Addressing Medical Issues Before International Travel

Briefly noted: An highly detailed but concise review of “Medical Considerations before International Travel” DO Freedman et al. NEJM 2016; 375: 247-60.

Figure 1:

  • Risk assessment: medical history, prior travel experience, specific itinerary (region, season), type of accommodations, risk tolerance, financial challenges
  • Standard Interventions: Immunizations, Malaria prophylaxis (if risk), Traveler’s diarrhea strategy
  • Focused education: vectorborne diseases, altitude illness, thrombosis risk, STDs/bloodborne infections, transportation risks (eg no car seats), respiratory infections, medical kit, medical insurance

Tables:

  • Table 1: Practices for reducing disease risk (too many to summarize)
  • Table 2: Vaccine Recommendations
  • Table 3: Malaria Prophylaxis
  • Table 4: Recommendations based on location

Short Take Video Link (2 min): Travel Health and Safety

CDC: Traveler’s Health Website

Travel Resource: GeoSentinel Website

My take: This is a handy updated reference for international medical travel

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beach hut

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Guidelines for Traveler’s Diarrhea in Adults

Full text: Guidelines on Traveler’s diarrhea in Adults from ACG

Some of the recommendations:

  • -use of oral rehydration if severe diarrhea (especially elderly).  “Most individuals with acute diarrhea…can keep up with fluids and salt by consumption of water, juices, sports drinks, soups, and saltine crackers
  • -against use of probiotics for acute diarrhea except in cases of post antibiotic-associated diarrhea
  • -for use of bismuth subsalicylates to slow stool passage
  • -for use of adjunctive loperamide in patients receiving antibiotics for traveler’s diarrhea (to increase chance for cure)
  • -for antibiotics in traveler’s diarrhea “where the likelihood of bacterial pathogens is high enough to justify the potential side effects of antibiotics”
  • -against antibiotics for community-acquired diarrhea

Table 4 outlines antibiotic selection.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

If I have diarrhea after vacation…

I may want to remember this reference: “Enteropathogens and Chronic Illness in Returning Travelers” NEJM 2013; 368: 1817-25.

Some “fun facts:”

  • In 2007, more than 30 million Americans traveled to developing regions. ~8% traveling to these regions needed medical care during or after travel.  Gastrointestinal symptoms were present in more than 25% who sought medical care.
  • According to the GeoSentinel Surveillance Network (42 travel medicine sites), between 1996-2005, 65% of enteric infections were due to parasites, 31% bacteria, and 3% viral. (J Infect 2009; 59: 19-27) (Parasites typically have more long-lasting infections which should be considered in interpreting this data; in addition, some pathogens are more difficult to isolate.)
  • Six pathogens were most prevalent: Giardia, Campylobacter, Entamoeba histolytica, Shigella, Stronglyoides, and Salmonella.

In addition to an enteric pathogen color-coded prevalence map, the article has a useful table identifying areas at high risk, mode of transmission, incubation period, common symptoms, recommended diagnostic tests and treatments.

To minimize the impact of these enteropathogens, physicians can help prepare travelers with appropriate vaccinations, malaria chemoprophylaxis (if needed), and effective anti-bacterial drugs for self-treatment should symptoms develop.

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Can I go?

How safe is it for IBD patients to travel?  A retrospective study from adult patients with IBD (n=222) compared with controls (n=224) indicates that the risk of travel for IBD patients is only a little more than the general population (Clin Gastroenterol Hepatol 2012; 10: 160-65).

IBD patients with an average age of 37 years had infections during 15% of trips compared with 11% for controls.  92% of infections were due to enteric disease. However, this increased risk was identified in travel to industrialized countries not to developing countries.  This likely indicates that much of the increase is due to IBD flares rather than increased susceptibility to infections.  Nearly half of patients in this study were receiving immunosuppression: immunomodulators 29%, biologics 5%, dual therapy 6%, or corticosteroids 4%.  Not surprisingly, patients with increased IBD flares (OR 1.9) and IBD-related hospitalizations (OR 3.5) represent a group with higher risk for illness.  Most illnesses were mild & self-resolving in a few days.  Only five IBD patients required hospitalization for the following: dehydration, perianal abscess, malaria, flare, & small bowel obstruction).

Additional references:

  • -Clin Gastro & Hep 2010; 8: 490. Review of traveler’s diarrhea. Recs pepto if emesis, rifaximin or cipro or azithromycin if watery diarrhea, azithromycin if bloody diarrhea
  • -Clin Gastro & Hep 2007; 5: 451. Use of rifaximin (200mg tid)-loperamide provided rapid improvement.
  • -NEJM 2006; 354; 119. Traveler’s diarrhea.
  • -NEJM 2002; 347: 505.  Illness after travel.
  • -www.cdc.gov/travel/index.htm