“What animal has its teeth in my arm?”
If you find yourself asking this question whilst exploring the outer reaches of the Amazon, it is perhaps a bit late to consider whether it would have been a good idea to visit a travel medicine clinic before you left home.
Most Americans don’t. Despite the fact that Americans are traveling more widely than ever, and ever more people are traveling—-87 million Americans traveled abroad in 2017 alone–almost half of the travelers at Logan airport had sought out no health information of any sort prior to visiting countries where the likelihood of coming into contact with an unusual infectious disease was relatively high, according to a study published in the Journal of Travel Medicine .
The most common reason? They weren’t worried about it. And if they were concerned, most looked for information on the internet or consulted their primary care provider.
Why worry? “There are two good reasons,” according to infectious diseases and travel medicine specialist Dr. Regina LaRocque, Assistant Professor of Medicine at the Massachusetts General Hospital. First, travelers are seeking out more exotic destinations, often in countries where they can acquire infections common to the place they are traveling– such as yellow fever, dengue, malaria, hepatitis A and typhoid –but uncommon here in the United States–which means they may have little to no immunity to them.
Second, there is a risk to their local community when they return, since they may bring back infections to which there is little native resistance, or so-called herd immunity, here in the United States (think: the recent measles epidemic in the US; also recent incidents where Zika, dengue and influenza have been brought unwittingly stateside).
Since many of these infections are preventable through vaccination or avoiding insect bites, visiting a travel clinic or your primary care provider to educate yourself about what infections you might encounter while abroad is time well spent.
Who Should Consider Consulting a Travel Medicine Clinic?
According to Dr. LaRocque, the following people may especially benefit from consultation with a travel medicine clinic:
- Immunocompromised travelers;
- Pregnant women;
- Young children;
- Anyone who is visiting friends and relatives (VFR);
- Travelers with complicated itineraries;
- Travelers who will be staying longer than four weeks in the destination country.
There are several advantages to seeking the advice of a specialist in these circumstances. Immunocompromised patients have to think carefully about whether they even CAN travel, and if travel is necessary, carefully selecting vaccines and prophylaxis that they can safely take.
Pregnant women, especially those traveling to areas where they may be exposed to Zika virus, will also want to consult a travel medicine specialist before embarking on a trip abroad; the same goes for young children. Many pediatricians may not know which vaccines are most effective in — or even required for — children.
Those least likely to be aware that travel poses a risk are so called “VFR” or folks who are “visiting friends and family.” People who have grown up elsewhere in the world and are returning there to visit relatives may be under the false impression that because they grew up in a certain place, they are immune to the common infectious diseases in their former communities.
Will’s is a case in point. A 58 year old businessman, he traveled to mainland China to visit family. Will had grown up there on a rural farm; he was quite confident that he was immune to hepatitis A. But he nevertheless returned to Boston with fever to 102 and severe jaundice after a trip to Bejing. The fulminant hepatitis A that he acquired there nearly put him on the liver transplant list. It is very easy to check a serology to determine if a patient is hepatitis A immune; about 30% of VFR are not, according to travel medicine physician Dr. Harry Schrager, and therefore require the vaccine.
Complicated itineraries can present special challenges that should be considered carefully before travel. For instance, when arriving in Tanzania from another country in Africa , it is necessary to show evidence of yellow fever vaccination. Those unaware of this regulation may have to get the vaccine right in the Dar es Salaam airport–an unhappy circumstance for many reasons.
Those staying in their destination country for longer than four weeks will also want to share that information with their doctor. For example, a college student taking a semester helping build houses in a rural area of Mexico will need to consider receiving the rabies vaccine, according to Dr. LaRocque, since he or she will likely be exposed to wild animals in a country where rabies is endemic.
But visiting a travel clinic before setting off can also be helpful to the broader public, who may benefit from the in-depth knowledge of a specialist. For example, recommendations for malaria prophylaxis may be complicated: they vary depending upon whether you plan to visit an urban or a rural area. So if you are traveling to a country where malaria is endemic, it is critical to know–and share with your doctor– what parts of that country you will be visiting. In addition to discussing prevention of disease with vaccines or malaria prophylaxis, you can also learn how to treat traveler’s diarrhea and receive other advice specific to the area you are visiting.
In addition, there are general safety issues to be aware of. A 24 year old visiting Machu Picchu might not know that injury, not infection, is the leading preventable cause of death in travelers; so learning that it is a really good idea to wear motorcycle helmets and seat belts and even consider hiring a local driver can be potentially life-saving advice.
Don’t Wait until the Last Minute to schedule an Appointment
Many patients have a sense that seeking out a travel clinic is a good idea, but often leave this detail until the last minute–and then have a hard time making an appointment.
I advocated for “Sylvia,” who contacted me a week before she was to leave for Cuba. Did she need vaccination against hepatitis A and typhoid? She thought she had had hepatitis A and typhoid vaccines in the distant past–maybe 15 years ago. She asked if she might need a booster?
According to CDC guidelines, hepatitis A and typhoid vaccines are recommended for travel to Cuba. While Sylvia’s hepatitis A vaccine should be good for life, according to Dr. LaRocque, typhoid vaccine would be recommended since the immunity conferred by the typhoid vaccine only lasts between 2-5 years.
Unfortunately, Sylvia was not able to schedule an appointment until the day before she left–which wouldn’t give the vaccine time to “take” and protect her while she was traveling. It may take two weeks or longer before an immune response is adequately elicited by a vaccine (though this will occur more quickly with a booster vaccine).
I referred Sylvia to Dr. Harry Schrager at Newton Wellesley Hospital, who did have room in his travel clinic. Sylvia was thrilled–and a little worried: “Dr. Schrager was so thorough I almost decided not to go to Cuba. Safer to read at home. In any event, thank you!”
Dr. Schrager also discussed common food borne illnesses with her–not just traveler’s diarrhea, but also ciguatera poisoning, not uncommon when eating certain fish including grouper, snapper, amberjack and barracuda; ciguatera is common especially in the western areas of Cuba.
Even using the best precautions,Dr. Schrager notes, it is not uncommon to pick up the occasional infectious disease while traveling. One 50 year old patient of his who traveled to Hong Kong acquired both salmonella and amoebic dysentery–despite staying in luxurious 5-star accommodations and closely following Dr. Schrager’s advice to eat food that had been thoroughly cooked, drink bottled water and refrain from using ice in drinks. At least the patient was already plugged into the travel clinic and therefore was seen and diagnosed promptly.
Better Late than Never!!
Dr. LaRocque emphasizes, however, that it is always a good idea to be seen: “we do like people to see us in travel clinic even if it is the day before they depart.”
For those who would like more information–please find below a list of resources and a list of travel suggestions adapted from the Journal of the American Medical Association “Travel Tips.”
Bon Voyage!
**Note: all patients’ names have been changed to protect patient confidentiality.
Resources
An excellent resource that I recommend to patients and doctors alike is Heading Home Healthy. The Traveler’s Rapid Health Information Portal on the website lets you input the countries you are traveling to and suggests which vaccines you may need. The website is supported by the Center for Disease Control (CDC), the Massachusetts General Hospital and Global TravEpiNet among other groups.
Centers for Disease Control (CDC)’s Yellow Book: an encyclopedia that details the vaccines needed for travel to any country;
CDC Travelers’ Health–which has a useful interactive malaria map
CDC malaria hotline (770-488-7788)
WHO International Travel and Health
For Clinicians:
American Society of Tropical Medicine and Hygiene
Travel Medicine guidelines of the Infectious Diseases Society of America (IDSA)
International Society of Travel Medicine
Preventing Travel-Related Illnesses: Tips for International Travel (adapted from the Journal of the American Medical Association)
Before your trip, visit a doctor or other health care provider, ideally 4 to 6 weeks before leaving the country.
Your doctor may recommend vaccines and medications based on your medical history, health conditions, and trip itinerary.
Health Insurance
- Learn what your health insurance covers while you are abroad. Most health insurance does not cover emergency evacuation.
- If you are traveling to parts of the world where evacuation could be necessary, these are helpful web addresses: International SOS–
How to Prevent Infections Transmitted through Food and Water:
- Drink bottled or disinfected (boiled, filtered, treated)water and use ice made from bottled or disinfected water.
- Eat fully cooked foods that are served hot.
- Eat only pasteurized dairy products.
- Wash your hands often. If soap and water are not available, use an alcohol-based hand rub containing at least 60% alcohol.
How to Prevent Tick and Mosquito Transmitted Illness:
- Avoid bug bites and be safe around animals. Use an insect repellent that contains at least 20% DEET. Wear long-sleeved shirts, long pants, closed shoes, and hats.
- Be aware that rabies is still common in many countries in the world. Do not pet, handle, or feed unfamiliar animals, even if they look safe. See a doctor immediately if you are bitten or scratched by any animal–even if you only remember to do this after you return home. You will want to discuss the potential need for a rabies vaccine with your doctor. If your travel involves lengthy stays in-countries where rabies is still endemic and your work may expose you to feral or other infected animals, your doctor may recommend receiving a rabies vaccine before you travel, according to Dr. LaRocque.
- Take all of your prescribed antimalarial medicines. They start before your trip and continue after you come home.
How to Help Prevent Respiratory Infections, especially Influenza:
- Prevent colds and flu by covering your mouth and nose with a tissue when coughing or sneezing. Avoid close contact with people who are coughing or sneezing. Wash your hands often or use an alcohol-based hand rub, especially after coughing or sneezing.
General Safety Tips while Traveling:
- Don’t forget to carry an adequate supply of your medications and medical supplies–and don’t check them with your luggage where they might get lost.
- Don’t forget to wear seatbelts in motor vehicles or a helmet when riding a bicycle or motorcycle.
- Stretch and walk often during long flights to prevent blood clots.
- Practice safe sex, i.e. use a condom, if you have a new sexual partner while traveling.
Fever in the Returning Traveler:
- If you have a fever after returning home, you will want to see a doctor immediately– particularly if your travels take you to an area of the world where malaria is endemic. It is important to tell your doctor where you traveled and for how long.
- If you have visited a malarious region, the possibility of malaria should be evaluated urgently; if the initial test is negative, it should be repeated, according to Dr. LaRocque.
- Malaria can develop as early as seven days or as late as several months after travel to a malaria-endemic region.
