Chapter 2 Preparing International Travelers
Although all travelers are encouraged to access pretravel services at least 1 month before departure, clinicians can provide pretravel care to those leaving on short notice, even within days or sometimes hours of departure. The category of “last-minute travelers” can include people who are leaving on short notice (such as humanitarian aid workers) or people who have planned a trip for some time but delayed receiving pretravel care.
Providing complete pretravel services to last-minute travelers can be challenging and there is typically time for only a single encounter.
Consider the traveler’s itinerary, trip activities, and risk of infection at the destination. Note that immunity varies by vaccine, so emphasize preventive behaviors for travelers who might not be adequately protected if they are vaccinated immediately before travel.
Most travelers who attended school in the United States have received standard routine vaccinations. If the traveler is not up-to-date, even when departure is imminent, provide the first or additional doses of routine vaccines, including a seasonal influenza vaccination, if needed.
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 (see the respective disease sections in Chapter 4 for indications and dosing).
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 approved accelerated schedules or information on resources for vaccination at the destination. It is unclear what level of protection any given traveler will have if he or she does not complete a full series of multi-dose vaccination.
An approved accelerated vaccination schedule can be used for people age ≥18 years traveling on short notice for any reason to countries with high or intermediate levels of endemic hepatitis B virus infection (hepatitis B surface antigen prevalence ≥2%). The accelerated vaccination schedule for the combined hepatitis A and hepatitis B vaccine, Twinrix, calls for vaccine doses administered at days 0, 7, and 21–30; a booster dose should be administered at 12 months to promote long-term immunity. Alternatively, Heplisav-B may be used as a 2-dose series at 0 and 4 weeks to protect against hepatitis B alone. For people of any age, the hepatitis B vaccine can be administered on a 0-, 1-, 2-, and 12-month schedule. If the 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 vaccine is administered as 2 doses on days 0 and 7–28 (see Chapter 4, Japanese Encephalitis). A study of adults given 2 doses of Ixiaro 7 days apart found that 99% were protected. However, people who receive only a single 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 several alternative vaccines that may be available at their destination, particularly if they will be long-stay travelers (Imojev Sanofi, SA14-14-2 Chengdu). However, travelers should be aware that vaccines received in some countries may be of substandard quality (see Chapter 6, Perspectives: Avoiding Poorly Regulated Medicines and Medical Products during Travel).
Because of the multiple immunizations required to complete a primary rabies vaccine series (0, 7, and 21 or 28 days), last-minute travelers may not be able to complete the series before departure. A person who starts but does not complete a primary series and is exposed should receive the same postexposure prophylaxis as a completely unimmunized person. Counsel travelers on animal avoidance and the need to seek care urgently after an exposure. Travelers should consider purchasing travel health insurance to pay for care and medical evacuation insurance in case evacuation is needed to receive timely postexposure prophylaxis.
Yellow fever vaccination certificates are valid 10 days after vaccine administration (the length of time considered necessary for immunity to develop). If a traveler plans to visit a country with a yellow fever vaccine requirement within this 10-day window, it may be necessary to rearrange the order of travel or reschedule the trip. Otherwise, the traveler risks being denied entry at the country’s border and would be at risk for yellow fever. Travelers for whom the yellow fever vaccination is contraindicated can be issued a medical waiver letter if a country entry requirement (and not risk of yellow fever infection) is the only reason to vaccinate.
Quadrivalent (ACWY) meningococcal vaccine is required of all travelers 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 (≤5 years for conjugate vaccine) before arriving in Saudi Arabia.
Certain countries require departing travelers to show proof of polio vaccination if they have been in the country >4 weeks. This requirement should not present a problem to travelers receiving the vaccine at the last minute. Countries with this requirement can change. Consult the CDC website (/travel/news-announcements/polio-guidance-new-requirements) for a current list. For more information, see Chapter 4, Poliomyelitis.
The choice of malaria prophylaxis for last-minute travelers must factor in time until departure. For travelers leaving in <2 weeks, doxycycline, atovaquone-proguanil, or, when appropriate, primaquine should be used.
Pretravel counseling is critical for last-minute travelers. During your risk assessment, determine prior knowledge and experience with travel health risks. Focus on major risks of the trip, and deliver simple messages about prevention and self-care. Provide travelers with education and prescriptions for travelers’ diarrhea and, if indicated, altitude illness. Encourage last-minute travelers to purchase all medications in the United States before departure to avoid buying medications that may be of poor quality or counterfeit. As time allows, provide counseling on topics such as preventing injuries, adhering to food and water precautions, and insect bite prevention (see The Pretravel Consultation in this chapter).
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 and recommendations for care 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.
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 medical evacuation insurance, and should carry an extra 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.
Recurring Last-Minute Travelers
Any clinic that frequently sees last-minute travelers may want to address this as an administrative issue. Consider building flexibility into the clinic schedule and proactively identifying people likely to travel at the last minute (such as college students and corporate employees). For these travelers, preemptive vaccinations for certain itineraries might also be considered.
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