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Foreign Travel

By Christopher Sanford, MD, MPH, DTM&H, University of Washington;University of Washington

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Patient Education

About 1 in 30 people traveling abroad requires emergency care. Illness in a foreign country may involve significant difficulties. Many US insurance plans, including Medicare, are not valid in foreign countries; overseas hospitals often require a substantial cash deposit for nonresidents, regardless of insurance. Travel insurance plans, including some that arrange for emergency evacuation, are available through commercial agents, travel agencies, and some major credit card companies.

Directories listing English-speaking physicians in foreign countries, US consulates who may assist in obtaining emergency medical services, and information about foreign travel risks are available (see Table: Useful Contacts for People Traveling Abroad). Patients with serious disorders should consider pretravel contact or arrangements with an organization that offers medically supervised evacuation from foreign countries. Certain infections are common when traveling to certain areas.

Useful Contacts for People Traveling Abroad

Organization

Phone Numbers

Web Site

International Association for Medical Assistance to Travellers (IAMAT)

US: (716) 754-4883 (Niagara Falls, NY)

Canada: (519) 836-0102 (Guelph, Ontario); (416) 652-0137 (Toronto, Ontario)

Centers for Disease Control and Prevention (CDC)

US: Toll-free (800) CDC-INFO (800-232-4636)

TTY: (888) 232-6348 (Atlanta, GA)

CDC Malaria Hotline

US: (770) 488-7788 or (855) 856-4713; after hours, (770) 488-7100 (Atlanta, GA)

CDC Zika Pregnancy Hotline

US: (770) 488-7100 (Atlanta, GA)

US Department of State, Overseas Citizens Services

From US & Canada: (888) 407-4747

From Overseas: (202) 501-4444

(Washington, DC)

World Health Organization (WHO)

International: (+41 22) 791-2111

(Geneva, Switzerland)

Americas: (202) 974-3000

(Washington, DC)

Vaccinations

Some countries require specific vaccinations (see Table: Vaccines for International Travel*,†,‡). General travel and up-to-date immunization information is available from the Centers for Disease Control and Prevention (CDC) (Travelers’ Health: Vaccinations) and malaria chemoprophylaxis requirements are available from the CDC's malaria hotline (855-856-4713) and web site (Malaria and Travelers).

Vaccines for International Travel*,†,‡

Infection

Regions Where the Vaccine is Recommended

Comments

All low-income countries

2 doses 6 mo apart; complete protection for 6–12 mo after the 1st dose and for life after the 2nd dose

All low-income countries, particularly China

Recommended for extended-stay travelers and all health care workers

Year-round in the tropics

April through September in the Southern Hemisphere; October through April in the Northern Hemisphere

Recommended for all travelers > 6 mo of age

Japanese encephalitis

Rural areas in most of Asia and South Asia, particularly in areas with rice and pig farming

2 doses at least 28 days apart

Not recommended for pregnant women

Northern sub-Saharan Africa from Mali to Ethiopia (the meningitis belt)

Required for entry into Saudi Arabia during Hajj or Umrah

Throughout the world, especially in crowded living situations (eg, dormitories)

Risk higher in Africa during the dry season (December through June)

All countries, including US

Recommended for travelers at risk of animal bites (eg, rural campers, veterinarians, field workers, people living in remote areas)

Does not eliminate need for additional vaccinations after animal bite for added protection

Recommended during pregnancy only if risk of infection is high

All low-income countries, especially in South Asia (including India)

Pill form: 1 pill taken every other day for a total of 4 pills; protects for 5 yr

  • Not safe for pregnant women

Single injection form: Protects for 2 yr and is thought to be safer for pregnant women than the pill form of the vaccine.

Tropical South America

Tropical Africa

Although this infection is rare, proof of vaccination required for entry into many countries§

Not safe for pregnant women

Increased risk of adverse effects in the elderly§

One dose provides protection for life

*In addition to the listed vaccinations, vaccinations for measles, mumps, rubella, tetanus, diphtheria, polio, pneumococcal disease, and varicella should be up to date.

All recommendations are subject to change. For the latest recommendations, see the Centers for Disease Control and Prevention (www.cdc.gov or 800-CDC-INFO [800-232-4636]).

§WHO no longer recommends a booster dose of yellow fever vaccine every 10 yr; however, this recommendation has not yet reached all international points of entry. For patients vaccinated > 10 yr previously who are traveling to countries that may require proof of vaccination within 10 yr, providers should consider completing the waiver section of the International Certificate of Vaccination or Prophylaxis (the “Yellow Card”) to excuse elderly travelers from yellow fever vaccination (unless risk of exposure is high) rather than vaccinating, although there is theoretical risk of the waiver not being accepted at the border.

Injury and death

Road traffic accidents are the most frequent cause of death of nonelderly international travelers. Travelers should use seat belts in vehicles and a helmet when cycling. Travelers should avoid motorcycles and mopeds and avoid riding on bus roofs or in open truck beds. To prevent drowning (another common cause of death while abroad), travelers should avoid beaches with turbulent surf and avoid swimming after drinking alcoholic beverages.

Traveler’s diarrhea

Traveler’s diarrhea (TD) is the most common health problem among international travelers. TD is usually self-limited, typically resolving in 5 days; however, 3 to 10% of travelers with TD may have symptoms lasting > 2 wk, and up to 3% of travelers have TD lasting > 30 days. TD lasting < 1 wk requires no testing. For persistent TD, laboratory testing is done.

Self-initiated treatment is indicated for moderate to severe symptoms ( 3 unformed stools over 8 h), especially if vomiting, fever, abdominal cramps, or blood in the stool are present. Treatment is with an appropriate antibiotic (eg, a fluoroquinolone for most destinations, a macrolide such as azithromycin for Southeast Asia). Additional measures include loperamide (except in patients with fever, bloody stools, or abdominal pain and in children < 2 yr); replacement of fluids; and, in the elderly and small children, electrolytes (eg, oral rehydration solution).

Measures that may decrease the risk of TD include

  • Drinking and brushing teeth with bottled, filtered, boiled, or chlorinated water

  • Avoiding ice

  • Eating freshly prepared foods only if they have been heated to steaming temperatures

  • Eating only fruits and vegetables that travelers peel or shell themselves

  • Avoiding food from street vendors

  • Washing hands frequently

  • Avoiding all foods likely to have been exposed to flies

Prophylactic antibiotics (eg, fluoroquinolones) are effective in preventing diarrhea, but because of concerns about adverse effects and development of resistance, they should probably be reserved for immunocompromised patients.

Schistosomiasis

Schistosomiasis is common and is caused by exposure to fresh water in Africa, Southeast Asia, China, and eastern South America. Risk of schistosomiasis can be reduced by avoiding freshwater activities in areas where schistosomiasis is common.

Problems after returning home

The most common medical problem after travel is

  • Persistent traveler's diarrhea

The most common potentially serious diseases are

People can also acquire lice and scabies after being in crowded living conditions or places where hygienic measures are poor.

Some diseases become evident months after a traveler has returned home; a travel history with exposure risks is a useful diagnostic clue when patients present with a puzzling illness. The International Society of Travel Medicine (www.istm.org) and the American Society of Tropical Medicine and Hygiene (www.astmh.org) have lists of travel clinics on their web sites. Many of these clinics specialize in assisting travelers who are ill after their return home.

Resources In This Article

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