In 2005 the World Tourism Organization reported 783 million international arrivals across international boundaries. This represents over a 71% increase in 15 years. In the same year there were 29 million international departures from the United States. A figure less than pre-September 11, 2001 levels, but still an increase of 23% in just 3 years. Travelers may be business travelers to large cities where there are special dangers related to urban travel, but increasingly travelers are seeking out exotic locations as tourist destinations. Pretravel advice is often an afterthought for these travelers.

It is estimated that fewer than half of travelers seek any kind of pretravel advice. Many people ask their family physicians for recommendations, and at times the advice they receive is either uninformed or out of date. Individuals returning to their country of origin are even less likely to consult a physician before travel and preventable systemic illness is seen more commonly in this group than other tourists. It is important for all primary care physicians to be prepared to give accurate advice to travelers about both pretravel preparation and how to deal with illnesses contracted abroad. Sometimes there is not enough time to obtain the required immunizations, and priorities must be established. The goal of this chapter is to enable the family physician to provide guidance to patients wishing to be prepared for illnesses and emergencies related to travel.

Case Illustration

A 28-year-old man in good health is planning a 2-month trip to Kenya. He will be working in Nairobi but also plans to visit game parks and participate in outdoor activities.

• What history must be obtained?
  
• What specific advice should the patient be given, especially regarding hygiene, safety, and food preparation?
  
• What immunizations are needed?
  
• What malaria prophylaxis is recommended?
  
• Where can the physician find the answers to these questions?

The first step is to obtain a thorough history—including any preexisting medical conditions and use of medications that may have side effects or may interact with other drugs that will be prescribed—and to perform a thorough physical examination. What is the patient’s exact itinerary, what countries will he visit en route, in what order? What accommodations will he have? Will he remain in urban areas or visit some rural regions? What is his immunization history? This information will help determine necessary immunizations and prophylaxis. The physician can also help the traveler ensure he has items, such as insect repellent, that may be essential. If the patient has a chronic illness, he should be given pertinent portions of his medical record and a list of allergies to take along in case he must seek medical care abroad.

Several web sites provide helpful information about travel and health requirements. (See listing at the end of this chapter.) After reviewing these requirements, the physician would find that this patient faces several risks that should be discussed. These include:

• Malaria, especially at lower elevations such as in game parks.
  
• Diarrhea, caused by parasites or bacteria such as Escherichia coli or Shigella.
  
• Typhoid fever and other salmonelloses.
  
• Hepatitis A, B, C, or E.
  
• Schistosomiasis, especially if swimming or wading in local bodies of water.
  
• Violence and petty thievery, especially in urban areas such as Nairobi.
  
• HIV/AIDS and other sexually transmitted diseases.
  
• Poor infrastructure for dealing with serious emergencies, such as motor vehicle accidents, especially outside of urban areas.

Travelers who monitor the most common risks found at their destination can better prepare in advance and equip themselves with resources to ensure a safe, smooth trip.

Travelers’ Medical Kit

Every traveler should carry a medical kit that addresses basic care for common illnesses and injuries. The essential components of such a kit are listed in Table 51-1, but they must be adjusted, depending on individual needs. If a patient uses a medication that is taken regularly, he or she should be advised to carry along enough to last for the entire trip and probably 1 or 2 weeks extra. This will allow for unexpected changes in travel plans. A small supply should be kept in the carry-on bags, in case luggage is lost or delayed. All applicable airline regulations regarding carry-on baggage must be observed so that the medication is not confiscated. The traveler should carry a letter from a physician if he or she plans to take along any controlled substance. This letter will help answer questions from immigration officials and other authorities in case questions are raised. Travelers should not forget to bring spare eyeglasses or contact lenses, contact lens solution, and their ophthalmologic prescription, in case of loss or breakage.

If the traveler is planning a long stay, the physician may be asked to supply prescribed medications on a regular basis from the United States, particularly if the drug in question is not available at the international destination. Increasingly, however, medications prescribed in the United States are available abroad (often much more cheaply) and can be obtained without difficulty by a knowledgeable traveler. Travelers should be cautioned to carefully examine any medications bought overseas, because ingredients may differ from those used in the US products, and some ingredients may not be considered safe by the US standards.

Insurance

Travelers should check their health insurance policies to determine whether they include coverage for medical expenses incurred abroad. If coverage is provided, they should bring a blank insurance form in case it is needed or it becomes necessary to contact the insurance company. Term travel health insurance policies are also available. Evacuation insurance is essential in the event of a serious accident or medical problem. Some policies will return travelers to their home cities; others will evacuate them to the nearest location where they can receive medical care comparable to that available in their home country. Among the more well-known companies offering evacuation insurance and emergency travel insurance are CSA Travel Protection (http://www.csatravelprotection.com), International SOS (http://www.internationalsos.com), MEDEX Insurance (http://www.medexassist.com), MedjetAssist (http://www.medjetassistance.com), and Multi- National—HCC Medical Insurance Services, LLC (http://www.hccmis.com/legal/). Policies can also be obtained through travel agencies. Finally, the traveler may wish to purchase trip insurance. This type of insurance ensures reimbursement in case a trip must be canceled for medical or other reasons beyond the traveler’s control. (It should be noted that most trip insurance policies do not cover cancellation for personal reasons, such as a change in plans.) This insurance is especially attractive for older travelers, who are more likely to have a medical emergency that prevents them from traveling.

Air Travel Concerns

Some medical conditions require special attention during air travel. These conditions include any severe, common illness; anemia; clotting disorders; disfiguring dermatoses; dyspnea at rest; incontinence; otitis media; pulmonary or acute upper respiratory infections; and sickle cell hemoglobinopathies. Medical contraindications to air travel are listed in Table 51-2. Any traveler with an acute infectious disease should be cleared by a physician before traveling. If there is any question about the diagnosis, the individual should not travel until the risk is known. Exposure to tuberculosis and other serious infections can occur in flight and an individual with a serious infectious disease should not travel on a commercial flight. Ill or handicapped travelers must notify the airline 72 hours before departure to be sure the plane is properly equipped. Services such as a wheelchair, oxygen, stretcher, and other necessary equipment can usually be provided with advance notice.

Food & Water Sanitation

Many infectious diseases can be prevented by attention to food and water sanitation and good hygiene. These diseases include intestinal viral, bacterial, and parasitic infections. The guidelines that follow can help travelers prevent many food- and water-borne illnesses.

Travelers should be advised to avoid eating food that has not been cooked adequately or peeled by them. Cooking must be thorough, not just warming, and a clean knife must be used for peeling. If fish are eaten, they should be fresh, not dried or old looking. Cans should be inspected for bulging or gas formation. Only dairy products that have been pasteurized should be consumed, and products that have been ultrapasteurized by the ultraheat treatment (UHT) method are preferred. Raw vegetables and fruits should be cleaned with a brush, soap, and water, and then ideally sterilized with boiling water or by soaking in a bleach solution (approximately 2 teaspoons or 10 mL of chlorine bleach in 1 L of clean water). Hands must be kept clean and fingernails trimmed. Clean silverware and plates should be used; these can be rinsed in boiling water or bleach rinse to sterilize them.

Travelers should be advised that bottled or canned drinks are safe as long as the seal is intact. Iced and lukewarm drinks should not be trusted, but hot drinks such as coffee or tea are generally safe if prepared recently and still hot when served. Tap water can be purified by either boiling it, treating it with iodine or chlorine, or by filtering it with a reliable ultrafilter water purification system, as described below:

• Bring water to a rolling boil for 1 minute. Although the actual temperature reached will be slightly lower at higher elevation, this does not seem to have clinical relevance.
  
• Treat the water with iodine (10 drops of tincture per liter) and let stand for 30 minutes, or treat it with chlorine (1-2 drops of 5% chlorine bleach per liter of water) and let stand for 30 minutes. Although chlorine may not kill all parasitic cysts or viruses, water treated with chlorine has a better taste than iodized water; furthermore, chlorine does not affect thyroid function over long periods of use.
  
• Reliable water filtration systems are available through various sources. (eg, Campmor [http://www.campmor.com] includes information on several systems.) A pore size of 0.2 μm is needed to filter out all enteric bacteria and parasites. If the water is cloudy or especially dirty-looking, some gross filtration or sedimentation must be done first before using a small-pore filter. Adding iodine resins to the filter will kill viruses if contact is sufficient.

Injury Prevention & Personal Security

The leading cause of mortality and morbidity in travelers is motor vehicle accidents. Drivers should be aware of local motor vehicle laws and never mix alcohol with driving or any activity that requires mental alertness. Other common accidents that occur during travel include drowning, carbon monoxide poisoning, electric shock, and drug reactions. Travelers should be aware that jet lag and other causes of drowsiness while traveling (eg, medications to alleviate motion sickness) may heighten the risk of injury. If a traumatic injury occurs, travelers should be cautioned not to agree to blood transfusions unless absolutely necessary.

Although the risks to personal security in many parts of the world may be similar to those encountered in many urban areas of the United States, a traveler may be at greater risk in areas where he or she is obviously a foreigner or tourist. Most commonly, the risks to personal security are related to theft of personal belongings and the occasional violent methods used, especially in the urban areas of Africa and Latin America. Women, especially those traveling alone, are at greatest risk of personal assault, often because the sexualized image of Western women portrayed by American media has given the men of many cultures a mistaken impression of their willingness and availability.

Another rarely discussed but important area of personal security is that of sexual activity while traveling. The freedom from a daily schedule and uniqueness of the situation may cause travelers to let down their normal guard. The incidence of sexually transmitted diseases, especially HIV, is quite high in many popular tourist destinations, including much of Africa, the Caribbean, Thailand, and some parts of Latin America. Travelers should be cautioned to use good judgment (especially in situations involving alcohol use), barrier protection such as condoms, and caution with oral-genital contact.

Obtaining Medical Care Abroad

Obtaining reliable medical care abroad can be difficult. Frequent travelers may wish to become members of the International Association for Medical Assistance to Travelers (IAMAT), which provides up-to-date advice on where to seek competent medical care for virtually any area of the world. (Contact information: 1623 Military Rd., No. 279, Niagara Falls, NY 14304-1745; (716) 754-4883; www.iamat.org.) The International Society of Travel Medicine (www.istm.org) and the American Society of Tropical Medicine and Hygiene (www.astmh.org) are also excellent resources for those seeking to find travel clinics anywhere in the world.

Immunizations

Up-to-date immunization information can be obtained from the Centers for Disease Control and Prevention (CDC) web site, www.cdc.gov/travel, which contains a wealth of information.

No vaccines are currently required for travel, with the exception of yellow fever vaccine if travel is planned through an endemic area. However, travelers from the United States should be up-to-date on all routine immunizations, including diphtheria, pertussis, tetanus, measles, mumps, varicella-zoster, rubella, influenza, pneumonia, and for children Haemophilus influenzae type b (see Chapter 7). For previously immunized adults, a single dose of polio vaccine is recommended if traveling to an area with a risk of polio. Europe, Australia and the Western Pacific, and the Western Hemisphere have been certified polio free.

Typhoid and hepatitis A vaccines are recommended for travelers to most areas of the world. Two typhoid vaccines are currently available in the United States: Ty21a and Vi. Efficacy of both vaccines is 50%-80%. Ty21a is a live oral vaccine that conveys protection for 5 years. It is taken as a series of four tablets, one every other day. The tablets must be kept refrigerated until taken. Vi is a parenteral vaccine that provides protection for 2 years. Persons receiving this vaccine have a higher incidence of systemic reactions such as fever or malaise for the first 2-3 days after administration than those who receive the oral vaccine, and they may also develop injection site soreness.

Meningococcal vaccine is indicated for travelers to areas of sub-Saharan Africa and any area where meningococcal disease is endemic or epidemic. Saudi Arabia now requires that Hajj and Umrah visitors be vaccinated with a tetravalent vaccine before entering the country. Meningococcal conjugate vaccine group 4 (MCV4) is preferred among persons aged 11-55 years, and meningococcal polysaccharide vaccine group 4 (MPSV4) is the recommended vaccine among persons aged 2-10 years and for those over 55 years. Duration of immunity lasts at least 5 years and adverse reactions are generally mild. Japanese encephalitis (JE) vaccine is recommended for travelers to endemic areas of rural Asia, especially if the traveler plans to live there or stay longer than 30 days. Cholera vaccine is no longer available in the United States; however, an oral vaccine, Vibrio cholerae whole cell/B subunit vaccine (Dukoral) is available abroad and may be useful in certain situations. No country now requires cholera vaccination; however, some local authorities may ask for this documentation. A single dose of the oral vaccine is sufficient or a medical waiver written on physician letterhead will satisfy this request. Rabies vaccine is recommended for travelers to high-risk developing countries and countries where rabies immune globulin is not available. Long-term travelers or those who may have extensive outdoor or nighttime exposure and those whose occupations place them at risk should consider this vaccine. Postexposure vaccination is still required.

Hepatitis B vaccine is recommended for travelers to high-risk areas, especially long-term travelers, and those engaging in high-risk sexual behaviors. Medical workers must be vaccinated, as should the future adoptive parents of children from a developing country.

Table 51-3 summarizes information for these and other vaccines. For additional information, refer to the CDC web site listed at the end of the chapter.