COMMENTARY

Staying Healthy While Traveling: Best Advice for Patients

Sandra Adamson Fryhofer, MD

Disclosures

June 07, 2017

Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic: travel health.

Before taking an international trip, travel health preparation is important. Unfortunately, as many as 80% of travelers don't prepare.[1] Those visiting friends and relatives have the highest morbidity. Healthy travel is more than just having an antibiotic in case of traveler's diarrhea. Destination and agenda dictate a traveler's needs.

No matter where you or your patients may be going, it's important to keep mosquitoes at bay. Educate patients to expose as little skin as possible. Use insect repellants. Wear permethrin-treated clothing. Consider the need to even hang bed nets.

Mosquitoes transmit flaviviruses like Zika, dengue, West Nile, Japanese encephalitis, and yellow fever. They can also transmit chikungunya and malaria. The US Centers for Disease Control and Prevention (CDC) provides specific information about when to prescribe medications for malaria prevention.

For immunization, start with the basics: influenza, tetanus (Tdap), and measles-mumps-rubella (MMR) vaccinations. A recent observational study of pretravel clinics, published in Annals of Internal Medicine, found that less than half of adults needing MMR vaccine actually received it.[2]

Individuals who are not protected and do get exposed could bring the viruses back home. International importation is the main source of measles transmission in the United States.[3]

Hepatitis A vaccination is a must for all international travelers. Hepatitis A is spread by contaminated food. A single dose of the vaccine is 94% effective.[1]

Hepatitis B vaccination is also a good idea for your traveling patients. You never know when you'll be exposed to contamination.

More "exotic" vaccinations may be needed depending on the destination. South Asia has the highest typhoid risk (more than 80% of cases occur in this region), but even travelers to the Caribbean are at risk.[4]

Japanese encephalitis is endemic in rural Asia near rice paddies and pig farms.[5]

Meningitis is a threat in sub-Saharan Africa during the dry season. Saudi Arabia requires vaccination for pilgrims undertaking the Hajj.[6]

Yellow fever vaccination is often required for those arriving from countries where yellow fever is endemic. An every-10-year booster used to be recommended for at-risk travelers. However, the Advisory Committee on Immunization Practices (ACIP) now says that a single dose of yellow fever vaccine provides lifelong protection and is adequate for most travelers.[7] As of June 2016, International Health Regulations from the World Health Organization also say that one dose is valid for life. If you need yellow fever vaccination, don't procrastinate. The company that makes YF-Vax® [the only yellow fever vaccine approved by the US Food and Drug Administration (FDA)], is having production delays, which means vaccine shortages through mid-2018.

But don't cancel your trip yet. FDA is allowing importation of Stamaril® under an investigational new drug (IND) program. This yellow fever vaccine has been used in Europe for decades, and the IND protocol will be discussed at the next ACIP meeting in June.

There's a new cholera vaccine, brand name Vaxchora™, which was FDA approved in June 2016. This is the only cholera vaccine currently licensed in the United States. It's a single-dose, live attenuated oral vaccine for adults 18-64, given at least 10 days before travel to a cholera-infected area.[8] It's mostly for aid workers, refugee workers, and healthcare workers. Check out the May 12, 2017 MMWR for all the details.

Monkeys and other native animals are cute, but don't touch them and don't feed them. Remember rabies. This warning also applies to pets and unknown animals, including dogs. Never assume that an animal is rabies free. Don't go bicycling or running in high-risk rabies areas. Depending on destination and activity, consider pre-exposure rabies vaccination. Patients who do get bitten, scratched, or even licked on broken skin should be told to immediately seek postexposure rabies prophylaxis even if the rabies vaccine was administered beforehand.[9]

For country-specific advice, check out the CDC travel site. You can also get a hard copy of CDC's Health Information for International Travel. This is often called the Yellow Book and it is updated every 2 years.

Here's a final reminder: Don't forget sun protection. Be sure to wear sunscreen (at least SPF 30). Put on sunscreen before applying insect repellant.

For Medicine Matters, I'm Dr Sandra Fryhofer.

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