travel medicine (traveler's health)

Introduction

CDC travel recommendations:

Etiology

Risk factors for acquiring endemic infection

• staying in endemic area for more than 1 month
• < 30 years of age
• working with indigenous people, especially in the tropics
• for most developed countries & for short stays, risk is small
• risk of acquiring infection on commercial transportation is very low

Febrile traveler returning from developing country

• incubation period < 2 weeks
  • malaria (most common cause)
  • typhoid fever
  • dengue
  • rickettsial disease
  • hepatitis A
  • yellow fever
  • Loeffler syndrome
• incubation period > 4 weeks
  • malaria
  • tuberculosis (case of cough & malaise but no fever)
  • brucellosis
  • mononucleosis syndrome
    • Epstein-Barr virus
    • Cytomegalovirus
• it may be difficult to determine the incubation period in a patient who has been abroad for an extended period
• other travel-associated infections
  • leptospirosis
  • Chikungunya fever
  • histoplasmosis
  • coccidioidomycosis
  • legionellosis
  • coronaviruses: SARS, MERS-CoV
  • Japanese encephalitis
  • hemorrhagic fever viruses
    • Ebola virus
    • Marburg virus
    • Lassa virus
  • Penicillium marneffei
  • Zika virus
  • cutaneous diphtheria

Special etiologies

• traveler's diarrhea
• consider malaria in any patient with fever with travel to an endemic zone within 1 year
• transient pulmonary infiltrates with eosinophilia (Loffler syndrome)
• several types of infections may occur 5 or more years after leaving an endemic area.

History

• what vaccinations or prophylaxis was taken?
• what was the purpose of travel?
• was travel to rural or urban areas?
• what were the departure & arrival dates?

Complications

• venous thromboembolism
  • risk increases with distance of travel
  • immobilization more important than travel per se
• travel-associated infection
• many international tourists return home colonized with multidrug-resistant enterobacteriaceae (MRE)
  • 31% for travelers to Latin America, 48% for travelers to sub-Saharan Africa, & 72% for travelers to Asia
  • destinations most commonly associated with MRE were Vietnam, India, Peru, & Togo
  • most of those colonized with MRE cleared the organisms within 1 month of return
  • 20% remained colonized at 2 months
  • rarely individuals remained colonized at 1 year
• circadian misalignment occurs when traveling east
  • major league teams 3.5% less likely to win when they travel east across at least two time zones
• insulin pumps over-deliver > 1/2 unit on takeoff & under-deliver a somewhat less on landing

Management

Immunizations

• varies with site of travel
• general recommendations (review status & immunize if indicated)
  • measles, mumps & rubella vaccine (MMR)
    • do not give live vaccine to pregnant women (MMR)
    • ~1/2 of those eligible for MMR actually receive it
  • influenza vaccine
  • pneumococcal vaccine (recheck indications i.e. smoking ...)
  • hepatitis: hepatitis A vaccine, hepatitis B vaccine
  • varicella (chickenpox)
  • Tdap
• review status of polio vaccination
  • travel to developing countries
  • CDC requires inactivated poliovirus vaccine booster for travel to Cameroon, Pakistan, & Syria
  • inactivated poliovirus vaccine booster recommended for travel to Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Somalia, & Nigeria
• yellow fever vaccine may be required
  • Africa, South America
• typhoid fever
  • typhoid attenuated oral vaccine (QOD for 4 doses)
  • single dose typhoid polysaccharide vaccine (typhim Vi)
  • travel to developing countries (not Taiwan)
• cholera vaccine
  • marginal effectiveness
  • significant side effects
• meningiococcal vaccines for travel to sub-Saharan Africa
• hepatitis:
  • hepatitis A vaccine &/or immune globulin
    • travel to developing countries
    • not needed for travel to western Europe, Australia ...
    • one month prior to travel, 2nd dose 6-12 months later
  • hepatitic B vaccine
    • travel to all developing countries
    • includes Southern Europe
    • accelerated schedule available
• Japanese B encephalitis vaccine
  • not required
  • advisable for persons visiting rural Southeast Asia & China for periods of a month or longer, particularly during summer months (rainy season)
  • allergic reactions may occur
• rabies pre-exposure prophylaxis
  • workers in endemic areas
  • 3 injections over one month
  • serologic testing for effectiveness every 6 months
  • booster vaccinations as guided by serologic testing & with exposure to rabies
• tick-borne encephalitis vaccine (not available in U.S.)
• adults with solid & hematologic cancers traveling to an area of risk should follow the CDC standard recommendations for the destination
  • non-live vaccines are safe
    • hepatitis A vaccine, typhoid vaccine, inactivated polio vaccine, hepatitis B vaccine, rabies vaccine, meningococcal vaccine, Japanese encephalitis vaccine

Notes

• caution:
  • some Brand names are used for different drugs in different countries (see Brand names for drugs in different countries)
• CDC travel recommendations:
• (877) FYI-TRIP

More specific terms

• Antarctic expedition
• jet lag
• medical tourism

Additional terms

• air travel
• airline travel & medications
• altitude sickness
• Brand names for drugs in different countries
• drug importation
• foreign drug
• traveler's diarrhea

Patient information

travel medicine patient information