Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Issues for Travelers
Key Points
-
Among travelers to developing countries, both tropical and non-tropical diseases are commonly reported problems and most of these are self-limited illnesses such as diarrhea, respiratory infections, and skin disorders.
-
Of the non-tropical diseases, dermatosis including cutaneous larva migrans, insect bites, and bacterial infections are the most frequent skin problems in ill travelers who seek medical care.
-
Physicians with patients who travel should be familiar with potential travel-related dermatoses, infectious diseases, and environmental hazards specific to the area of patient travel, and physicians should also discuss general preventive measures against dermatoses, infectious diseases, and environmental hazards, including vaccinations.
-
Travelers should be educated and prepared for travel-health-related issues including: blood clot risks; the effects of high-altitude destinations; jet lag; acclimatization; potential contaminated water, food and beverages; prolonged exposure to the sun, insect or animal bites; transmission of sexually transmitted diseases; malaria prophylaxis; and traveler's diarrhea.
-
Evaluation of travelers with skin lesions or fevers (> 38°C) must include an extensive travel history with discussion of epidemiologic exposures along with a complete physical examination, and differential diagnosis will depend on travel location, length of stay, exposures, physical exam, skin lesions based on morphology (e.g., macule, papule, vesicle, and nodule), clinical presentation, and microbiological, serologic, and laboratory studies.
Introduction
Both tropical and non-tropical diseases are commonly reported problems among travelers to a developing country. More than 522 million people from developed countries travel overseas and an estimated 50–100 million people travel to developing countries. Approximately 8% of travelers to the developing world require medical care during or after travel. Most of the medical problems are self-limiting, such as diarrhea, respiratory infections, and skin disorders. Gastrointestinal symptoms, fever, and dermatologic complaints are among the most common reasons for returning travelers to visit doctors.
The GeoSentinel Global Surveillance System is the largest repository of provider-based data on travel-related illness from specialized travel or tropical-medicine clinics on six continents. From 2000 to 2010 the most common destinations from which travelers returned ill were sub-Saharan Africa (26%), Southeast Asia (17%), South–Central Asia (15%), and South America (10%). Among travelers evaluated in US GeoSentinel sites after returning ill from international travel, gastrointestinal diagnoses were the most frequent patient complaint (the incidence rate is 20–90% depending on the country visited). For all regions except Southeast Asia, parasite-induced diarrhea was more common than bacterial diarrhea among ill returned travelers; patients with bacterial diarrhea presented most commonly after travel to Southeast Asia. The most common febrile / systemic diagnosis was Plasmodium falciparum malaria, which constitutes an important risk in some frequently visited areas such as tropical Africa (where up to 95% of infections are due to P. falciparum ), Asia, and Latin America. Travelers with dengue presented more frequently than those with malaria for every region except sub-Saharan Africa and Central America. In the developing world, tuberculosis infection rates exceed those in the developed world, with prevalence reaching 35% in sub-Saharan Africa; contact with locals and greater length of stay increase infection risk. The finding that fewer than half of all patients reported having made a pretravel visit with a health-care provider indicates that a substantial portion of US travelers might not be following the Centers for Disease Control and Prevention (CDC) travelers' health recommendations for international travel.
Of the non-tropical diseases, dermatosis has been reported to be one of the three most common reasons (12–18%) that a traveler sought consultation from a physician. The largest case series of dermatologic problems in returned travelers from the GeoSentinel Surveillance Network between 1997 and 2006 showed that cutaneous larva migrans, insect bites, abscesses, and bacterial infections were the most frequent skin problems in ill travelers who sought medical care, making up over 30% of the 4742 diagnoses ( Table 2-1 ). Cutaneous larva migrans is the most common dermatologic disorder among patients presenting after travel to the Caribbean, whereas bacterial skin infections are more commonly found among patients returning from sub-Saharan Africa, South–Central Asia, or Southeast Asia ( Table 2-2 ). A retrospective analysis in travelers who acquired leishmaniasis within Europe diagnosed between 2000 and 2012 found 40 cases, the majority of which were acquired in Spain ( n = 20, 50%), Malta and Italy (each n = 7, 18%). In one prospective study of 269 consecutive patients (out of 7886) who presented to a French tropical disease unit during or after return from short-term travel over a 2-year period, 61% presented during travel and 39% after travel, and cutaneous larva migrans, pyodermas, and arthropod bites were among the top diagnoses. Physicians with patients who travel should be familiar with potential travel-related dermatoses, infectious diseases, and environmental hazards ( Table 2-3 ) specific to the area of travel. The physician should also discuss general preventive measures against dermatoses, infectious diseases, and environmental hazards, including vaccinations that are recommended to the traveler ( Tables 2-4 and 2-5 ). With an increasing number of children traveling internationally, dermatologic problems are among the leading health concerns affecting children during and after return from international travel. Most are mild and self-limited; children may be especially at risk for infections related to environmental exposures, arthropod-related problems, and animal bites.
TABLE 2-1
Skin Lesions in Returned Travelers, by Cause, from the Geosentinel Surveillance Network, 1997–2006
| Skin Lesion | Percentage of all Dermatological Diagnoses ( n = 4742) |
|---|---|
| Cutaneous larva migrans | 9.8 |
| Insect bite | 8.2 |
| Skin abscess | 7.7 |
| Superinfected insect bite | 6.8 |
| Allergic rash | 5.5 |
| Rash, unknown origin | 5.5 |
| Dog bite | 4.3 |
| Superficial fungal infection | 4.0 |
| Dengue | 3.4 |
| Leishmaniasis | 3.3 |
| Myiasis | 2.7 |
| Spotted-fever group rickettsiae | 1.5 |
| Scabies | 1.5 |
| Cellulitis | 1.5 |
TABLE 2-2
Top Dermatological Disorders from Geosentinel Sites According to Travel Region (1996–2004) *
| Dermatological disorder ( n = 2947) | All Regions | Caribbean | Central America | South America | Sub-Saharan Africa | South–Central Asia | Southeast Asia | Other or Multiple Regions |
|---|---|---|---|---|---|---|---|---|
| Insect bite with or without superinfection | 187 | 192 | 235 | 156 | 194 | 201 | 179 | 166 |
| Cutaneous larva migrans | 129 | 299 | 134 | 122 | 86 | 64 | 171 | 68 |
| Allergic rash or reaction | 113 | 148 | 128 | 97 | 105 | 112 | 93 | 132 |
| Skin abscess | 97 | 34 | 47 | 50 | 136 | 144 | 122 | 105 |
| Animal bite requiring rabies prophylaxis | 47 | 3 | 13 | 25 | 9 | 90 | 124 | 4 |
| Leishmaniasis | 38 | 0 | 64 | 143 | 14 | 19 | 0 | 36 |
| Myiasis | 35 | 0 | 101 | 100 | 40 | 0 | 0 | 14 |
TABLE 2-3
Potential Environmental Hazards Associated with Travel
| Environment | Factors and Potential Hazards to Consider |
|---|---|
| Terrain concerns | Traversing safely and maintaining orientation |
| Ability to find camping / safe shelter | |
| Exposure to air, wind, and solar radiation | |
| Exposure to animals or insects that may cause bites, injury, or infection | |
| Extreme temperatures / weather | Appropriate clothing for extreme temperatures (i.e., risk for hypothermia and heat stroke) and prevention of solar radiation exposure |
| Carry plenty of water to prevent dehydration | |
| Air | Existing pulmonary disease and airway hyperreactivity |
| Outdoor pollutants | |
| Indoor pollutants from fossil fuels / inadequate ventilation | |
| High altitudes and mountain sickness | |
| Water | Exposure, including ingestion of and direct contact with contaminated water with water-borne infectious diseases (e.g., schistosomiasis, leptospirosis), industrial waste dumping, chemical toxins |
| Exposure to aquatic life that may cause bites, injury, or infection |
TABLE 2-4
Routine and Recommended Commercially Available Vaccines for International Travel
| Vaccine | Antigenic form | Schedule / indications | Adverse effects |
|---|---|---|---|
| REQUIRED BY LAW | |||
| Yellow fever | Live-attenuated | One dose, 10 days before travel, with a booster every 10 years for those travelling to endemic areas | Fever (2–5%), headache, myalgia |
| ROUTINE | |||
| Diptheria–tetanus–pertussis | Inactivated | Three doses at 2, 4, and 6 months of age | Local reactions a , occasional risk of systemic reactions b |
| H. influenzae b | Capsular polysaccharide | Four doses at 2, 4, 6, and 12–15 months of age | Local reactions, occasional risk of systemic reactions |
| Influenza | Inactivated | One dose annually to travelers at increased risk of complications from influenza | Local reactions, occasional risk of systemic reaction |
| MMR | Live-attenuated | Two doses given to all persons born after 1956 | Fever (5–15%), rash (5%) joint pains (up to 40% in postpubertal females), local reactions (4–55%) |
| Poliomyelitis | Inactivated | Three doses: the first two are given at 4–8-week intervals; the third is given 6–12 months after the second, for non-vaccinated persons > 18 years and immunocompromised hosts at increased risk of exposure to poliovirus; a single booster dose is given prior to departure to certain countries | Local reactions |
| Tetanus–diphtheria | Adsorbed toxoids | Previously unvaccinated adults, 1 dose of Tdap followed by Td every 10 years for all adults | Local reactions, occasional systemic symptoms |
| Varicella | Live-attenuated | Two doses 4–8 weeks apart for persons without a history of varicella | Local reactions (25–30%), fever (10%), rash (8%) |
| Meningococcal (A, C, Y, W-135) | Polysaccharide | One dose, with a booster every 5 years for those traveling to Saudi Arabia or sub-Saharan meningococcal belt, Haj pilgrims, and those who have had a splenectomy | Local reactions, fever (2%) |
| RECOMMENDED | |||
| Encephalitis, Japanese (Ixiaro) | Inactivated | Two doses, 28 days apart, for those traveling to endemic areas (Asia and Southeast Asia) | Local reactions at injection site, systemic reactions (≥ 10%) |
| Hepatitis A | Inactivated | Two doses, 6–12 months apart for those traveling to all developing countries | Local reactions, systemic reactions (10%) |
| Hepatitis B | Recombinant-derived hepatitis B surface antigen | Three doses: two doses 1 month apart; third dose 5 months after dose 2 for health-care workers and persons in contact with blood, body fluids, or potentially contaminated medical instruments, and persons (i.e., expatriates) residing in areas of high endemicity for hepatitis B surface antigen Accelerated regimen: 0, 7, 21–30 days and 1 month 12 booster dose |
Local reactions (10–20%), systemic reactions (rare) |
| Combined hepatitis A / B | Inactivated hepatitis A / recombinant B surface antigen | Three doses: two doses 1 month apart; third dose 5 months after dose 2 as listed above Accelerated regimen: 0, 7, 21–30 days and 1 month 12 booster dose |
Local reactions, systemic reactions (rare) |
| Pneumococcal | Capsular polysaccharide | One dose for immunocompromised hosts, splenectomy, and the elderly | Local reactions, fever, rash, arthritis, serum sickness |
| 13-valent pneumococcal conjugate vaccine (Prevnar 13) | One dose for immunocompromised hosts, functional or anatomic asplenia, cerebrospinal fluid leak, cochlear implant, or immunocompetent adults aged ≥ 65 years with none of the above conditions | Local reactions, fever, rash arthritis, immune complex reactions | |
| Rabies | Inactivated | Three doses at days 0, 7, and 21 or 28 for travelers to areas for > 1 month where rabies risk is considerable: a booster may be given 1 year later | Local reactions (30%), systemic reactions, immune complex reactions (6%) |
| Typhoid | Live-attenuated (oral) | Four doses at days 0, 2, 4, 6 for travelers to endemic areas boost every 5 years | Gastrointestinal symptoms c , systemic reactions |
| Vi capsular polysaccharide | One dose and a booster every 2–3 years for travelers to endemic areas | Local reactions, systemic symptoms (rare) | |
a Local reactions include pain, swelling, and induration at site of injection.
b Systemic symptoms include fever, headaches, and malaise.
c Gastrointestinal symptoms include nausea, vomiting, and diarrhea.
TABLE 2-5
General Preventive Measures for the Traveler
| Altitude | All travelers should be encouraged to drink plenty of water, avoid caffeine and alcoholic beverages and tobacco, especially those who are climbing mountains and traveling to high-altitude destinations. Care should be taken not to participate in excessive exercise. Acetazolamide (Diamox) 125 mg BID or for convenience, 500 mg extentabs once daily may be taken 24 hours before ascent and for an additional 2 days after arrival at highest altitudes to prevent altitude-related problems |
| Dehydration | Similar to those traveling to high-altitude destinations, all travelers should be encouraged to drink plenty of water, and avoid caffeine and alcoholic beverages, especially in hot climates. The elderly should not depend on thirst as an indicator of sufficient fluid intake |
| Envenomation | As a general rule, travelers should not touch or walk on what cannot be seen, especially in areas that contain venomous animals (scorpions, snakes, spiders, or other biting animals). Travelers should wear long-sleeved shirts and pants (trousers) and avoid walking bare-footed. Boots are recommended, with pants tucked into them. Snake-bite kits containing antivenom against venomous animals should be readily available at local heath clinics and hospitals |
| Food | Food should be boiled, well cooked (i.e., served hot), or peeled as appropriate before eating. Uncooked or unfresh food or unpeeled fruits and vegetables should be completely avoided. Careful attention should be taken to ensure that prepared foods are not contaminated by dirty surfaces, water, or insects. Dairy products should be avoided unless it is known that they have been properly refrigerated, and hygienically prepared |
| Injuries | Travelers should purchase health insurance before traveling. Injuries commonly occur during travel and many accidents can be prevented with common sense. The most common causes of injury include motor vehicle accidents, violence and aggression, drowning, sports, animal attacks, and other accidents |
| Mosquitoes / other insects | Insect repellents containing diethyltoluamide (DEET) in a 20–35% concentration or picaridin-containing repellents in a 20–30% concentration; long-sleeved shirts and pants should be worn; shirts should be tucked in. Beds covered with mosquito nets, and preferably impregnated with permethrin repellent, should be encouraged in areas of infected mosquitoes, especially in malarial areas. Home windows and doors should also be well screened. Travelers should be advised to inspect themselves and their clothing for ticks, both during outdoor activity and at the end of the day. Ticks are detected more easily on light-colored or white clothing. Prompt removal of attached ticks can prevent some infections |
| Sexual activities | The avoidance of casual sexual encounters or, at the least, safe sex with barrier protection (i.e., condoms) should be emphasized, especially in areas with a high risk of contracting human immunodeficiency virus (HIV) and other sexually transmitted diseases and to provide birth control |
| Sun | Sufficient sun protection should be encouraged in travelers who spend time outdoors (e.g., hat, cap, sunglasses, and sunblock). Overly strenuous exercise should also be avoided. Sunscreen that blocks both UVA and UVB should be applied to the skin 30 min before sun exposure. Sunscreens with a protection factor of 30–40 are generally safe and are necessary to reliably block both UVA (skin damage and cancer risk) and UVB (sunburn) rays. Sunscreen should be reapplied every 1–3 h if swimming regardless if labelled “waterproof” |
| Walking | Covered footwear should be encouraged, especially in areas where contaminated soil may contain infected insects (e.g., sand flies), excrement, or worm larvae (e.g., hookworm and strongyloides). These areas should be avoided, especially by children |
| Water / beverages | In areas without clean drinking water, the use of bottled water, bottled beverages, and drinks prepared with boiling water (boiled for at least 3 min) should be encouraged. In these areas, ice cubes may represent a risk of infection owing to the unknown purity of the water. Chlorination, iodination, water filters, and disinfectants may also be used in water of unknown purity. Milk should be boiled before drinking. Generally, hot (> 50°C) tap water is relatively safer than cold tap water; although hot tap water can also be contaminated. Beverages mixed with water and non-carbonated drinks should be avoided. Coffee and tea made with boiled water and hot milk, beer, and wine are generally safe. |
Pretravel Advice
Pretravel Preparation
One month prior to travel, individuals with a preexisting medical condition, especially immunosuppressed travelers, should be examined by their primary care physician. Immunosuppressed travelers may be at increased risk of acquiring intestinal protozoa, including Giardia lamblia ( G. intestinalis , G. duodenalis ), Isospora belli , Entamoeba histolytica , and Cryptosporidium parvum . In addition, special precautions should be discussed with those patients with allergies, diabetes, or dermatologic, cardiac, pulmonary, or gastrointestinal disorders.
Individuals who are planning international travel will need individualized travel-related medical advice based on their duration of travel, season of travel, countries and regions that will be visited, planned activities during travel, and place of residence during travel. Even travel to westernized nations such as Europe is not without risk. Travel instructions should be prepared and include specific details concerning the prevention and care of common dermatoses (e.g., sunburn), infectious diseases (e.g., malaria and traveler's diarrhea), and injuries related to environmental hazards. The physician should also discuss vaccinations appropriate to the area of travel (see Table 2-4 ). Interestingly, worldwide GeoSentinel sites between 1997 and 2007 found that women were statistically significantly more likely to obtain pretravel advice (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.23–1.32) and that ill female travelers were less likely than ill male travelers to be hospitalized (OR, 0.45; 95% CI, 0.42–0.49).
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here