–Dec;17(6):410–5.
- Toovey S, Moerman F, van Gompel A. Special infectious disease risks of expatriates and long-term travelers in tropical countries. Part II: infections other than malaria. J Travel Med. 2007 Jan–Feb;14(1):50–60.
- World Health Organization. International travel and health. Geneva: World Health Organization; 2012 [cited 2012 Sep 25]. Available from: http://www.who.int/ith/en/.