International Travel to Deliver Healthcare in Resource-Limited Settings

Introduction

Healthcare workers practicing in resource-limited settings outside the United States face unique health hazards, including exposure to infectious disease threats through interactions with patients, contact with the healthcare environment, or by handling clinical specimens. Any type of healthcare worker (e.g., ancillary clinical staff, nurses, physicians, veterinarians, public health personnel, researchers, students, and trainees on international rotations) working in clinical areas or handling specimens can be at risk (Box 8.2.1). Certain extremely resource-limited settings, such as humanitarian emergencies, present specific challenges and risks to healthcare workers (Box 8.2.2).

Box 8.2.1

Box 8.2.2

Infectious agents can be spread through contact with blood, bodily fluids, respiratory secretions, or contaminated materials or surfaces. Healthcare workers might be exposed through contact, percutaneous, or inhalation routes. Risks vary depending on assigned duties, geographic location, and practice setting. Of note, healthcare workers working abroad can be at risk for exposure to patients with emerging, highly pathogenic, or uncommon infectious diseases (e.g., Ebola disease, Middle East respiratory syndrome [MERS], or extensively drug-resistant tuberculosis). See Post-Travel Evaluation to Rule Out Viral Special Pathogen Infection and Tuberculosis chapters.

Pre-travel vaccination and screening

Before traveling or working abroad, all healthcare workers should be up to date with their routine age-appropriate vaccines and vaccines recommended for employment in healthcare settings. In addition, ensure that healthcare workers receive vaccinations specifically indicated for the country visited. Cholera vaccine, meningococcal vaccine, or inactivated polio vaccine (given as an adult booster dose) could be indicated for healthcare workers traveling to locations experiencing high incidence or outbreaks of these diseases. Hepatitis A and typhoid vaccination are recommended for most people visiting low- and middle-income countries. Depending on location and potential risk factors, Japanese encephalitis, rabies, tick-borne encephalitis, or yellow fever vaccines may also be indicated.

Ebola virus disease

Consider vaccinating healthcare workers responding to Ebola disease outbreaks with the Ebola vaccine approved for use by the U.S. Food and Drug Administration (FDA). See also Ebola Vaccine: Information about ERVEBO.

Hepatitis B

Because hepatitis B immune globulin (HBIG) and urgent hepatitis B virus (HBV) infection testing might not be available in resource-poor or field practice settings, be certain traveling healthcare workers have documentation of post-vaccination antibodies to HBV. Healthcare workers without documented response to vaccination should receive ≥1 additional dose of hepatitis B vaccine and further serologic testing to assess response.

Hepatitis C and HIV

Pre-travel baseline testing for hepatitis C virus (HCV) and HIV infection is not routinely recommended; consider performing baseline testing for people who will be working in areas with high incidence of disease where reliable testing will not be available locally in the event of an exposure. Healthcare workers should consider in advance the availability of HIV post-exposure prophylaxis (PEP) at their destination. If a reliable supply of HIV-PEP is not available, providing the traveler with their own supply might be considered (see Post-Exposure Prophylaxis section later in the chapter).

Tuberculosis

The Centers for Disease Control and Prevention (CDC) recommends baseline screening for latent tuberculosis infection (LTBI) with tuberculin skin test or interferon-γ release assay for U.S. healthcare workers; this is particularly important for healthcare workers traveling to countries with greater tuberculosis (TB) transmission risk or working in high-risk settings (e.g., healthcare facilities, prisons, refugee camps; for more details, see Tuberculosis chapter).

For people without a documented history of LTBI, perform repeat testing 8–10 weeks after travel if they had known exposure to an infectious patient or worked for a prolonged period in an area with a high incidence of TB disease. Routine vaccination of U.S. healthcare workers with bacillus Calmette-Guérin (BCG) is not recommended; by contrast, some experts advise vaccinating healthcare workers who will work in settings with high TB transmission risk and a high prevalence of isoniazid-resistant and rifampin-resistant strains. Currently, however, no FDA-approved BCG formulations are available in the United States.

Personal protective equipment

Healthcare workers should consistently follow Standard Precautions and apply other Transmission-Based Precautions as needed; anyone untrained in infection prevention and control practices should not participate in patient care or in activities with risk for exposure to infectious materials. Healthcare workers should be familiar with the most recent guidelines on Standard Precautions and personal protective equipment (PPE). PPE approved for single use only should not be reused. Healthcare workers should maintain strict safety standards, even if local practices are less stringent.

Aprons, gloves, gowns, surgical masks, protective eyewear, and air-purifying respirators (e.g., a National Institute for Occupational Safety and Health [NIOSH]-approved N95 filtering facepiece respirator fit-tested to the worker) might all be necessary to achieve an adequate level of personal protection. Specialized (enhanced) PPE and infection control techniques might be indicated for infections (e.g., avian influenza, MERS, viral hemorrhagic fevers) that pose a high risk to healthcare workers. Travel health notices on current outbreaks can be found on the CDC Travelers' Health website.

Because equipment and facilities with airborne infection isolation rooms are limited or unavailable in many countries (whenever possible, local resources should be determined in advance), healthcare workers should consider bringing a personal supply of PPE. This includes NIOSH-approved respirators with a ≥N95 level of protection (e.g., a reusable elastomeric half-mask respirator, a supply of disposable filtering facepiece respirators). Considering the available equipment, healthcare workers should be properly trained for all anticipated procedures (e.g., PPE donning and doffing, respirator fit testing). Laboratorians should consider their facilities and equipment in advance to determine if appropriate levels of biosafety are met.

Healthcare workers should anticipate environmental conditions (e.g., high heat, humidity) that can make PPE, particularly high-level PPE (e.g., gowns, respirators), challenging to wear and use for extended periods. In addition, identifying situations where enhanced PPE is needed can be difficult, especially when working in locations where TB is highly prevalent and patient isolation is suboptimal.

Infection transmission routes

Respiratory infections

Although some respiratory diseases (e.g., COVID-19, seasonal influenza, measles) are vaccine-preventable, others (e.g., MERS, pneumonic plague, TB) do not have routine or even available vaccines. The possibility of acquiring TB infection is a particular concern for healthcare workers going to areas with high incidence of disease (see Tuberculosis). In addition to assuring access to a reliable supply of appropriate PPE, healthcare workers should also consider the ventilation of clinical workspaces (i.e., air changes per hour, filtration, and air treatment) when assessing the risk of respiratory infections.

Infections transmitted by blood and body fluids

Healthcare workers are at risk for infections transmitted through blood or body fluids via mucous membrane, percutaneous, or nonintact skin exposures. Bloodborne pathogens (e.g., HBV, HCV, HIV) can be transmitted through these routes. Other bodily fluid sources of infection for hepatitis viruses and HIV include amniotic fluid, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid, semen, synovial fluid, and vaginal secretions.

Other pathogens transmitted to healthcare workers via blood or bodily fluids include several not endemic to the United States (e.g., Brucella species, the bacteria that cause brucellosis; viruses like dengue virus and Ebola virus; and parasitic infections, such as malaria).

Percutaneous and contact exposure

Typically, exposure to bloodborne pathogens occurs as a result of percutaneous exposure to contaminated sharps, including lancets, needles, scalpels, and broken glass from capillary or test tubes. Infection risk is increased after percutaneous exposures to larger blood volumes (e.g., deeper injuries, hollow-bore needles, procedures involving direct cannulation of an artery or vein, or visible blood on the injuring device).

Needlestick injuries are a common mode of percutaneous exposure to bloodborne pathogens; healthcare workers should avoid practices known to increase risk for needlestick injuries (e.g., recapping or using needles to transfer a bodily fluid between containers). Healthcare workers should be aware that safety-engineered medical devices and biosafety equipment (e.g., sharps containers) might not be available.

Mucous membrane exposure to potentially infectious bodily fluids can also result in risk of transmission, while skin exposures are only considered a risk for bloodborne pathogen infection if skin integrity is compromised (e.g., through dermatitis, abrasion, open wounds). Higher circulating viral load in the source patient is also thought to increase transmission risk, which can be of particular concern in resource-poor settings where treatments for viral hepatitis and HIV are limited.

Infection risk

Healthcare workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. Reported risk for HCV transmission after a percutaneous exposure to HCV-infected blood or body fluid varies. While previous studies suggested rates as high as 1.8%, recent studies report rates around 0.2%. The risk for HIV transmission is approximately 0.3% after a percutaneous exposure to HIV-infected blood, and approximately 0.09% after a mucous membrane exposure. Unless visibly bloody, the following are not considered infectious for HCV or HIV: feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus.

Post-exposure intervention

Immediate actions

Healthcare workers with occupational exposures to blood or body fluids should thoroughly wash the exposed area with soap and water. If mucous membrane exposure has occurred, the area should be flushed with copious amounts of water or saline.

If possible, assess both HCV and HIV infection status of the source patient; rapid HIV testing of the source patient is preferred. Exposures originating from source patients who test HIV negative are considered not to pose HIV transmission risk unless they have clinical evidence of primary HIV infection or HIV-related disease. HBV testing of the source patient might be indicated if the healthcare worker is not a documented responder to hepatitis B vaccination.

Perform baseline testing of the exposed healthcare worker for HCV and HIV infection immediately after exposure. In addition, if the exposed healthcare worker has no documented serologic response to hepatitis B vaccination, perform baseline testing for HBV infection. Seek qualified medical evaluation as soon as possible to guide decisions for PEP.

Post-exposure prophylaxis

A decision to initiate PEP is based on the timing, nature, and source of the exposure. Regimen choice is affected by available drugs, the exposed person's medical history and pregnancy status, potential drug interactions, and the possibility of exposure to a drug-resistant strain. Expert consultation is important when considering PEP. When expert advice is not immediately available, physicians with a U.S.-based affiliation may contact the National Clinician Consultation Center (888-448-4911) using a U.S. phone number for assistance in managing occupational exposures to HBV, HCV, and HIV.

Hepatitis B

If the source patient is not confirmed to be hepatitis B surface antigen (HBsAg) negative, begin PEP with HBIG and vaccination for healthcare workers who do not have documented serologic response to hepatitis B vaccination or who are incompletely vaccinated against hepatitis B.

HIV

To reduce the chance of HIV transmission after percutaneous or mucous membrane exposures to potentially infectious bodily fluids from patients with known or potential HIV infection, PEP is recommended. The specific PEP regimen should be based on current recommendations or expert consultation. HIV PEP should be initiated as soon as possible after exposure. PEP efficacy is thought to decrease with increasing time after exposure, particularly if initiated >72 hours after exposure, and PEP can be stopped if new information changes the decision to treat. Counsel PEP recipients about drug interactions, drug toxicities, and the importance of adherence. In some countries, travelers may encounter challenges if found carrying medicines to treat HIV (see Travelers with HIV).

Testing and counseling

Post-exposure testing and counseling are important follow-up measures for exposed healthcare workers. If possible, exposed workers should follow up with appropriate occupational health or infectious diseases specialists for post-exposure testing. Although no PEP option is available to prevent hepatitis C, post-exposure testing is important in order to start direct-acting antiviral treatment against HCV, which is curative among >95% of those treated.

Exposed healthcare workers should be advised to take precautions to prevent secondary transmission of blood and bodily fluid-borne pathogens (e.g., abstain from sexual contact, use condoms or other barrier methods to prevent sexual transmission, avoid blood or tissue donations, and refrain from breastfeeding, if possible), especially during the first 12 weeks after exposure. Psychological counseling is also essential because the emotional impact of occupational exposures can be substantial and can be exacerbated by stressors inherent to the overseas work environment.