Travel Immunization

people looking at a map, with a camera, laptop and other travel gear around
You’ve thought of everything for your trip abroad – but did you remember your travel immunizations?

Destination-specific pre-travel consultations are customized to the needs of our patients. During the approximately 1-hour pre-travel consultation and physical examination, patients learn all potential risks of their trip and are given specific instructions for contacting us if they become ill while abroad. Pre-travel consultations also include immunity screening and prophylactic antibiotic, anti-diarrheal, altitude illness, and anti-malaria prescriptions.

Same day appointments available.

All routine, required, and recommended vaccinations are available. These include vaccinations against yellow fever, rabies, meningitis, hepatitis A, hepatitis B, hepatitis A/B combined vaccine, polio, diphtheria/tetanus, oral typhoid, typhoid injection, Japanese encephalitis, influenza, pneumonia, measles, mumps, rubella, Gardasil and varicella (chickenpox). The risks and benefits of medications and vaccinations are discussed, and the patient’s questions are answered. Travel insurance and security issues are discussed in detail. All patients receive customized trip itineraries containing destination-specific health information.

Services are also available for completion of visa requirement forms for international travel.

We are the primary immunization provider for Hill Physicians HMO patients in San Francisco.

 

Travelers’ Health Related Sites

CDC Traveler’s Health Center

World Health Organization

The American Society of Tropical Medicine & Hygiene

The International Society of Travel Medicine

International Association of Medical Assistance to Travelers

CIA World Fact Book

State Department Travel Advisories

US Customs Information

Country Specific Information

World Climate Information

International Weather Forecast

 

RECOMMENDATIONS FOR PRACTICE: CLINICAL RECOMMENDATION

  1. International travelers should receive routine domestic immunizations as well as travel-specific immunizations to reduce the risk of illness and death from vaccine-preventable diseases.
  2. Travelers to endemic regions should receive malaria prophylaxis.
  3. A short course of antibiotics reduces the duration of traveler’s diarrhea.

Also note: Use of personal protection measures, including applying DEET or picaridin on exposed skin and permethrin on clothing, and using a permethrin-impregnated bed net, reduces risk from arthropod-borne illnesses (e.g., malaria, dengue fever) in travelers.

Emergency Medical Evacuation Insurance

Emergent medical evacuation from a low-income nation can cost $50,000 to $75,000 or more. Emergency medical evacuation insurance is particularly important for older travelers, for those with chronic medical conditions, and for those engaged in high-risk activities, such as high-altitude climbing. Travelers can visit squaremouth.com to compare travel insurance options, including medical and emergency evacuation insurance

Recommended Components of the Pretravel Consultation

Assessment

Upcoming trip: dates, itinerary, reason for trip, travel style, special activities (e.g., mountain climbing, diving, rafting)

Medical history: medications, allergies, surgeries, hospitalizations, special conditions (e.g., pregnancy, breastfeeding, recent myocardial infarction or cerebrovascular accident, immunocompromise, psychiatric condition), immunizations, prior experience with malaria prophylaxis, illnesses related to travel

Immunizations

Routine (eTable A)

Travel-specific (e.g., typhoid fever, yellow fever, Japanese encephalitis, rabies, cholera)

Arthropod-borne disease risk reduction

Personal protection measures (applying insect repellent, such as DEET or picaridin, to exposed skin and permethrin to clothing; sleeping under a permethrin-impregnated bed net)

Malaria prophylaxis

Traveler’s diarrhea

Risk reduction (e.g., hand washing, cautious food and drink selection)

Carry-along medication, such as an antibiotic and antimotility agent (e.g., loperamide [Imodium]), for as-needed self-treatment

Counseling for further risk reduction

Avoidance of motor vehicle crashes, deep venous thrombosis, high-altitude illness, drowning

Crime, security

Emergency evacuation insurance

Safe sex practices

Sun protection

Traveler resources


DEET = diethyltoluamide.

Information from references 5 and 6.

Resources for Clinicians Who Provide Pretravel Services

Resource Comments

Professional organizations

American Alpine Club

Mountaineering association; some rescue benefits with membership

https://www.americanalpineclub.org

American Society of Tropical Medicine and Hygiene

U.S. clinicians can join the American Committee on Clinical Tropical Medicine and Travelers’ Health

https://www.astmh.org/subgroups/acctmth

Divers Alert Network

Diving safety; sells reasonably priced insurance for emergency medical assistance and transportation in case of illness or injury while traveling

http://www.diversalertnetwork.org/

International Society of Travel Medicine

Medical professionals and others with an interest in travel medicine from more than 90 countries

http://www.istm.org/index.asp

Royal Society of Tropical Medicine and Hygiene

Based in the United Kingdom

https://rstmh.org

Wilderness Medical Society

Wilderness activities, including mountaineering

http://www.wms.org/

Courses

CDC free online courses

Tropical medicine and travel health

http://wwwnc.cdc.gov/travel/page/ce-courses-training

HIV Web Study

Education service funded through the Health Resources and Services Administration and the U.S. Department of Health and Human Services

http://www.hivwebstudy.org

University of Minnesota Online Global Health Course

Completion of the online Global Health Course partially fulfills the content requirement for the American Society of Tropical Medicine and Hygiene’s CTropMed certification

http://www.globalhealth.umn.edu/education/online-global-health-course

University of Washington continuing medical education

Biennial, two-and-a-half-day course on travel medicine held in Seattle, Wash.

https://uw.cloud-cme.com/Ap2.aspx

Certificates of expertise

American Society of Tropical Medicine and Hygiene’s CTropMed certificate

Tropical medicine, pre- and posttravel medicine

http://www.astmh.org/education-resources/certificate-programs

International Society of Travel Medicine’s Certificate in Travel Health

Pretravel medicine

http://www.istm.org/certificateofknowledge

Other

CDC’s Health Information for the International Traveler (Yellow Book)

A comprehensive text on pretravel medicine; available for free online or as a mobile app, and a hard copy edition is available for purchase

http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014

CDC’s TravWell mobile app

Safe travel planning

http://wwwnc.cdc.gov/travel/page/apps-about

CDC’s yellow fever vaccination clinic search

List of clinics by state

http://wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search

International Association for Medical Assistance to Travellers

List of approved clinics with English-speaking clinicians around the world

https://www.iamat.org/

Program for Monitoring Emerging Diseases (ProMed) Listserv

Internet-based reporting system for infectious disease outbreaks

http://www.promedmail.org/

U.S. Department of State

Online list of statements on safety and security for every country in the world; regularly updated travel alerts and warnings for selected nations

http://www.travel.state.gov


CDC = Centers for Disease Control and Prevention; HIV = human immunodeficiency virus.

Risk Reduction Strategies for Selected Travel Hazards

Hazard Strategies

Blood-borne illnesses

Getting tattoos or piercings in low-income nations increases the risk of blood-borne illnesses, including HIV infection and hepatitis C, because unclean needles may be used.

Counterfeit, adulterated, or expired medications

Obtaining medications in low-income nations is not recommended.

Crime, security

Pickpocketing is common in urban settings around the world; the use of a money bag worn under clothing, around the neck or waist, reduces the likelihood of theft.

Drowning

Learn to swim, use personal flotation devices, avoid going into the water after drinking alcohol, know local water currents and conditions.

High-altitude sickness

Acute mountain sickness, which can cause headache and nausea, is common in those traveling to areas above 8,000 ft (2,400 m). It is less likely in those who ascend slowly; prophylactic use of acetazolamide reduces the risk of acute mountain sickness (one commonly used dosage is 125 mg twice a day for three days, starting one day before ascent).

HIV infection in medical volunteers

Medical volunteers who could be exposed to HIV may consider traveling with the first several doses of a 28-day course of HIV postexposure prophylaxis medications. The U.S. Public Health Service recommends one tablet per day of tenofovir/emtricitabine (Truvada; 300 mg/200 mg) plus one tablet twice per day of raltegravir (Isentress; 400 mg).

Motor vehicle crashes810

Use seat belts, age-appropriate car seats or booster seats, and bicycle or motorcycle helmets. Avoid riding on motorcycles, traveling in motor vehicles at night, and riding on the roof of a bus or in the back of an open truck.

Sexually transmitted infections, unintended pregnancy

The incidence of travel-associated casual sex is about 20%, approximately one-half of which is unprotected.11 Latex condoms should be used.

Solar injury

Travelers should be encouraged to use sunscreen with an SPF of at least 15 that protects against ultraviolet A and B rays. Sunscreen should be applied before insect repellent; combination products containing sunscreen and insect repellent should be avoided.

VTE

For long-distance travelers at increased risk of VTE: walk around often, do calf muscle exercises, and sit in an aisle seat if feasible; use of properly fitted, below-the-knee graduated compression stockings that provide 15 to 30 mm Hg of pressure at the ankle is suggested during travel. Use of graduated compression stockings and aspirin or anticoagulants are not recommended to prevent VTE in other long-distance travelers.12


HIV = human immunodeficiency virus; SPF = sun protection factor; VTE = venous thromboembolism.

Information from references 8 through 12.

Personal Protection Measures Against Arthropod-Borne Diseases

Measure Comments

Insect repellent applied to exposed skin

The most effective insect repellents contain 20% to 50% DEET or 20% picaridin.

DEET should be avoided in infants two months and younger. Picaridin does not have the petrochemical odor of DEET and may be better tolerated by children and travelers sensitive to the odor.

Other effective options are oil of lemon eucalyptus (PMD) and IR3535 (available as Skin-So-Soft Bug Guard Plus IR3535 lotion). IR3535 does not provide adequate protection against Anopheles mosquitoes and should not be used in malaria-endemic areas.

Insect repellent should not be applied onto or under clothing; regular reapplication is important.

Permethrin applied to clothing

Travelers may apply permethrin to clothing or purchase clothing pretreated with permethrin. It should be applied to outer clothing only and not to underwear.

Bed nets

A bed net is most effective when impregnated with permethrin. The bed net should reach the floor or be tucked under the mattress to provide a seal.

Activity modification

Outdoor activities should be avoided during dusk, nighttime, and dawn hours when mosquitos are more active.

Checking for ticks

Travelers should inspect their bodies and clothing after outdoor activity and at the end of the day with the aid of a mirror or companion.

Climate modification

Air-conditioning reduces the risk of malaria; malaria transmission usually occurs between 77°F (25°C) and 86°F (30°C).

Long sleeves and pants

Wearing long sleeves, tucking the shirt into pants, tucking pants into socks, and wearing closed-toe shoes are beneficial but may be difficult in hot or humid climates.


DEET = diethyltoluamide.

Information from reference 17.

Drugs for Malaria Prophylaxis

Drug Dosage Comments

Chloroquine-resistant malaria

Atovaquone/ proguanil (Malarone)
Begin 1 to 2 days before travel and continue for 1 week after leaving malaria-endemic area
Adults: 250 mg/100 mg per day
Children: 1 tablet = 62.5 mg/25 mg per day
< 5 kg: not recommended
5 to 8 kg: one-half of a children’s tablet daily
9 to 10 kg: three-fourths of a children’s tablet daily
11 to 20 kg: 1 children’s tablet daily
21 to 30 kg: 2 children’s tablets daily
31 to 40 kg: 3 children’s tablets daily
> 40 kg: 1 adult tablet daily
Useful in regions of mefloquine resistance
Contraindicated in patients with severe renal impairment (a creatinine clearance < 30 mL per minute per 1.73 m2 [0.50 mL per second per m2]); high cost makes this drug less desirable for longer trips
Avoid in pregnant women and mothers who are breastfeeding infants weighing < 11 lb (5 kg)
Should be taken with food or a milky drink

G6PD = glucose-6-phosphate dehydrogenase.

Adapted with permission from Bazemore AW, Huntington M. The pretravel consultation. Am Fam Physician. 2009;80(6):589, with additional information from reference 20.