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Chapter 2 The Pretravel Consultation

The Pretravel Consultation

Lin H. Chen, Natasha S. Hochberg, Alan J. Magill

The pretravel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pretravel consultation are:

  1. To perform an individual risk assessment.
  2. To educate the traveler regarding anticipated health risks and methods for prevention.
  3. To provide immunizations for vaccine- preventable diseases and medications for prophylaxis, self-treatment, or both.

THE TRAVEL HEALTH SPECIALIST

The outcome of a pretravel consultation likely depends on the fund of knowledge, expertise, and communication skills of the provider, as well as the health beliefs of the traveler. Counseling by trained staff can effectively deliver many messages, such as those regarding the need for appropriate immunizations, and malaria risk and prevention. Familiarity with the traveler’s destination, its culture, infrastructure, and disease patterns can assist the travel health advisor in providing more personalized advice.

Travel medicine specialists have in-depth knowledge of 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 (such as traveling at high altitudes or working in refugee camps), or exotic or complicated itineraries. Those clinicians who wish to be travel health providers are encouraged to take advantage of one of the many travel health educational opportunities available, join the International Society of Travel Medicine, attend conferences, and obtain their Certificate in Travel Health.

COMPONENTS OF A PRETRAVEL CONSULTATION

Effective pretravel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-01). The pretravel consultation is the major opportunity to educate the traveler about health risks at the destination and how to mitigate them. The typical pretravel consultation does not include a physical examination; a separate appointment with the same or a different provider may be necessary to assess a person’s fitness to travel. Because the traveler does not need to be physically present to receive pretravel education, pretravel consultations are ideally suited to be done remotely. In addition, because travel medicine clinics are not available in many communities, remote consultations can give more travelers access to the information they need.

Travel health advice should be personalized, highlighting the likely exposures and also reminding the traveler of ubiquitous risks, such as injury, foodborne and waterborne infections, vectorborne disease, respiratory tract infections, and bloodborne and sexually transmitted infections. Written information is essential to supplement the discussion and highlight key advice for travelers. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pretravel consultation. Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the recommended immunizations and medications, a situation that requires prioritizing interventions. (See Perspectives: Prioritizing for the Resource-Limited Traveler later in this chapter.)

Table 2-01. Information necessary for a risk assessment during pretravel 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
  • Immunocompromising conditions or medications
  • Older age
  • Psychiatric condition
  • Seizure disorder
  • Recent surgery
  • Recent cardiopulmonary event
  • Recent cerebrovascular event
  • History of Guillain-Barré syndrome
Immunization history
  • Routine vaccines
  • Travel vaccines
Prior travel experience
  • Experience with malaria chemoprophylaxis
  • Experience with altitude
  • Illnesses related to prior travel
Trip Details
Itinerary
  • Countries and specific regions, including order of countries if >1 country
  • Rural or urban
Timing
  • Trip duration
  • Season of travel
  • Time to departure
Reason for travel
  • Tourism
  • Business
  • Visiting friends and relatives
  • Volunteer, missionary, or aid work
  • Research or education
  • Adventure
  • Pilgrimage
  • Adoption
  • Seeking health care(medical tourism)
Travel style
  • Independent travel or package tour
  • Propensity for "adventurous" eating
  • Traveler risk tolerance
  • 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
  • Medical care (providing or receiving)
  • High altitude
  • Diving
  • Cruise ship
  • Rafting or other water exposure
  • Cycling
  • Extreme sports
  • Spelunking
  • Anticipated interactions with animals

 

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks (Table 2-01). Certain travelers may confront special risks. Recent hospitalization for serious problems may lead the advisor to recommend delaying travel. Air travel is contraindicated for certain conditions, such as <3 weeks after an uncomplicated myocardial infarction and <10 days after thoracic or abdominal surgery. The travel health provider and traveler should consult with the relevant health care providers most familiar with the underlying illnesses. Other travelers with specific risks include travelers who are visiting friends and 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. Providers should determine whether recent outbreaks or other safety notices have been posted for the traveler’s destination; information is available on the CDC website and in various other resources.

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 could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk of histoplasmosis. Flying from lowlands to high-altitude areas and trekking or climbing in mountainous regions introduces the risk of altitude illness. Therefore, the provider should inquire about plans for specific activities.

Manage Risk

Immunizations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. For example, providers should consider whether there is sufficient time before travel to complete a vaccine series; the purpose of travel and specific destination within a country will inform the need for particular vaccinations. At the same time, the pretravel consultation presents an opportunity to update routine vaccines (Table 2-02). Particular attention should be paid to vaccines for which immunity may have waned over time or a recent immunocompromising condition (such as after a hematopoietic stem cell transplant). Asking the question, “Do you have any plans to travel again in the next 1–2 years?” may help the traveler justify an immunization for this particular trip, such as rabies preexposure or Japanese encephalitis. Travelers should receive a record of immunizations administered and instructions to follow up as needed to complete a vaccine series.

Another major focus of pretravel consultations for many destinations is the prevention of malaria. Malaria continues to cause substantial morbidity and mortality in travelers. In 2011, the number of US malaria cases reported to CDC was the highest since 1971; therefore, pretravel consultation must carefully assess travelers’ risk for malaria and recommend preventive measures. For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, and recommendations for chemoprophylaxis.

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; travelers should be encouraged to discuss with their primary care provider how to plan for treatment and bring necessary medication in case of asthma exacerbation. Travelers should be counseled on how they can find reputable medical facilities at their destination, such as using the ISTM website (www.istm.org) or the American Society of Tropical Medicine and Hygiene website (www.astmh.org) to find suitable clinics. Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

The pretravel consultation also provides another setting to remind travelers of basic health practices during travel, including frequent handwashing, wearing seatbelts, and using car seats for infants and children. Topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues (Table 2-03). General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement oral advice and enable travelers to review the instructions from their clinic visits; educational material is available on the CDC Travelers Health webpage (http://www.cdc.gov/travel). Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad and possibly lead to faster return to good health.

Table 2-02. Vaccines to update or consider during pretravel 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%. Vaccination may be considered for all international travelers, regardless of destination, depending upon the traveler’s behavioral risk and potential for exposure as determined by the provider and traveler.
Human papillomavirus (HPV) No report of travel-acquired infection; however, sexual activity during travel may lead to HPV and other sexually transmitted infections.
Influenza Year-round transmission may occur in tropical areas. Outbreaks have occurred on cruise ships, and 2009 influenza A (H1N1) illustrated the rapidity of spread via travel. Novel influenza viruses such as avian influenza H5N1 and H7N9 can be transmitted to travelers visiting areas with circulation of these viruses.
Measles, mumps, rubella Infections are common in countries and communities that do not immunize children routinely, including Europe. Outbreaks have occurred in the United States as a result of infection in returning travelers.
Meningococcal Outbreaks occur regularly in sub-Saharan Africa in the "meningitis belt" during the dry season, generally December through June, although transmission may occur at other times for those with close contact with local populations. Outbreaks have 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 become infected with either wild poliovirus or vaccine-derived poliovirus. Because the international spread of wild poliovirus in 2014 was declared a Public Health Emergency of International Concern under the International Health Regulations, temporary recommendations for polio vaccination are in place for countries with wild poliovirus circulation for their residents, long-term visitors, and international travelers.
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 varicella zoster reactivation, but causal relationship is difficult to establish.
Travel Vaccines
Cholera Cases in travelers have occurred recently in association with travel to the Dominican Republic and Haiti.
Hepatitis A Prevalence patterns of hepatitis A virus infection may vary among regions within a country, and missing or obsolete data present a challenge. Serologic testing may be considered in travelers from highly endemic countries since they may already be immune. 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, as adequately screened immunoglobulin may be difficult to obtain in many destinations.
Tickborne encephalitis [vaccine 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), although risk is substantial in many destinations.
Yellow fever Risk occurs mainly in defined areas of sub-Saharan Africa and the Amazonian regions 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 pretravel consultations

Immunizations
  • Review routine immunizations and those travel immunizations indicated for the specific itinerary and based on the traveler's medical history.
  • Discuss utility of titers when records are unavailable or unreliable, particularly for measles, mumps, rubella, and hepatitis A.
  • Screen for chronic hepatitis B for people born in countries with HBsAg prevalence ≥2% (see Map 3-04).
  • Discuss indications for, effectiveness of, and adverse reactions to immunizations.
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.
Other vectorborne diseases
  • Define risk of disease in specific itinerary and insect precautions as needed.
Respiratory illnesses
  • Discuss areas of particular concern (such as avian influenza in Asia or MERS in the Arabian Peninsula).
  • Consider influenza treatment for high-risk travelers.
Travelers’ diarrhea
  • Recommend strategies to decrease risk of diarrhea.
  • Discuss antibiotics for self-treatment, adjunct medications such as loperamide, and staying hydrated.
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 travelers to avoid contact with animals to reduce the potential for bites and scratches that can transmit rabies.
  • Advise travelers to avoid walking barefoot to avoid certain parasitic infection..
  • Advise travelers 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 travelers 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.
  • Advise travelers to look for security bulletins related to their destination and consider areas to avoid.
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.
  • Inform travelers who will provide health care overseas what to do in case of needlestick or bloodborne pathogen exposure.
Disease-specific counseling
  • Remind travelers to hand carry medications and supplies.
  • Advise travelers to prepare for exacerbations or complications from underlying disease.

Abbreviation: HBsAg, hepatitis B surface antigen; MERS, Middle East respiratory syndrome.

Self-Treatable Conditions

Despite providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pretravel counseling may actually result in a more accurate self-diagnosis and treatment than relying on local medical care in some areas. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in the developing world (as many as 50% of the drugs on the shelves) makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Perspectives: Pharmaceutical Quality & Falsified Drugs later in this chapter).

Travel health providers need to recognize the conditions for which the traveler may be at risk and educate the traveler about the diagnosis and treatment of those particular conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:

  • “Travelers’ diarrhea” is the sudden onset of abnormally loose, frequent stools.
  • Most cases will resolve within 2–5 days, and symptoms can be managed with loperamide or bismuth subsalicylate.
  • For diarrhea severe enough to interrupt travel plans, an antibiotic can be prescribed that travelers can carry with them (see Travelers’ Diarrhea section in this chapter).
  • The traveler should feel better within 6–24 hours.
  • If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.

To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:

  • Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.
  • A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.
  • Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.

The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the particular destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book or discussed below.

  • Travelers’ diarrhea (see section in this chapter)
  • Altitude illness (see section in this chapter)
  • Jet lag (see section in this chapter)
  • Motion sickness (see section in this chapter)
  • Respiratory infections (see section in this chapter)
  • Skin conditions: skin reactions due to allergic or irritant triggers usually respond to topical steroids; discomfort from superficial fungal infections respond to antifungal creams. See Chapter 5, Skin and Soft Tissue Infections in Returned Travelers.
  • Urinary tract infections: common among many women; carrying an antibiotic for empiric treatment may be valuable.
  • Vaginal yeast infections: self-treatment course of patient’s preferred antifungal medication can be prescribed for women who are prone to infections, sexually active, or who may be receiving antibiotics for other reasons (including doxycycline for malaria chemoprophylaxis).
  • Occupational exposure to HIV (see Chapter 8, Health Care Workers)
  • Malaria self-treatment (see Chapter 3, Malaria)

In sum, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. Providers should review medication lists for possible drug interactions. More detailed information for providers and travelers is given in Chapter 2, Travel Health Kits; supplementary travel health kit information for travelers with specific needs is given in Chapter 8.

 

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