The Three Basic Topics

The three basic topics that should be covered during a travel clinic encounter are:

• Immunizations for vaccine-preventable diseases

• Medications for malaria chemoprophylaxis, as appropriate for the planned itinerary

• Instructions for management and treatment of travelers' diarrhea.

The advice given for each of these topics will be determined by the specific geographic destinations and activities planned at each.

All travelers should be requested to bring records of previous immunizations with them. An old 'Certificates of Immunization' form is ideal for assessing the current vaccine status of repeat travelers. If old immunization records are not available at the initial clinic visit, then a systematic review of the routine (standard), the required, and the recommended travel immunizations, combined with a knowledge of the patient's health status, previous travel, and detailed itinerary (see below) for the new trip, will enable formulation of a travel immunization plan. Serum antibody tests to determine immunity to specific vaccine-preventable diseases can be performed as needed if there is sufficient time before trip departure.

As mentioned earlier, many ailments of travelers are not vaccine-preventable. The health care provider in a travel immunization clinic has an opportunity and an obligation to advise the traveler if further pretravel health measures beyond immunizations are prudent for the planned itinerary—even if this might necessitate an additional pretravel clinic visit with another provider or even at another clinic.

The selection of malaria chemoprophylaxis and the need to employ additional precautions to decrease the risk of malaria infection are determined by the age and health status of the traveler, history of drug allergies or drug intolerance, and anticipated patient compliance with the recommended regimen. Recommendations on the drug of choice for a given malaria risk assessment may vary from country to country and depend somewhat on which drugs are approved, licensed, and marketed in the country where travel advice is being given.

Traveler education on the relative advantages and disadvantages of the various malaria drug regimens and on the compliance issues is often a time-consuming process. The relative risks of adverse drug reactions with a given antimalarial drug regimen must be balanced against the risk of malaria infection when a suboptimal regimen is selected. Traveler acceptance of malaria chemopro-phylaxis recommendations will be influenced by dosing interval: weekly (chloroquine, mefloquine) versus daily (doxycycline, primaquine, atovaquone plus proguanil (Malarone)). Other factors include duration of post-travel chemoprophylaxis, i.e. 1 week (primaquine, Malarone) versus 4 weeks (chloroquine, doxycycline, mefloquine) after leaving the endemic area, and last, but not least, the total cost of one drug regimen versus another for the recommended duration of therapy. Travelers also need to understand the importance of not discontinuing or switching regimens while traveling, except as advised by knowledgeable health care professionals, despite well-intentioned warnings and advice from friends and fellow travelers. The emergence of resistant strains of chloro-quine-resistant Plasmodium falciparum (CRPF) and multidrug-resistant malaria, and widespread publicity in the lay press about adverse side-effects associated with mefloquine (Lariam), one of the highly efficacious drugs that may be used for prevention of CRPF, add to the challenge of giving advice on malaria chemoprophylaxis.

Travelers' diarrhea is a common and well-known scourge of international travel, and a leading motivation for travelers to seek pretravel health advice. Questions about vaccines for diarrheal diseases, preventive therapy with probiotics, prophylaxis with bismuth subsalicylate or antimicrobials, and advice on the safety of food and water at their destination(s) are common. International travelers need clear instructions about how to select and use oral rehydration fluids, bismuth subsalicylate, probiotics, and antimotility drugs such as loperamide alone or combined with single dose or short-term antimicrobial therapy as self-treatment once stricken by travelers' diarrhea. Patient care instructions about signs and symptoms indicating a need for professional medical care are also important.

Emerging drug resistance among enteric pathogens to antimicrobials commonly used in the treatment of travelers' diarrhea (trimethoprim plus sulfamethoxazole, ciprofloxacin, and others) fuels the search for new approaches for prevention and treatment of travelers' diarrhea. Highly efficacious vaccines against common forms of travelers' diarrhea and the potential benefits from alteration of intestinal microecology are two areas of continuing research

Health Status of the Traveler

The travel clinic intake form records age, place of birth, general health status, allergies to medications or other substances, prior residence overseas and or international travel, general health (acute or chronic illness, disability, pregnancy or planned pregnancy, lactation), list of medications taken on a regular basis (both prescribed and over-the-counter), vitamins, herbal preparations, and dietary preferences.

Review of Itinerary

Dates of trip departure and return home, and a list of interim destinations with anticipated dates at each destination, plus the accommodations and activities at each destination should be the first items on the patient intake sheet. These data are needed to determine the time available to do pretravel immunizations and to calculate appropriate supplies of malaria chemoprophylaxis, medications for travelers' diarrhea, and other drugs to be included in the travel medicine kit, and to assess the potential health risks of the given itinerary.

In terms of health risks, multiple destinations add to the complexity of pretravel preparation and planning because of varying health regulations and environmental conditions. Hygiene, sanitation, and insect control are more challenging in a tropical climate compared to a temperate climate. As travelers go from urban to rural to remote locations within a country, access to organized health care, in case of an emergency, and telecommunications, to indicate the need for emergency evacuation, become more and more difficult. When the duration of a trip is prolonged, the chance of a traveler becoming ill while still away from home, with the necessity of consulting unfamiliar medical systems, is more likely than with a shorter trip because many of the common diseases of travelers have short incubation periods ( < 3 weeks).

Learning the details about the anticipated style of travel, such as mode of transportation, accommodations, level of contact with local residents, and living conditions, may suggest other topics for advice which might benefit the traveler; for example, hazards of rural travel, vector-borne diseases (besides malaria), animal bites, tuberculosis, sexually transmitted infections, and nutritional concerns. Identifying the purpose of travel, such as tourism, educational or cultural exchange, missionary work, volunteer work, political action, competitive sports, expedition, field work, expatriate assignment, etc., can also highlight special exposures that the traveler can prepare for. Special travel health advice is needed for travel during pregnancy, travel with infants and children, travel with medical conditions, HIV-infected travelers, travel with physical disabilities, senior travel, and adventure and wilderness travelers.

• Traveling with children

• Medical evacuation insurance

• Travel medicine kits.

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