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Chapter 2 The Pre-Travel Consultation

Perspectives: Prioritizing Care for the Resource-Limited Traveler

Zoon Wangu, Elizabeth D. Barnett

Travelers seen in pre-travel clinic consultations often have financial constraints. Prioritizing immunizations and prophylactic medications should be part of an individualized assessment based on the travel itinerary, efficacy and safety of vaccines and medications, and associated costs. Travelers must often pay out of pocket for pre-travel care, as many health insurance plans do not cover travel immunizations or prophylaxis. As an example, the estimated cost of a US pre-travel consultation for a backpacker planning a 4-week trip to West Africa may be as high as $1,400 for the initial consultation and vaccinations, excluding malaria chemoprophylaxis. However, travelers with limited budgets tend to be at higher risk for travel-associated infections, as they often visit remote areas, stay in lower-grade accommodations, and are more likely to eat local street food. Therefore, the cost of disease (such as malaria) may, in many cases, outweigh costs of vaccination and prophylaxis. The financial benefits of obtaining travel health insurance and evacuation insurance before travel must also be considered (see Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance later in this chapter). Clinicians need to understand travelers’ financial constraints in order to provide realistic recommendations. The variety of insurance plans, number of travelers without adequate insurance coverage, and number of student and budget travelers challenges even the most savvy travel medicine clinicians. This section provides guidance for busy practitioners in prioritizing vaccine and prophylaxis choices.


Required Vaccines

Only 2 vaccines are categorically required for some travelers: meningococcal vaccine for pilgrims traveling to Mecca during the Hajj and yellow fever vaccine for travelers to certain countries in Africa and South America (see Chapter 3, Yellow Fever & Malaria Information, by Country). If either of these vaccines is required for an itinerary, prioritize it since the traveler may be denied entry to the country without proof of vaccination. Note that travelers who may only be staying in a yellow fever–endemic country briefly (such as during an airport layover) may still need evidence of vaccination to enter other countries on their itinerary. In a few specific circumstances, travelers to countries that are exporting polio may be asked to show proof of polio vaccination before they are allowed to leave those countries if they have spent >4 weeks in the country (see Chapter 3, Poliomyelitis).

Routine Vaccines

CDC recommends that all travelers should be up-to-date with routine vaccines before international travel, regardless of destination. The benefits of vaccine administration extend beyond the travel period, and in many cases lifelong immunity is achieved. Routine vaccines are generally associated with lower costs, since they are mass-produced as part of the scheduled national childhood and adult vaccination programs. Moreover, many health insurance plans will reimburse the patient for the cost of vaccine administration. If cost of routine vaccines is a limitation, a traveler can explore opportunities for obtaining them in a health department or primary care setting, where cost may be lower than in a travel clinic. Prioritize the routine vaccines that protect against diseases for which the traveler is most likely to be at general risk. At this time, top priorities for most destinations would include vaccines against influenza, measles, and hepatitis A and B.

Recommended Vaccines

Review the itinerary to determine the need for specific vaccines based on destination or purpose of travel, such as rabies vaccine for adventure travelers going to endemic countries or Japanese encephalitis vaccine for travelers to rural areas of Asia during the local transmission season. In addition, availability of postexposure rabies prophylaxis in the destination country should be considered. Recent surveys of US embassy medical staff show that in up to 37% of locations worldwide, rabies vaccine or immune globulin were available only “sometimes” to “never.”

In some cases, the patient may be immune to the disease for which immunization is being considered. Testing for antibody concentrations may be covered by insurance while vaccines are not. Specifically, hepatitis A and B vaccines should be considered for most travelers, especially those with underlying liver disease. Testing for immunity to these infections may determine whether vaccination is warranted.

Also consider time until departure, risk of disease at the destination, effectiveness and safety of vaccine, and likelihood of repeat travel. For example, parenteral typhoid vaccine may be less cost-effective for certain travelers (especially when departures are imminent and trip duration is short) because of the relatively low efficacy, short duration of protection, and time needed for onset of protection.

Educate about alternative ways to reduce risk. For example, advise travelers to avoid animal bites and seek care for such bites should they occur, use insect precautions, and observe food and water precautions at all times. All travelers should practice these preventive behaviors, but they are critical for travelers who elect not to receive recommended vaccinations for any reason.


Malaria chemoprophylaxis can be a financial burden for the traveler. The risk of acquiring malaria in a traveler staying in air-conditioned hotels and commuting in a rented car is much lower than that assumed by the backpacker staying in a rural guesthouse or the traveler returning to his or her native land staying with friends or relatives. Tailoring advice to the traveler’s financial needs in addition to his or her medical needs can improve compliance with prophylaxis and protect those who are at highest risk.

Every pre-travel consultation should include detailed advice about preventing mosquito bites (see Protection against Mosquitoes, Ticks, & Other Arthropods later in this chapter). Malaria chemoprophylaxis, if needed, should be offered based on the risk profile of the traveler.

Costs associated with the different regimens vary widely. For example, based on current prices in the United States, a prophylactic treatment course for a 3-week trip to a malaria-endemic destination would cost $100–$250 for doxycycline, $50–$70 for chloroquine, $100 for mefloquine, and $200–$250 for atovaquone-proguanil (depending on health insurance and other factors). Atovaquone-proguanil cost may be equivalent to that of mefloquine for short trips, but mefloquine (or chloroquine, in the few regions where malaria remains susceptible) will be more cost-effective for trips lasting 2 weeks or more. Travelers who raise the question of purchasing antimalarial drugs at their destination must be advised about the risk of inappropriate, substandard, and counterfeit medications (see Perspectives: Pharmaceutical Quality & Counterfeit Drugs later in this chapter).


Budget travelers and those who cannot afford costly travel vaccines will continue to challenge travel medicine practitioners. Such travelers will benefit from additional strategies to safeguard their health during travel. These strategies include following safety (especially road traffic safety) and security guidelines and observing sun protection, following insect precautions, avoiding food hazards, and following safe sexual practices. Travelers can be reassured that the actions they take to avoid these hazards may, in the long run, be more beneficial than obtaining vaccines or prophylaxis for diseases of low prevalence.


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Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official recommendations contained in the book. The views and opinions expressed in this section are those of the author and do not necessarily represent the official position of CDC.