Students Traveling Abroad

The Pre-University Student

Health-associated risk and specific disease entities in adolescent international travelers are underreported in the medical literature. Analysis of the GeoSentinel surveillance data shows that travel for tourism is the most common reason for travel in the 12- to 17-year-old group, but conclusions about diseases acquired while traveling cannot be drawn due to limitations created by the methods of data collection in this age group. In this age group, a case report of 29 female student New Zealand travelers (mean age 16) and six accompanying adults including one physician traveling to Peru found the following percentages of illness based on organ system: 37% gastrointestinal, 16% respiratory, 12% altitude, 7% dermatologic, 5% each for anxiety, genitourinary, neurologic, and musculoskeletal, and 3% adverse drug reactions.

University Students

More information can be found in the literature for this group of travelers. University students traveling for pleasure often do so during designated school breaks, such as spring break, and travel for shorter periods of time (1-2 weeks), with “fun” being the driving force for the trip. Excessive alcohol consumption and risky sexual behavior have been associated with spring break vacations.

Students who travel for longer tourist excursions usually travel in the low-budget category, including backpacking and camping, which puts them at greater risk for various mosquito-, fly-, tick-, and water-borne diseases. These trips may include travel to more than one country. “Adventure” is often the driving force for travel in this population. The backpack traveler is more likely to take risks with personal safety; the lack of social norms, lack of an anchoring job or school responsibility, and freedom experienced in a new exotic environment lead to risky sexual behavior that may or may not be associated with alcohol and drug usage.

Another group of university students travel for study-abroad programs for 1-3 months at a time. This group often has a more formalized agenda than the adventure traveler; however, these students may seek adventure on the weekends or tack on an adventure trip at the end of their stay.

Students on longer trips for any reason are at risk for several additional health problems. Longer duration of stay is associated with chronic diarrhea, giardiasis, chronic fatigue, eosinophilia, cutaneous leishmaniasis (CLM), schistosomiasis, and Entamoeba histolytica diarrhea. Sometimes, traveler loneliness can precipitate a reactive depression. Anticipation of these problems and arrangement for post-travel follow-up may be needed.

Health Science Students Abroad

The advent of global health programs has spurred health science students' interest in participating in clinical programs in less developed countries. An interest in international health, a desire for increased cultural competency, the need for hands-on clinical experiences, and the desire to help have all been cited as reasons for the growth in electives abroad for health science students. These students are more mature than undergraduate students; however, they still may not perceive true risks in less developed countries. Surveys of medical students and nursing students with high-risk blood-borne pathogen exposure including human immunodeficiency virus (HIV) have shown that students rarely if ever report such injuries and do not take HIV post-exposure prophylaxis (PEP), even if they bring the medicines with them.

Many health science schools have developed specific curriculum criteria such that only experienced students participate in higher-level clinical activities. However the literature still reports that “junior” students participate in risky procedures such as surgeries and delivery of babies. In addition, provision of care in less developed countries exposes students to illnesses related to poverty and crowding, such as tuberculosis and meningococcal disease.

Counseling for health science students traveling internationally for clinical rotations should include the standard destination-specific travel advice: vaccine recommendation, malaria prophylaxis, medication for travelers' diarrhea, and insect precautions. Students in health science fields usually have already been vaccinated with hepatitis B vaccine. The counseling should include screening pre and post travel for tuberculosis either with a purified protein derivative placement or one of the interferon gamma-releasing assay (IGRA) blood tests. Meningococcal vaccine should be offered if the student is traveling to high-risk countries (e.g., the meningitis belt in Africa) or will have prolonged clinical contact with host populations.

Universal precautions, high-risk procedures (e.g., surgical procedures in regions with a high prevalence of HIV), and the need for HIV PEP should be discussed, offering HIV PEP if necessary. Due to the costs and side effects of such medications, students are often given a 3- to 5-day quantity with the understanding that the exposure necessitates an immediate trip back to the home country for more medication and monitoring. Current recommendations for HIV PEP can be found at http://nccc.ucsf.edu/clinical-resources/pep-resources/pep-guidelines .

Some studies show that despite their medical education, health science students are less likely to follow recommendations for malaria prophylaxis and insect precautions. This disparity between perceived and real risk is of paramount importance due to the intimate nature of contact with patients. As for all students traveling abroad, the risks of motor vehicle safety, drug usage, alcohol overconsumption, and unprotected sexual experiences should also be discussed.

Vaccines for Students

Routine childhood vaccinations vary by country. Recommended schedules for European countries can be found at http://vaccinews.net/vaccination_schedule.php . However, a review of actual vaccines received by the specific student is needed to avoid any gaps in coverage.

Students who are under-immunized present a unique problem for the travel medicine provider. Increasing rates of vaccine refusal in childhood puts this subset at risk of acquiring preventable illness while traveling. Healthcare providers encountering an under-immunized student will need to have a frank discussion about the suitability of travel to the desired destination without proper immunization and discuss strategies for “catch-up” immunizations (see http://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html ). The risk of acquiring vaccine-preventable disease while traveling is not trivial; there are many reports of under-immunized travelers returning with vaccine-preventable diseases.

Students traveling to remote destinations or for long periods of time are more likely to need rabies pre-exposure prophylaxis and Japanese encephalitis vaccines than others. Students are typically unaware of the dangers of encounters of potentially rabid animals. Rabies avoidance precautions are essential, since the long-term traveler who is feeling lonely may want to pet an animal. Many students forego rabies vaccine due to the high cost in the developed world without realizing the difficulty of obtaining rabies immune globulin in the event of a bite. Students should be encouraged to purchase travel health insurance with evacuation to assist with obtaining appropriate wound care in a timely manner.

Medications for Traveling Students

Pediatric dosing schedules for medications should be used for students between 12 and 17 years of age. Consult Chapter 8 , on pediatric travelers, for advice about appropriate dosing of altitude and malaria medications. Traveler's diarrhea is treated with azithromycin 10 mg/kg/day for 3 days up to a maximum of 500 mg per day for 3 days. Some students will need their antibiotics in dry powder form with instructions for reconstitution, and others can manage tablets easily. Rifaximin or symptomatic care can be used for the azithromycin-intolerant adolescent.

University and graduate students use adult doses of medications. Obtaining the patient's medication list is very important when prescribing either ciprofloxacin or azithromycin. Given the stress of higher education, many students are taking medication for depression and/or mood stabilization. These drugs may cause prolongation of the QT interval when used in combination with azithromycin or ciprofloxacin. Consultation with a pharmacist is recommended. Rifaximin is an alternative for these patients. Also, one should always be mindful that unintended pregnancy is a possibility. Medications that are inappropriate for pregnant women should be avoided.