Each year, an estimated 8 million Americans visit countries where tropical disease are endemic. Before departing, however, many travelers do not obtain information on how to avoid diseases during their trip, and if they do receive advice on preventive measures, they may not follow the advice, or the information itself may be incorrect. [1,2]
Most of the diseases that affect travelers are well characterized, have known treats and are largely preventable. Adhering to preventive measures during travel will decrease the chance of acquiring travel will decrease the chance of acquiring travel-related illness.
General Guidelines
PRETRAVEL MEDICAL HISTORY
The travel who plants a two-year anthropological study of a remote tribe in the rain forests of equatorial Africa will obviously be exposed to different diseases than a tourist taking a world tour on a luxury cruise liner. Travelers will also have different preexisting illnesses, current medications and lifestyles. Because of these variations, a complete itenerary for each traveler should be reviewed, including expected activities that will relate to specific risks of disease in each location (Table 1).
IMMUNIZATIONS
A cornerstone of travel medicine is the prevention of infectious disease through proper vaccination, including up-to-date routine immunization, specific vaccines that will be required by any of the countries visited and which vaccines will be needed based on expected exposures. Vaccines are expensive and often are not covered by insurance unless a business trip is involved.
Tables 2 and 3 list schedules and indications for vaccines in adults and children. Special considerations for vaccines is pregnant or immunocompromised patients are listed in Table 4. For current travel-related vaccine requirements and recommendations, physicians are advised to consult Health Information for International Travel, an annual publication of the Centers for Disease Control. Another resource is the International Association for Medical Assistance to Travelers, which annually publishes a table of vaccines required by each country. Table 5 lists additional resources for physicians and travelers.
TRAVEL ON AIRLINES
Limiting air travel for certain patients may prevent in-fight medical emergencies. Studies of emergency medical care related to airline travel have found that in-flight emergencies occur at a rate of 4.5 to 26.0 incidents per 1 million passengers. [3,4] In one study, [3] 43 percent of in-flight medical emergencies were related to gastrointestinal, cardiac or respiratory problems.
All planes flying in the United States
[TABULAR DATA OMITTED]
are equipped with a medical kit containing basic emergency drugs, a stethoscope and a sphygmomanometer, which can be used by a physician rendering aid during an in-flight emergency. [4] Physicians must ask a crew member for acces to these kits. Oxygen is also available. The pilot has the authority to do whatever is needed to handle an emergency medical situation, including diverting the plane to a closer airport and flying at a lower altitude.
The Federal Aviation Administration requires commercial airlines at cruising altitudes to maintain a cabin pressurization equivalent to air pressure at an altitude of 8,000 ft (2,438m) or less. For travelers at risk of hypoxia, the lower oxygen partial pressure at this altitude may exacerbate underlying disease.
In patients who recently have had a sizeable myocardial infarction, airline travel should be prohibited for four to six weeks to prevent ischemia. Further recommendations should be made on the basis of exercise tolerance testing. [4] Patients who are recovering from surgery are at higher risk of wound complications due to air pressure differences between internal organs and the changing ambient cabin pressure. Guidelines regarding airline travel
[TABULAR DATA OMITTED]
TABLE 5
Resources for Physicians and TravelersResources for physicians
Centers for Disease Control. Health information
for international travel, 1990. Washington, D.C.: Government
Printing Office, 1990; DHHS publication
no. (CDC) 90-8280. (Updated yearly, this "yellow
book" contains information regarding the precautions
and diseases of major interest in travelers and has a
section detailing malaria risk and vaccine requirements
by country.)
International travel: vaccine requirements and
health advice. Geneva: World Health Organization,
1991. (Updated yearly, this publicationi lists countries
with their immunization requirements and malaria
risks. Contains tables of food-and water-borne diseases
with areas of risk and routes of transmission.)
ACP Task Force on Adult Immunization and
Infectious Diseases Society of America. Guide for adult
immunization. 2d ed. Philadelphia: American College
of Physicians, 1989. (This is a comprehensive listing
of vaccine recommendations with attention to the
patient with special considerations.)
Centers for Disease Control. Weekly summary of
health information for international travel. Atlanta:
U.S. Department of Health and Human Services.
(Updated weekly, the "blue sheet" tables countries with
endemic quarantinable diseases.)
Centers for Disease Control. Traveler's Information
Hotline: 404-332-4559. (This 24-hour hotline can be
accessed with a touch-tone telephone. Callers can
select any or all of a variety of messages.)
International Association for Medical Assistance
to Travelers, 417 Center St., Lewistown, NY 14092. Telephone:
716-754-4883. (Information on various
tropical diseases, table of vaccines recommended and
required by country, list of English-speaking
physicians overseas, mosquito net purchase.)
Resources for travelers
International SOS Assistance, P.O. Box 11568
Philadelphia, PA 19616. Telephone:
215-245-4707. (Information
on English-speaking physicians,
emergency mediuation assistance for
members.)
U.S. State Department, Overseas Citizens
Emergency Center, Washington, D.C.
Telephone: 202-647-5225. (Assistance
to Americans abroad in
medical, financial or legal difficulties.)
U.S. Embassy in destination country. (Often has
lists of English-speaking physicians, information on
available vaccines, reliable sources of medication.)
Interantional Association for Medical Assistance
to Travelers, 417 Center St., Lewistown, NY 14092. Telephone:
716-754-4883. (Information on various
tropical diseases, list of English-speaking physicians
overseas, mosquito net purchase.)
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