In 2004 approximately 16% of adult US residents (CDC, unpublished data) spent at least one night outside the US. In the same year, there were 62 million trips outside the US, a 24% increase over the 52 million in 1995 (1). Whether a frequent international traveler or on the trip of a lifetime, the traveler can take steps to plan for healthy travel.
The first step is to consult with one’s health-care provider well in advance of the planned date of departure. Even healthy young adults going to developed areas should be up to date on their routine vaccinations. For example, vaccination practices in other parts of the world vary; travel anywhere outside the United States, including to industrialized regions such as Western Europe, presents a risk for exposure to measles and other vaccine-preventable conditions (2). General recommendations may be found here, but situations can change. Thus, prior to embarking, travelers and their health-care providers should consult sources such as the Travel Notice section of the CDC Travelers’ Health website (http://wwwn.cdc.gov/travel) for current information on outbreaks or other health-related travel issues. Since 2004, the Travel Notices have been presented in four tiers of increasing magnitude, described below, to assist the traveler in weighing the potential impact of the information. The majority of Notices appear under “In the News” or “Outbreak.” In only one instance, during the outbreak of SARS in 2003, postponement of nonessential travel was recommended.
In The News, the lowest level of notice, will provide information about sporadic cases of disease or an occurrence of a disease of public health significance affecting a traveler or travel destination. The risk for an individual traveler does not differ from the usual risk in that area.
Outbreak Notice provides information about a disease outbreak in a limited geographic area or setting. The risk to travelers is defined and limited, and the notice will remind travelers about standard or enhanced travel recommendations, such as vaccination.
Travel Health Precaution provides specific information about a disease outbreak of greater scope and over a larger geographic area so travelers can take measures to reduce the risk of infection. The precaution also provides guidance to travelers about what to do if they become ill while in the area. CDC does not recommend against travel to a specific area but may recommend limiting exposure to a defined setting, such as poultry farms or health-care settings.
Travel Health Warning recommends against nonessential travel to an area because a disease of public health concern is expanding outside the areas or populations that were initially affected. The purpose of a travel warning is to reduce the volume of traffic to affected areas, thus limiting the risk of spreading the disease to unaffected areas.
A complete description of the definitions and criteria for issuing and removing travel notices can also be found in Table 2-1 and at http://wwwn.cdc.gov/travel/notices.aspx#TravelNoticeDefinitions.
Occasionally Travel Notices may contain changes to existing recommendations, such as adding antimalarial prophylaxis for an area previously thought to be malaria free. If the situation resolves, the recommendation may be retired, or if it becomes permanent the notice will be removed but linked to an archive and the change will be highlighted and incorporated into the text of the online Health Information for International Travel.
Several topics, such as polio and avian influenza, have appeared as Travel Notices for extended periods of time because the risk to travelers is ongoing but evolving. In each case the notice is periodically updated and has a link to a WHO website where international case counts are maintained. Avian influenza, like SARS, represents an emerging zoonotic infection. No cases of SARS have been identified since 2003, but many lessons were learned in the role of international travel in global spread and, concomitantly, the role of social distancing measures, such as voluntary home quarantine and exit screening of travelers, even in the absence of specific measures such as medication or vaccine. Due to concern about the potential for an influenza pandemic, these measures are being closely studied and could be imposed quickly, providing another reason to monitor official websites such as CDC and WHO, not only prior but during and after travel.
Concerns about pandemic influenza are another reason travelers should be up to date on routine vaccination, such as for seasonal influenza. Travelers should prepare and carry a travel health kit (see the Travelers’ Health Kit section in this Chapter) equipped with hand gel containing >60% alcohol. These concerns also illustrate the importance of hand washing, not just for protection against travelers’ diarrhea but also against respiratory pathogens. Increased awareness of cough hygiene or respiratory etiquette (i.e., cover your cough) is not only a courtesy but if generally practiced would play a role in reducing transmission of respiratory and influenza-like illnesses. Travelers are also encouraged not to travel while ill.
Business travelers and those who travel spontaneously may not always have sufficient time before their departure to visit their health-care provider. However, travelers who often travel on short notice should consider a baseline visit with their health-care provider, at which time a review can be done, pertinent vaccinations given and options for future travel discussed so that perhaps only filling a prescription might be needed for the next departure.
Health-care providers can also play a role in inquiring about the travel history of patients being seen for acute illness and about the role of travel in the patient’s future. The latter is extremely important, not just for the business or occasional traveler but for those visiting friends and relatives (VFR) abroad. Twelve percent of the US population is foreign born (3) and the number is thought to be closer to 20% when both foreign born and their family members (e.g., US-born children and/or spouse) are included (4). VFR was listed as the main reason for travel for 46% of international travelers in 2004 (5). VFRs (see Chapter 9) for these purposes are individuals who have typically migrated from a less developed to a developed area and are returning to the region of their birth, often with new family members. The traveler returning home may not understand the dynamics of risk and waning immunity; thus, health-care providers can anticipate by asking about past travel and future plans of immigrants in their care. The goal of inquiring well in advance would allow the opportunity to convey risk information over time, to provide appropriate vaccine immunity by administering needed vaccines well in advance, and to provide the opportunity to ameliorate costs over several months rather than require the patient to choose at the time of a single interaction. Inquiries regarding travel plans could be included in the anticipatory guidance for parents of immigrant children, particularly those traveling to sub-Saharan Africa where malaria risks are high and the need for prophylaxis both for parents and children may not be appreciated. Parents could be referred to re-sources such as the CDC Malaria website, which contains informational tools and cautionary tales of real people who acquired malaria after travel without adequate prophylactic measures (http://www.cdc.gov/malaria/travel/index.htm). Travelers could plan to take insecticide treated bed nets to use during the trip and then leave them as presents. There are also free four-color posters that illustrate several methods of prevention being practiced by families of different ethnic origins. These posters can be downloaded (http://wwwn.cdc.gov/travel/contentDiseases.aspx#malaria) and strategically placed in the office, with signs prompting the patient to tell the health-care provider about anticipated travel or travel history prior to the presenting illness.
In summary, health issues related to travel are dynamic. The traveler and the health-care provider each have a role in staying aware and developing an individual plan for healthy travel.
