Pre-Travel Prophylaxis Helps Ensure a Bon Voyage
What are the key steps in preventing travel-related illnesses, particularly in patients visiting “exotic” destinations?
Four facts regarding international travel should capture the attention of primary care physicians. First, it has increased by 50% in the past decade (or 983 million international tourist arrivals in 2011).1 Second, emerging economies in Asia and Africa have beckoned many new business travelers.2 Third, travelers today have more comorbid conditions than previously.2 Finally, primary care providers may be the first to see travelers before and after their trips.2
A recent “Top Paper”2 frames the issues of “exotic” travel comprehensively. Let’s look at a portion of important information contained in this article (have a copy at the ready).
8 TIPS TO HELP PREVENT TRAVEL-RELATED DISEASES
The largest available database for diseases in travelers (GeoSentinel at www.geosentinel.org) has 53 clinical sites in 24 countries. Patient records are kept for 170,000 international travelers and immigrants since its founding in 1995. A selected sampling of their sage information follows2:
1. Gastrointestinal illnesses were the most common reported encounters after travel (34.0% of returnees). Implicated bacteria were Campylobacter, Salmonella, and Shigella. Please be aware that quinolone resistance is increasing in Campylobacter species. The most common responsible parasite in this cohort was Giardia.
2. Approximately 30% of returning travelers with a febrile illness had malaria. Dengue infections were next in likelihood (a 7-day incubation). Of the 28 deaths reported in the GeoSentinel database, one-quarter were a consequence of malaria. After extensive workup, 40% of those with a post-travel febrile illness had no identifiable cause.
3. We have forgotten about rabies to our detriment. Rabies is not a rarity in countries of international travel. More than 12% of post-travel dermatologic presentations required rabies prophylaxis. (Indonesia is an important risk location for rabies.)
4. Although neurologic diagnoses were less common, ciguatera intoxication (from eating reef seafood) was diagnosed in 51 returnees. Not an easy diagnosis to make, so be on the lookout.
5. Do not ignore travelers to “developed” areas! One-third of returning Legionella infections were acquired in Europe.
6. Clinicians should become versed in identifying the serpiginous lesions of cutaneous larva migrans (easily treated with ivermectin or albendazole) and healing animal bites or scratches.
7. Common diseases can be acquired with travel and should not be ignored. These include HIV infection and hepatitis A and B. (Why, see below.)
8. Why do these common diseases occur with travel? Only 40.5% of returning ill travelers reported pre-travel medical visits! A potpourri of illnesses tabulated above could have been prevented by a primary care and infectious disease specialty visit.
Ask your patients about travel. It may not be mentioned casually if it is business-related. The sites today are various, and the risk can be prohibitive, especially in persons with underlying disease (eg, HIV infection). Attention to pre-travel prophylaxis is a good idea.
REFERENCES:
1. United Nations World Tourism Organization, 2011 Edition. http://mktunwto.org/sites/all/files/docpdf/unwtohighlights 1 1enlr_1.pdf. Accessed April 19, 2013.
2. Leder K, Torresi J, Libman MD, et al. GeoSentinel Surveillance of Illness in Returned Travelers, 2007-2011. Ann Intern Med. 2013;158:456-468.