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Chapter 8 Advising Travelers with Specific Needs

Last-Minute Travelers

Gail A. Rosselot

Ideally, travelers should seek medical advice at least 4–6 weeks before departure, but clinicians are frequently asked to provide pretravel care to travelers leaving on short notice, sometimes within days or even hours. “Last-minute travelers” can refer to people who are leaving on short notice (such as some business travelers or immigrants returning to their home country for a family emergency), or it may refer to people who have planned a trip for some time but delayed seeking pretravel care. Regardless of the reason, clinicians can offer travelers support for their upcoming trip even on short notice. This support could include vaccination with standard or accelerated immunization schedules, health counseling, prescriptions, and referrals to services at the destination.

VACCINATIONS

Consider the traveler’s itinerary and activities at the destination when assessing which vaccines might be indicated. Note that immunity generally takes approximately 2 weeks to develop after vaccination (although this duration is shorter after booster vaccinations), so travelers might not be adequately protected if they are vaccinated immediately before travel. Counsel travelers to adhere to preventive behaviors regarding food, water, and insects (see the Food & Water Precautions and Protection against Mosquitoes, Ticks, & Other Arthropods sections in Chapter 2) in case they are incompletely protected, as well as to prevent diseases for which no vaccine is available.

Routine Vaccinations

Most travelers who attended school in the United States have received standard routine vaccinations. If the traveler is not completely up-to-date on age-appropriate routine vaccines, administer first or additional doses of these. Throughout the season and while supplies remain, provide the seasonal influenza vaccination, if needed. Depending on the age and medical conditions of the traveler, pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines may also be indicated. Note that if the traveler needs >1 live-virus vaccine (yellow fever, measles-mumps-rubella, varicella, intranasal influenza, zoster), they must be given on the same day or separated by ≥28 days.

Recommended Vaccinations: Single-Dose Protection

Even when a traveler has limited time before departure, research supports the use of certain single-dose vaccines, if indicated, to initiate protection. These include hepatitis A (monovalent), typhoid (injectable), polio (inactivated), cholera, and quadrivalent (ACWY) meningococcal meningitis vaccines. The booster dose of the hepatitis A vaccine should be given ≥6 months after the first dose is administered.

Recommended Vaccinations: Multiple Doses Needed

Last-minute travelers often cannot complete the full course of vaccines that require multiple doses to induce full protection. If a traveler needs protection against hepatitis B, Japanese encephalitis, or rabies, the clinician can consider alternative approaches.

HEPATITIS B

As time allows, complete the accelerated monovalent hepatitis B (Engerix-B) schedule (0, 1, and 2 months, plus a 12-month booster) or the super-accelerated combination hepatitis A/B (Twinrix) schedule (0, 7, 21–30 days, plus a 12-month booster). If an accelerated schedule cannot be completed before travel, start the vaccination series and schedule a follow-up visit to complete it, or, for extended-stay travelers or expatriates, help them identify resources at the destination to complete the series.

JAPANESE ENCEPHALITIS

At present, no accelerated schedule for Japanese encephalitis vaccine (Ixiaro) has been approved in the United States. A study of adults given 2 doses of Ixiaro 7 days apart found that 99% were protected, and the vaccine has been licensed in Europe for use on this schedule (days 0 and 7). However, people who receive only 1 dose may have a suboptimal response and may not be protected. Travelers who cannot complete the primary vaccine series ≥1 week before travel should be counseled to adhere rigidly to mosquito precautions if they will be at risk for Japanese encephalitis. Alternatively, the clinician can help them identify resources for vaccination with Ixiaro or alternative vaccines at their destination.

RABIES

Because of the multiple immunizations required to complete a primary rabies vaccine series (0, 7, and 21 or 28 days), it may be difficult for last-minute travelers to complete the series before departure. A person who starts but does not complete a primary series and is potentially exposed should receive the same postexposure prophylaxis as a completely unimmunized person. Counsel travelers about the importance of avoiding animals, washing any bite thoroughly with soap and water, and seeking immediate medical care. Travelers to developing or remote destinations should consider medical evacuation insurance in case evacuation is needed to receive timely postexposure prophylaxis.

Required Vaccinations

Documentation of a yellow fever vaccine becomes valid 10 days after administration. If a yellow fever vaccine is required by a country in the traveler’s itinerary and the traveler lacks sufficient time, it may be necessary to rearrange the order of travel or reschedule the trip. Otherwise, the traveler risks entry problems at the country’s border or risks yellow fever vaccination at the border. Additionally, the traveler who receives the yellow fever vaccine <10 days before entering a yellow fever risk area risks yellow fever infection. Travelers for whom the yellow fever vaccination is contraindicated can be issued a medical waiver letter.

Quadrivalent (ACWY) meningococcal vaccine is required of all adults and children aged >2 years traveling to Saudi Arabia for religious pilgrimage, including Hajj. Hajj visas cannot be issued without proof that applicants received meningococcal vaccine ≥10 days and ≤3 years (≤8 years for conjugate vaccine) before arriving in Saudi Arabia.

The World Health Organization has asked certain countries to require travelers leaving those countries to show proof of polio vaccination before they leave, if they have been in the country >4 weeks. The proof of vaccination should be documented on an International Certificate of Vaccination or Prophylaxis and is valid from 4 weeks to 1 year after the vaccine is administered. This requirement should not present a problem to travelers receiving the vaccine at the last minute, since if they stay for >4 weeks, the vaccination will be valid, even if administered on the day of travel. However, if travelers stay in the country for >1 year, they should be advised to get revaccinated >4 weeks before they plan to leave. Countries with this requirement can change. Consult the CDC website (wwwnc.cdc.gov/travel/news-announcements/polio-guidance-new-requirements) for a current list. For more information, see Chapter 3, Poliomyelitis.

MALARIA

Effective malaria chemoprophylaxis is possible for the last-minute traveler. The choice of antimalarial agent depends on a number of factors, including itinerary, drug resistance at the destination, medication contraindications and precautions, cost, and patient preference. Chloroquine and mefloquine should be initiated 1–2 weeks before departure, so most clinicians recommend doxycycline or atovaquone-proguanil for travelers who are departing in <1–2 weeks. Both doxycycline and atovaquone-proguanil can be started 1– 2 days before arriving in an endemic area. Instruct the traveler to purchase malaria medication before departure, and reinforce the importance of minimizing insect bites and of seeking medical care if a febrile illness occurs during or after the trip.

HEALTH COUNSELING

Pretravel counseling is critical for last-minute travelers. Determine prior knowledge and experience with travel health risks, and direct your advice accordingly. Focus on major risks of the trip, and deliver simple, customized messages about prevention and self-care. Provide travelers with education and prescriptions for travelers’ diarrhea, such as a fluoroquinolone or macrolide, as well as education and prescriptions for altitude illness, if indicated. Last-minute travelers may be tempted to buy medications at their destination. Encourage them to purchase all medications in the United States before departure to avoid buying medications that may be counterfeit.

Counsel the traveler on these topics (see related in-depth discussions on the following topics in Chapters 2 and 3):

  • Destination- and activity-specific risks
  • Unintentional injuries, including motor vehicle accidents (the leading cause of preventable death in healthy travelers), and personal safety
  • Accessing health care abroad and the need to consider travel health and evacuation insurance
  • Packing a carry-on travel health kit that includes an extra supply of usual prescriptions and over-the-counter medications
  • Insect precautions
  • Rabies avoidance and what to do in the event of an animal bite
  • Food and water safety
  • Sexually transmitted diseases
  • Issues related to long flights, including venous thromboembolism (for at-risk travelers) and jet lag
  • The State Department’s Smart Traveler Enrollment Program (STEP, https://step.state.gov/step)
  • Resources for further travel health information, including those from CDC (www.cdc.gov/travel)

Clinicians should also encourage last-minute travelers to schedule an appointment after the trip to complete any needed vaccinations and to initiate preparation for the next potential “spur of the moment” trip. For travelers likely to have future last-minute trips, preemptive vaccinations or “pre-loading” for certain itineraries might also be considered.

SPECIAL CHALLENGES AND ADDITIONAL CONSIDERATIONS

The Traveler Leaving in a Few Hours: If time does not permit an appointment, the clinician can still provide general prevention messages by telephone or secure digital messaging. Refer the traveler to useful websites such as CDC (www.cdc.gov/travel), the Department of State (www.travel.state.gov), the Heading Home Healthy Program (www.headinghomehealthy.org), and the International Society of Travel Medicine clinic directory (www.istm.org). Emphasize and reassure the traveler that many travel health risks can be prevented by adhering to healthy behaviors. Recommend travel health kit items that can be purchased at the airport, if necessary. Some international airports now have travel health or vaccination clinics; suggest the traveler try to visit one before departure.

The Traveler with Preexisting Medical Conditions: These patients may be at increased risk for travel-related illness if they have inadequate time for preparation. They should consider purchasing travel health insurance, trip insurance, and possibly medical evacuation insurance, and should carry a sufficient supply of all medications and a portable medical record. Emphasize the importance of a pretravel appointment or conversation with their treating clinician. Some conditions, such as pregnancy and immunosuppression, often require additional discussion and advance planning and may warrant delaying departure.

The Last-Minute, Extended-Stay Traveler: Advise these travelers to arrange an early visit with a qualified clinician at their destination for additional evaluation and education. A last-minute consultation does not provide an expatriate with adequate time for a full medical and psychological evaluation.

Requests for Off-Label Vaccine Dosing: Because of time constraints, some travelers may ask for a vaccine to be administered off-label (different schedule, double dosing, partial series). Using a vaccine in a nonstandard manner can have consequences that include medical-legal issues and inducing a false sense of protection in the traveler.

Recurring Last-Minute Travelers: Any clinic that frequently sees last-minute travelers may want to address this as a management issue. One option is to build some flexibility into the appointment schedule. Another option, which may be particularly relevant for clinics that are part of a corporation or university, is to attempt early identification of people who are likely to travel internationally and to intervene proactively.

BIBLIOGRAPHY

  1. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation; 2015 [cited 2016 Mar. 23]; Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/index.html.
  2. Chen LH, Leder K, Wilson ME. Business travelers: vaccination considerations for this population. Expert Rev Vaccines. 2013 Apr; 12(4):453–66.
  3. Cramer JP, Jelninek T, Paulke-Korinek M, Reisinger EC, Dieckmann S, Alberer M, et al. One-year immunogenicity kinetics and safety of a purified chick embryo cell rabies vaccine and inactivated Vero cell-derived Japanese encephalitis vaccine administered concomitantly according to a new, 1-week, accelerated primary series. J Travel Med. 2016 Mar;23 (3).
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  5. Zuckerman JN, Van Damme P, Van Herck K, Loscher T. Vaccination options for last-minute travellers in need of travel-related prophylaxis against hepatitis A and B and typhoid fever: a practical guide. Travel Med Infect Dis. 2003 Nov;1(4):219–26.
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