In the last decade, a major increase in international travel has been seen. Each year, more than a billion international tourist arrivals are counted. 15-65% of those experience some sickness and 5-15% need to seek medical care. About 1/100.000 travelers die during their journey. Of travel related deaths 50% are due to accidents (car, drowning, …), 40% due to a cardiovascular event, 9% secondary to neoplasms or other underlying diseases and only 1% due to an infectious cause.
A pre-travel consultation is a perfect example of preventive medicine. It is more than delivering vaccinations and prescribing antimalarial pills. The aim of a pre-travel consultation is to inform the traveler about potential health risks while travelling and to discuss possible interventions (like vaccinations, antimalarial pills).
Taking a glance at the above figures, the importance of safe travel vehicles with seat-belts cannot be underestimated: this advice might be much more cost-effective than any pre-travel vaccine given. Making sure that people with underlying conditions travel in their best possible health-status is also of major importance.
Possible health risks depend on several factors:
- The traveler: pre-existing conditions, risk behavior, vulnerable travelers like the elderly, pregnant and young children
- Type of travel: expat, backpacking, cruise…
- Special activities: diving, high altitude, biking…
Each pre-travel consultation should include:
- Discussion about pre-existing conditions: is the traveler fit enough for this travel? What about travel insurance? Especially in case of vulnerable travelers, the risks of traveling should be discussed. In any case, it is always a shared decision, but sometimes, the traveler may want to postpone the travel or to change the destination after being informed. E.g. people who have a contra-indication for yellow fever vaccine, pregnant women may not go to a country with an ongoing Zika virus outbreak.
- Prevention of travel related infectious diseases
- Malaria risk: is there malaria, which precautions to take? Only mosquito bite prevention or also prophylactic antimalarial drugs? Continuous malaria pills or only during shorter periods (“on demand”) when entering a higher risk region (e.g. South-East Asia)? No preventive measure protects 100%, so in case of fever up to 3 months after return, malaria needs to be ruled out.
- Risk for other diseases transmitted by mosquitos? Think of dengue, chikungunya, zika, Japanese encephalitis…?
- Travelers diarrhea: how to prevent, what to do when diarrhea occurs, whether or not to prescribe antibiotics, when and how to take them?
- Sexual transmittable diseases: always to be discussed when people travel without their partner. Take condoms! Even though it is generally not “planned”, many travelers have sex occasionally while traveling.
- Other infectious diseases: schistosomiases, larva migrans, tunga penetrans, …
- Mandatory vaccines?
- Yellow fever: this vaccine is subject of the International Health Regulations. Proof of vaccination – written down in the” yellow vaccination card”- can be a requirement for entry in some countries. Since 1/7/2016 the vaccination is lifelong valid, however for some people the duration of protection might not be lifelong (eg HIV infected patients, pregnant women, young children, …), but there are no international accepted criteria about these “exceptions”.
- Meningitis ACW135Y (pilgrimage to Mekka)
- Polio in Afghanistan and Pakistan if staying longer than 4 weeks
- Are standard vaccinations updated?
- tetanus-diphtheria-whooping cough;
- hepatitis B when risk behavior or social volunteer work or medical sector
- What about flu vaccination in vulnerable travelers?
- Travel related vaccines:
- Hepatitis A,
- Japanese encephalitis
- Tick borne encephalitis
- BCG: seldom necessary, but sometimes mandatory in young children of expats (in e.g French Lycee or American Lycee). In some European countries, this vaccine is not available anymore.
Guidelines: Guidelines can change in each country; the Belgian Guidelines can be found on the website of Institute of Tropical Medicine: www.itg.be.
ALWAYS USE THE LATEST UPDATE!!! ESPECIALLY YELLOW FEVER RECOMMANDATIONS AND RECOMMANDATIONS ABOUT MALARIA CHANGE!
WHO guidelines of travel medicine: http://www.who.int/ith/en/
CDC yellow book (cave malaria guidelines are very “American” and in Europe we prescribe usually less frequently anti-malarial pills): http://wwwnc.cdc.gov/travel/yellowbook/2016/table-of-contents
Polio recommendations: http://www.polioeradication.org/
Travel medicine: Travel medicine 3rd edition, Keystone
General, information about vaccines: Vaccines, 6th edition, Plotkins
Info about travel equipment, survival: Field guide to wilderness medicine, P S Auerbach, 4th edition
Ongoing epidemics: Promed: http://www.promedmail.org/, CDC, ECDC