Author(s): Zoon Wangu, Elizabeth Barnett

Travelers seen in pretravel clinic consultations often have financial constraints and must pay out of pocket for pretravel care, because many health insurance plans provide no or limited coverage for travel immunizations and prophylactic medications. Optimizing care for travelers without adequate insurance coverage or with only modest means can challenge the abilities of even the savviest travel medicine clinician. As an example, the estimated cost of a pretravel consultation for a backpacker from the United States planning a 4-week trip to West Africa could easily exceed $1,000 for the initial consultation and vaccinations, excluding malaria prophylaxis.

Travelers on a limited budget might be at increased risk for travel-associated infections because they are more likely to visit remote areas, stay in more modest accommodations, and eat in restaurants with lower hygiene standards. However, the total cost of hospitalization, treatment, and lost wages after becoming ill with a vaccine- or prophylaxis-preventable disease can easily exceed the upfront cost of vaccination and prophylaxis, making the pretravel consultation particularly important. Travelers also must consider the cost and benefit of purchasing travel health insurance and medical evacuation insurance before travel (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Use the pretravel consult as an opportunity to help guide travel health recommendations for travelers with financial constraints.

Vaccines

Required Travel Vaccines

Only meningococcal and yellow fever vaccines are required categorically, and then only 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 Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country). Prioritize administration and documentation of these vaccines; travelers without them could be denied entry to their destination. Be aware that even travelers staying only briefly in a yellow fever-endemic country (e.g., during an airport layover) might still need evidence of vaccination to be permitted entry to other countries on their itinerary.

In a few specific circumstances, travelers to polio-affected countries might be asked to show proof of polio vaccination before departure if their stay is >4 weeks (see Sec. 5, Part 2, Ch. 17, Poliomyelitis). Travelers and clinicians should check the Centers for Disease Control and Prevention (CDC) Travelers’ Health website for the latest recommendations for their destinations.

Routine Vaccines

All travelers should be current with routine vaccines before international travel, regardless of destination. The benefits of routine vaccines extend beyond the travel period, and many provide lifelong immunity. Because these vaccines are mass-produced as part of scheduled national childhood and adult vaccination programs, associated costs generally are low, and many insurance companies reimburse the patient for the cost of administration. Travelers also can obtain these vaccines in a health department or primary care setting, where costs might be lower than at a travel clinic.

For travelers not up to date with routine vaccines, prioritize administration of those that protect against diseases for which the traveler is most likely to be at general risk (e.g., hepatitis A, influenza, and measles). Children in the United States routinely receive hepatitis A vaccine, but it is not included in the adult immunization schedule. Some travelers might be immune to diseases for which travel medicine providers would consider immunization; pretravel antibody testing might be covered by insurance when vaccines are not. Assess the time to departure to decide whether to test rather than vaccinate.

Recommended Travel Vaccines

When prioritizing recommended vaccines, consider time until departure (see Last-Minute Travelers, Sec. 2, Ch. 11), risk for disease at the destination, effectiveness and safety of the vaccine, and likelihood of future benefit because of repeat travel. As previously noted, hepatitis A vaccine is not currently listed as a routine vaccine for US adults; however, this vaccine can provide lifelong immunity and clinicians should consider administering it to any traveler not previously vaccinated. Hepatitis B vaccine is recommended for all US adults under age 60; since hepatitis B acquisition is not frequently associated with travel, however, vaccination against hepatitis B might be a lower priority for travelers with limited resources, unless their destinations are areas of high disease incidence or they plan to engage in activities that place them at increased risk of exposure to bloodborne pathogens (see Sec. 5, Part 2, Ch. 8, Hepatitis B). Typhoid vaccine is ≈50%–80% effective in preventing disease, and protection is not long-lasting. Thus, typhoid vaccine is more critical for travelers to higher-risk destinations where acquiring typhoid is more likely, and to areas where typhoid is harder to treat because of multidrug resistance (e.g., Southeast Asia and the Indian subcontinent).

Coronavirus Disease 2019

Clinicians should discuss and recommend vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), regardless of destination (see Sec. 5, Part 2, Ch. 3, COVID-19).

Japanese Encephalitis

Review the traveler’s itinerary in detail to determine the need for Japanese encephalitis (JE) vaccine (see Sec. 5, Part 2, Ch. 13, Japanese Encephalitis). Some travelers might be able to obtain the single-dose JE vaccine, which is much less expensive and is available outside the United States, but bear in mind (and educate travelers about) issues surrounding quality of vaccines in many countries (see Sec. 6, Ch. 3, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel). Whether or not travelers accept the JE vaccine, provide instructions for when and how to use insect repellents and other measures to prevent mosquito bites (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Rabies

When considering rabies vaccine for resource-limited travelers, factor in the risk for animal exposure, access to local health care, and availability of rabies immune globulin and rabies vaccine at the traveler’s destination (see Sec. 5, Part 2, Ch. 18, Rabies). Advise travelers who decline preexposure immunization to devise a plan of action in case an exposure occurs. In many areas, rabies vaccine or rabies immune globulin are difficult or impossible to obtain, and travelers might need to be medically evacuated to receive full and proper postexposure prophylaxis.

Malaria Prophylaxis

Every pretravel consultation should include detailed advice about preventing mosquito bites (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods). Malaria risk varies widely depending on destination, accommodations, and activities during travel. Costs associated with the different regimens vary widely. Providers should stay up to date on the cost of antimalarial medications in their region and at pharmacies, so they can recommend the most cost-effective drug based on the traveler’s planned itinerary. If travelers ask whether they can purchase antimalarial drugs at their destination, advise them about the risk of inappropriate, substandard, and counterfeit medications and discourage them from this practice (see Sec. 6, Ch. 3, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel).

Travelers’ Diarrhea

Travelers’ diarrhea (TD) is among the most common travel-related illnesses. Consider prescribing antibiotics to travelers to treat incapacitating diarrhea. Prophylaxis is indicated only in select patients at high risk for complications from TD (Sec. 2, Ch. 6, Travelers’ Diarrhea). As with antimalarial drugs purchased at the destination, advise travelers about the risk of purchasing counterfeit antibiotics overseas.

Preventive Behaviors

For each traveler, weigh the potential severity of illness against the affordability and availability of immunization or prophylaxis, as well as the level of protection provided. In cases where a disease is potentially deadly but where affordable, effective chemoprophylaxis options exist (e.g., malaria), work with the traveler to identify an acceptable prescribed chemoprophylaxis regimen and emphasize the importance of not eschewing medication due to cost.

In addition, educate all travelers about the importance of employing preventive behaviors that can serve to reduce their exposure risks: avoiding animals, using insect bite precautions, following safe sex practices, washing their hands or using alcohol-based hand sanitizer frequently, and observing food and water precautions to the best of their ability. Strongly advise all travelers, and especially those unable to afford some of the more costly immunizations or prophylactic medications, to practice these behaviors. In the era of the COVID-19 pandemic, offer advice about mask use, encourage travelers to take note of the level of SARS-CoV-2 infection at their destination, and to be mindful about avoiding large gatherings. Reassure travelers that the actions they take to avoid preventable health risks also can protect against travel-associated conditions that are more prevalent than certain vaccine-preventable diseases.