The Pretravel Consultation
CDC Yellow Book 2024
Preparing International TravelersAuthor(s): Lin Hwei Chen, Natasha Hochberg
The pretravel consultation offers a dedicated time to prepare travelers for health concerns that might arise during their trips. During the pretravel consultation, clinicians can conduct a risk assessment for each traveler, communicate risk by sharing information about potential health hazards, and manage risk by various means. Managing risk might include giving immunizations, emphasizing to travelers the importance of taking prescribed malaria prophylaxis and other medications (and highlighting the risks of not taking them correctly), and educating travelers about steps they can take to address and minimize travel-associated risks. The pretravel consultation also serves a public health purpose by helping limit the role international travelers could play in the global spread of infectious diseases.
The Travel Medicine Specialist
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 all international travelers and is particularly important for those with a complicated health history, anyone taking special risks (e.g., traveling at high elevation, working in refugee camps), or those with exotic or complicated itineraries. Clinicians aspiring to be travel medicine providers can benefit from the resources provided by the International Society of Travel Medicine (ISTM) and might consider specialty training and certification (see Sec. 1, Ch. 4, Improving the Quality of Travel Medicine Through Education & Training).
Components of a Pretravel Consultation
Effective pretravel consultations require attention to the traveler’s health background, and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-01). The pretravel consultation is the best 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, and a separate appointment with the same or a different provider might be necessary to assess fitness for travel. Because travel medicine clinics are not available in some communities, primary care physicians should seek guidance from travel medicine specialists to address areas of uncertainty. The Centers for Disease Control and Prevention (CDC) Travelers’ Health website also has materials and an interactive web-tool to guide primary care physicians through a pretravel consultation.
Personalize travel health advice by highlighting likely exposures and reminding the traveler of ubiquitous risks (e.g., injury, foodborne and waterborne infections, vectorborne diseases, respiratory tract infections—including coronavirus disease 2019 [COVID-19]—and bloodborne and sexually transmitted infections). Balancing cautions with an appreciation of the positive aspects of the journey can lead to a more meaningful pretravel consultation. In addition, pay attention to the cost of recommended interventions. Because some travelers are unable to afford all the recommended immunizations and medications, prioritize interventions (see Sec. 2, Ch. 15, Prioritizing Care for Resource-Limited Travelers).
Table 2-01 The pretravel consultation: medical history & travel risk assessment
Health Background
Past medical history
- Age
- Allergies (especially any pertaining to vaccines, eggs, or latex)
- Medications
- Sex
- Underlying conditions
Special conditions
- Breastfeeding
- Cardiopulmonary event (recent)
- Cerebrovascular event (recent)
- Disability or handicap
- Guillain-Barré syndrome (history of)
- Immunocompromising conditions or medications
- Older age
- Pregnancy (including trimester)
- Psychiatric condition
- Seizure disorder
- Surgery (recent)
- Thymus abnormality
Immunization history
- Routine vaccines
- Travel vaccines
Prior travel experience
- High-elevation travel/ mountain climbing
- Malaria chemoprophylaxis
- Prior travel-related illnesses
Travel Risk Assessment (Trip Details)
Itinerary
- Countries and specific regions, including order of countries if >1 country
- Outbreaks at destination
- Rural or urban destinations
Timing
- Season of travel
- Time to departure
- Trip duration
Reason for travel
- Adoption
- Adventure
- Business
- Education or research
- Medical tourism (seeking health care)
- Pilgrimage
- Tourism
- Visiting friends and relatives
- Volunteer, missionary, or aid work
Travel style
- Accommodations (e.g., camping/ tent, dormitory, guest house, hostel/ budget hotel, local home or host family, tourist/ luxury hotel)
- "Adventurous" eating
- Independent travel or package tour
- Level of hygiene at destination
- Modes of transportation
- Traveler risk tolerance
- Travel with children
Special activities
- Animal interactions (including visiting farms, touring live animal markets)
- Cruise ship
- Cycling/motorbiking
- Disaster relief
- Diving
- Extreme sports
- High elevations
- Medical care (providing or receiving)
- Rafting or other water exposure
- Sexual encounters (planned)
- Spelunking
Assess Individual Risk
Traveler characteristics and destination-specific risk provide the background to assess travel-associated health risks. Such characteristics include personal health background (e.g., past medical history, special conditions, immunization history, medications); prior travel experience; trip details, including itinerary, timing, reason for travel, travel style, and specific activities; and details about the status of COVID-19 and other infectious diseases at the destination. Certain travelers also might confront special risks. Recent hospitalization for serious problems might lead to a decision to recommend delaying travel. Air travel is contraindicated for patients with certain conditions. For instance, patients should not travel by air <3 weeks after an uncomplicated myocardial infarction or <10 days after thoracic or abdominal surgery. Consult relevant health care providers most familiar with the traveler’s underlying illnesses.
Other travelers with specific risks include those who have chronic illnesses, are immunocompromised, or are pregnant. Travelers visiting friends and relatives, long-term travelers, and travelers with small children also face unique risks. More comprehensive discussion on advising travelers with additional health considerations is available in Section 3. Determine whether recent outbreaks or other safety notices have been posted for the traveler’s destination by checking information available on CDC Travelers’ Health and US Department of State websites and other resources.
In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, discuss anticipated exposures related to special activities. For example, river rafting could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk for histoplasmosis. Flying from lowlands to high-elevation areas and trekking or climbing in mountainous regions introduces the risk for altitude illness. Inquire about plans for specific leisure, business, and health care-seeking activities.
Communicate Risk
Once destination-specific risks for a particular itinerary have been assessed, communicate them clearly to the traveler. Health-risk communication is an exchange of information in which the clinician and traveler discuss potential health hazards for the trip and any available preventive measures. Communicating risk is one of the most challenging aspects of a pretravel consultation, because travelers’ perception of and tolerance for risk can vary widely. For a more detailed discussion, see Sec. 2, Ch. 2, . . . perspectives: Travelers’ Perception of Risk.
Manage Risk
Vaccinations
Vaccinations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. Consider whether the patient has sufficient time to complete a vaccine series before travel; the purpose of travel and specific destination within a country will inform the need for vaccines. At the same time, the pretravel consultation presents an opportunity to update routine vaccines (Table 2-02) and to ensure that eligible travelers are up to date with their COVID-19 vaccinations.
Pay attention to vaccine-preventable diseases for which immunity might have waned over time or after a recent immunocompromising condition (e.g., after a hematopoietic stem cell transplant). Asking whether travelers plan to travel again in the next 1–2 years can help them justify an immunization for travel over several years (e.g., rabies preexposure, Japanese encephalitis) rather than only the upcoming trip. Provide travelers with a record of administered immunizations and instructions to follow up as needed to complete a vaccine series.
Table 2-02 The pretravel consultation: vaccines to update & consider1
| VACCINE | TRAVEL-RELATED OCCURRENCES AND RECOMMENDATIONS |
|---|---|
| Routine Vaccines | |
| COVID-19 | International travelers should be fully vaccinated with a COVID-19 vaccine, including all recommended booster doses. |
| Haemophilus influenzae type b | No report of travel-related infection; organism ubiquitous worldwide. |
| Hepatitis B | Recommended for travelers visiting countries where HBsAg prevalence is ≥2%. Vaccination can be considered for all international travelers, regardless of destination, depending upon individual behavioral risk and potential for exposure. |
| Human papillomavirus (HPV) | No reports of travel-acquired infection; sexual activity during travel might lead to HPV and other sexually transmitted infections. |
| Influenza | Year-round transmission can occur in tropical areas. Outbreaks have occurred on cruise ships. Novel influenza viruses (e.g., avian influenza viruses H5N1 and H7N9), can be transmitted to travelers visiting areas where these viruses are circulating. |
| Measles, mumps, rubella | Infections are common in countries and communities that do not immunize children routinely, including parts of Europe. Outbreaks have occurred in the United States because of infection in returning travelers. |
| Meningococcal (serogroups A, C, W, and Y) | Outbreaks occur regularly in sub-Saharan Africa in the meningitis belt during the dry season, generally December–June, although transmission can 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 | Streptococcus pneumoniae is ubiquitous worldwide; causal relationship to travel is difficult to establish. |
| Polio | Unimmunized or under-immunized 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 for young children. |
| Tetanus, diphtheria, pertussis | Rare cases of diphtheria have been attributed to travel. Pertussis has occurred in travelers whose immunity has waned. |
| Varicella | Infections are common in countries that do not immunize children routinely, as in most low- and middle-income countries. |
| Zoster | Travel is a form of stress that might trigger varicella zoster reactivation, but causal relationship is difficult to establish. |
| Travel Vaccines | |
| Cholera | Infections in travelers have been rare. Vaccination can be considered for those participating in humanitarian relief efforts. |
| Hepatitis A | Hepatitis A is one of the most common vaccine-preventable diseases acquired during travel. Prevaccination serologic testing for hepatitis A immunity before vaccination is not routinely recommended but may be considered in specific settings to reduce costs by not vaccinating people who are already immune. |
| Japanese encephalitis | Rare cases have occurred, estimated at <1 case/1 million travelers to endemic countries. However, the severe neurologic sequelae and high fatality rate warrant detailed review of trip plans to assess the level of risk. |
| Rabies | Rabies preexposure immunization simplifies postexposure immunoprophylaxis; rabies immunoglobulin (RIG) might be difficult to obtain in many destinations. |
| Tickborne encephalitis (TBE) | Cases have been identified in travelers with an estimated risk of 1/10,000 person-months in travelers. Endemic areas are expanding in Europe. The US Food and Drug Administration has approved the use of TBE vaccine, and the Advisory Committee on Immunization Practices has voted to recommend its use in selected travelers. |
| Typhoid | The highest risk is for travelers going to Bangladesh (21 cases/100,000 visits), Pakistan (9 cases/100,000 visits), and India (6 cases/100,000 visits), areas where drug-resistant isolates have been increasing. |
| 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, sequence of country entry can affect yellow fever vaccination requirement. |
Abbreviation: HBsAg, hepatitis B surface antigen.
1 Based on Advisory Committee on Immunization Practices guidelines, current as of October 21, 2021
Malaria Prevention
Malaria continues to cause substantial morbidity and mortality in travelers. Since 1973, the annual number of US malaria cases reported to CDC has increased; therefore, clinicians must carefully assess travelers’ risk for malaria and recommend preventive measures during the pretravel consultation. For travelers going to malaria-endemic countries, discuss malaria transmission, ways to reduce risk including mosquito avoidance, recommendations for prophylaxis, and symptoms of malaria. Additional information on malaria is available in Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country, and Sec. 5, Part 3, Ch. 16, Malaria.Self-Treatable Conditions
Despite health care providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. Consequently, consider prescribing certain medications in advance to enable the traveler to treat common health problems. Box 2-01 provides a list of some of the most common situations for which travelers find self-treatment useful.
Travel health providers need to recognize conditions for which travelers might be at risk and provide information about appropriate self-diagnosis and treatment. Keys to a successful treatment strategy include sharing a simple disease or condition definition, recommending or prescribing treatment, and educating the traveler about the expected outcome of treatment. As an example, for travelers’ diarrhea, inform travelers that most symptoms can be managed with fluid replacement plus loperamide or bismuth subsalicylate; prescribe travelers antibiotics they can carry with them for use in selected cases of incapacitating diarrhea (see Sec. 2, Ch. 6, Travelers’ Diarrhea, and Sec. 2, Ch. 7 . . . perspectives: Antibiotics in Travelers’ Diarrhea—Balancing Benefit & Risk); and tell them to seek medical attention if symptoms persist for 24–36 hours or are particularly severe.
With some activities in remote settings (e.g., trekking), the only alternative to self-treatment would be no treatment. Pretravel counseling might 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 certain countries makes it important for travelers to bring quality manufactured drugs with them from a reliable supplier (see Sec. 6, Ch. 3, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel).
Encourage travelers to carry a travel health kit with prescription and nonprescription medications and review each traveler’s medication list for possible drug–drug interactions. More detailed information for providers and travelers is included in Sec. 2., Ch. 10, Travel Health Kits, and Section 3 has supplementary travel health kit information for travelers who have additional health needs and considerations.
Box 2-01 The pretravel consultation: self-treatable conditions
The following list includes common situations for which travelers might find self-treatment useful. The extent of self-treatment recommendations offered to travelers should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the destination. Recommended self-treatment options for each of the listed diseases are provided below or in the designated sections of this text.
ALTITUDE ILLNESS: Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness
HIV EXPOSURE (OCCUPATIONAL): Sec. 9, Ch. 4, Health Care Workers, Including Public Health Researchers & Medical Laboratorians
JET LAG: Sec. 8, Ch. 4, Jet Lag
MALARIA: Sec. 5, Part 3, Ch. 16, Malaria
MOTION SICKNESS: Sec. 8, Ch. 7, Motion Sickness
TRAVELERS’ DIARRHEA: Sec. 2, Ch. 6, Travelers’ Diarrhea
URINARY TRACT INFECTIONS: common among many women; carrying a prescribed antibiotic for empiric treatment can be helpful.
VAGINAL YEAST INFECTIONS: self-treatment course of patient’s preferred antifungal medication can be prescribed for people who are prone to infections, sexually active, or who might be receiving antibiotics for other reasons, including doxycycline for malaria chemoprophylaxis.
Address Special Health Risks
Travelers with underlying health conditions require additional attention to health issues related to the destination and activities. For instance, travelers with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma can flare in a traveler visiting a polluted city or from physical exertion during a hike; recommend that travelers discuss with their primary care provider a plan for treatment and carry necessary medication in case of asthma exacerbation.
Instruct travelers on how to obtain travel medical insurance and direct them to resources that provide lists of reputable medical facilities at their destination (e.g., the ISTM website; the American Society of Tropical Medicine and Hygiene website; the US Department of State’s Your Health Abroad website). Advise travelers to identify any allergies or serious medical conditions on a bracelet or a card to expedite medical care in emergency situations (see Sec. 3, Ch. 4, Highly Allergic Travelers). Section 6 provides more information on preparing for and obtaining health care abroad.
Educate to Change Behavior
The pretravel consultation provides another setting to remind travelers of basic health and safety practices during travel, including frequent handwashing, wearing seatbelts, using car seats for infants and children, safe sexual practices, and COVID-19 prevention. Organize topics into a checklist and place priority on the most serious and frequently encountered issues (Table 2-03 and Box 2-02). In addition, address general issues (e.g., preventing injury, sunburn). Written information is essential to supplement oral advice and enables travelers to review the instructions from their clinic visits. CDC’s Travelers’ Health website provides educational material. By giving advice on health risks and self-treatable conditions, clinicians can minimize the traveler’s need to seek medical care while abroad and possibly help them return to good health faster.
Table 2-03 The pretravel consultation: key discussion topics
TRAVEL-ASSOCIATED RISK
DISCUSSION POINTS
TRAVEL-ASSOCIATED RISK
Altitude illness
DISCUSSION POINTS
- Determine if the itinerary puts the traveler at risk of altitude illness.
- Discuss preventive measures (e.g., gradual ascent, adequate hydration, medications to prevent and treat).
TRAVEL-ASSOCIATED RISK
Bloodborne pathogens
DISCUSSION POINTS
- Avoid potential exposures (e.g., injections, piercings, tattoos, shared razors).
- Inform travelers who will provide health care overseas what to do in case of needlesticks or bloodborne pathogen exposures; discuss use of HIV postexposure prophylaxis.
- See Box 2-02 for summary on sexual health recommendations for travelers.
TRAVEL-ASSOCIATED RISK
Disease-specific counseling
DISCUSSION POINTS
- Advise travelers to prepare for exacerbations or complications from underlying disease(s).
- Remind travelers to keep medications and supplies in carry-on luggage, to keep medications in their original prescription bottles, and to carry copies of their written prescriptions.
TRAVEL-ASSOCIATED RISK
Environmental hazards
DISCUSSION POINTS
- Advise travelers to avoid walking barefoot to reduce their chances of certain parasitic infections.
- Advise travelers to avoid wading or swimming in freshwater where where risk for schistosomiasis or leptospirosis is possible.
- Caution travelers to avoid contact with animals to reduce the potential for bites and scratches that can transmit rabies. This is particularly important advice for the parents of young children.
- Remind travelers to apply sunscreen to sun- exposed skin.
TRAVEL-ASSOCIATED RISK
Immunizations
DISCUSSION POINTS
- Discuss indications for, effectiveness of, and adverse reactions to immunizations.
- Discuss benefit of antibody titers when past vaccine records are unavailable or unreliable, particularly for hepatitis A, measles, mumps, rubella, and varicella.
- Review routine immunizations and travel immunizations indicated for the specific itinerary and based on the traveler's medical history.
- Screen for chronic hepatitis B for people born in countries with HBsAg prevalence ≥2% (see Map 5-07).
TRAVEL-ASSOCIATED RISK
Malaria, yellow fever, & other vectorborne diseases
DISCUSSION POINTS
- Define vectorborne disease risks at the destination.
- Discuss personal protective measures and recommended insect bite precautions.
- For itineraries where malaria transmission is a risk: discuss risks and benefits of malaria chemoprophylaxis and recommended chemoprophylaxis choices.
- For itineraries where yellow fever virus transmission is a risk (see Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country, and Sec. 5, Part 3, Ch. 16, Yellow Fever): assess individual traveler precautions and contraindications for receiving yellow fever vaccine; discuss risks and benefits of vaccination; discuss alternatives to vaccination for travelers at increased risk for adverse events from yellow fever vaccine.
TRAVEL-ASSOCIATED RISK
Personal safety
DISCUSSION POINTS
- Advise travelers to look for security bulletins related to their destination and consider areas to avoid.
- Discuss precautions travelers can take (including avoiding excess alcohol consumption) to minimize risk for traffic accidents, personal assault, robbery, or drowning.
- Provide information on travel health and medical evacuation insurance.
TRAVEL-ASSOCIATED RISK
Respiratory illnesses
DISCUSSION POINTS
- Consider influenza self-treatment for high-risk travelers.
- Discuss diseases and destinations of particular concern.
TRAVEL-ASSOCIATED RISK
Travelers’ diarrhea and other food/waterborne illnesses
DISCUSSION POINTS
- Discuss food and water safety.
- Discuss antibiotics for self- treatment, adjunct medications (e.g., loperamide), and staying hydrated.
- Recommend strategies to decrease risk of diarrhea.
Abbreviation: HBsAg, hepatitis B surface antigen
Box 2-02 The pretravel consultation: summary of sexual health recommendations for travelers
Before Travel
- Get recommended vaccinations, including those that protect against sexually transmitted infections (STIs).
- Get recommended tests for HIV and treatable STIs. Be aware of STI symptoms in case any develop.
- Obtain condoms to carry on trip.
- Consider preexposure prophylaxis medication for HIV for high-risk travelers.
- Review local laws about sexual practices and obtain contact information for medical and law enforcement services.
- If pregnant or considering pregnancy, review whether Zika virus infection is a risk at destination.
During Travel
- Use condoms consistently and correctly to decrease the risk of HIV and STIs.
- If indicated, be prepared to start taking medications for HIV postexposure prophylaxis or unintended pregnancy within 72 hours after a high-risk sexual encounter.
- Never engage in sex with a minor (<18 years old), child pornography, or trafficking activities in any country.
- Report suspicious activity to US and local authorities as soon as it occurs.
After Travel
- Avoid exposing sexual partners at home. See a clinician to get recommended tests for HIV and STIs.
- Get treatment for all diagnosed, treatable STIs.
The following authors contributed to the previous version of this chapter: Lin H. Chen, Natasha S. Hochberg