International Travel by Persons With Medical Comorbidities: Understanding Risks and Providing Advice

doi:10.1016/j.mayocp.2013.07.018

Mayo Clinic Proceedings

Volume 88, Issue 11, November 2013, Pages 1231-1240

https://doi.org/10.1016/j.mayocp.2013.07.018 Get rights and content

Abstract

Objective

To describe the medical conditions, travel plans, counseling, and medications prescribed for high-risk international travelers.

Patients and Methods

This cross-sectional study was conducted from March 1, 2008, through July 31, 2010, in 5 clinics in the greater Boston area. We assessed all travelers seen for pretravel care and compared demographic characteristics, travel plans, pretravel counseling, and interventions for healthy and high-risk travelers (as defined by medical history or pregnancy).

Results

Of 15,440 travelers, 2769 (17.9%) were high-risk; 644 of 2769 (23.3%) were immunocompromised travelers, 2056 (74.3%) had medical comorbidities, and 69 (2.5%) were pregnant women. The median age of high-risk travelers was 47 years compared with 32 years for healthy travelers (P=.0001). High-risk travelers visited the clinic a median of 25 days (range, 10-44 days) before departure. Overall, 2562 (93.9%) of high-risk travelers visited countries with medium or high risk of typhoid fever, 2340 (85.7%) visited malaria-risk countries, and 624 (22.8%) visited yellow fever–endemic countries. Of travelers to yellow fever–endemic countries, 8 of 23 (34.8%) pregnant women and 64 of 144 (44.4%) immunocompromised travelers received yellow fever vaccine. Of eligible high-risk travelers, 11 of 76 (14.5%) received a pneumococcal vaccine, 213 of 640 (33.3%) influenza vaccine, and 956 of 2681 (35.7%) either tetanus-diphtheria or tetanus-diphtheria-pertussis vaccine.

Conclusion

High-risk travelers made up nearly 20% of patients in these travel clinics, and they mostly traveled to destinations with malaria and typhoid risk. For health care professionals caring for travelers with underlying medical problems, providing appropriate travel counseling and making vaccine decisions, such as for yellow fever, are complex. Travelers with complicated medical histories may warrant evaluation by an experienced travel medicine specialist.

Section snippets

Network and Study Sites

The BATMN is a research collaboration of 5 travel medicine clinics in the greater Boston area. They represent a mix of urban and suburban sites in university-affiliated and independent settings.

Data Collection

For all travelers seen at each site from March 1, 2008, through July 31, 2010, we collected de-identified information on demographic characteristics, medical history, travel plans, provider recommendations for vaccines and medications, and pretravel counseling. Pretravel counseling topics were selected

Demographic Characteristics

Of the 15,440 BATMN travelers, 12,671 (82.1%) were healthy and 2769 (17.9%) were high-risk travelers (Table 1). Of the high-risk travelers, 644 (23.3%) were immunocompromised travelers, 2056 (74.3%) had medical comorbidities, and 69 (2.5%) were pregnant women. Compared with healthy travelers (43.5%), persons with medical comorbidities were significantly more likely to be men (46.1%; P=.03) whereas immunocompromised persons were significantly less likely (38.7%; P=.02). High-risk travelers were

Discussion

Information on numbers and characteristics of persons going overseas has not been as readily available as reports of disease in returning travelers.25, 26, 27, 28, 29, 30, 31, 32 We report one of the first studies to provide such information on high-risk persons in which travel and demographic characteristics are stratified by traveler health status.³² We found that high-risk travelers accounted for almost 1 in 5 persons seeking pretravel advice and that these travelers were visiting countries

Conclusion

High-risk travelers made up nearly 20% of patients in the travel clinics participating in this study, and they mostly traveled to destinations with malaria and typhoid risk. For most of them, decisions about live virus vaccines were required that involved potentially complex decisions about whether these vaccines were appropriate given their medical conditions. Referral to a travel clinic 4 to 6 weeks before travel is a way to address the specialized needs for these travelers. Visits must be of

Acknowledgments

We gratefully acknowledge the contributions of Melissa Pfaff, MPH, and Julie Trivedi, MD, for their assistance with data analysis; Manveen Bhussar, MD, Millie Sosa, BA, Deb Gannon, MS, Rebecca Dufur, JD, Erika Gleva, PA-C, and Natasha Soodoo, MA, for their assistance with data collection and data entry; and Rachel Kubiak, MPH, for assistance with manuscript preparation.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of

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The pretravel management of the international traveler should be based on risk management principles. Prevention strategies and medical interventions should be based on the itinerary, preexisting health factors, and behaviors that are unique to the traveler. A structured approach to the patient interaction provides a general framework for an efficient consultation. Vaccine-preventable diseases play an important role in travel-related illnesses, and their impact is not restricted to exotic diseases in developing countries. Therefore, an immunization encounter before travel is an ideal time to update all age-appropriate immunizations as well as providing protection against diseases that pose additional risk to travelers that may be delineated by their destinations or activities. This review focuses on indications for each travel-related vaccine together with a structured synthesis and graphics that show the geographic distribution of major travel-related diseases and highlight particularly high-risk destinations and behaviors. Dosing, route of administration, need for boosters, and possible accelerated regimens for vaccines administered prior to travel are presented. Different underlying illnesses and medications produce different levels of immunocompromise, and there is much unknown in this discipline. Recommendations regarding vaccination of immunocompromised travelers have less of an evidence base than for other categories of travelers. The review presents a structured synthesis of issues pertinent to considerations for 5 special populations of traveler: child traveler, pregnant traveler, severely immunocompromised traveler, HIV-infected traveler, and traveler with other chronic underlying disease including asplenia, diabetes, and chronic liver disease.
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Increasingly, travelers with varying levels of immunocompromise travel to regions of the world with significant risk for infection. This chapter addresses how to best advise such travelers. For some individuals, travel to destinations with yellow fever may present a significant risk. We generally avoid using live vaccines in the more significantly immunocompromised and offer inactivated vaccinations to gain the best protection possible. Individuals with immune defects due to asplenia, human immunodeficiency virus (HIV), immunomodulatory agents, and bone marrow or solid organ transplantation can prepare for safe travel with vaccinations, education, and self-treatment options that prevent or avoid drug interactions. This chapter distinguishes the “must-nots” from the “musts” for safe journeys for immunocompromised hosts. Careful, compassionate discussions can help immunocompromised patients weigh their options and make informed choices on how to pursue their travel dreams.
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Children travel with their families, including children with chronic illness. We know that adults with chronic illness who travel are more likely than their healthy peers to become sick while traveling. A review of the literature was undertaken to identify what is known about traveling with children with special health care needs and to identify gaps in our knowledge.
An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel, air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food allergies, Attention Deficit Hyperactivity Disorder (ADHD), and seizures. The search was limited to years 2000-2019. A secondary search of relevant articles was conducted using the reference sections of articles identified in the primary search.
185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized and reviewed by organ systems. The articles were primarily descriptive and did not lend themselves to a systematic review.
Children traveling with chronic and complex health conditions are a heterogeneous group of vulnerable travelers. Closing the knowledge gap about how to best help these travelers requires a multipronged approach. Research is urgently needed to identify best practices for five of the most common chronic childhood diseases: asthma, depression, ADHD, food allergies and autism. For less common illnesses, ones typically cared for in specialty clinics, expert consensus opinion and multi-center studies are needed. Families and disease advocacy societies should be included in the research as they may have already identified the most pressing travel-related health concerns and solutions for these problems.
Travel-related health problems in the immunocompromised traveller: An exploratory study
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To evaluate self-reported travel-related health problems, antibiotic use, medical visits and risk behaviours in ICTs and controls.
We conducted a questionnaire-based observational study with pilot character. We recruited participants from a (medical) pre-travel clinic. Telephone interviews were conducted 2–4 weeks post-travelling, applying a structured questionnaire.
We included 30 ICTs and 30 controls. More ICTs than controls reported travel-related health problems, antibiotic use and medical visits, although not statistically significant. Travellers' diarrhoea appeared to be more severe in ICTs. Furthermore one ICT was hospitalized post-travel due to pneumonia. Of ICTs, 2/30 (7%) used on demand antibiotics while not indicated (according to the protocol of the Dutch national coordinating centre for travel advice or prescribed by a physician). Reversely, 6/30 (20%) did not use on demand antibiotics while actually indicated according to this protocol.
Our findings substantiate the recommendation of on demand antibiotics. However, ICTs did often not use on demand antibiotics correctly; they therefore need very careful instructions.
The Ready-To-Go Questionnaire predicts health outcomes during travel: a smartphone application-based analysis
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View all citing articles on Scopus

: Grant Support: This study was funded by a cooperative agreement between the CDC and Boston Medical Center (U19C100508-01).

: Potential Competing Interests: Dr Barnett has received research funding from Intercell, Cerexa, and Sanofi Pasteur and royalties from Elsevier. Dr Chen has received honoraria from Thompson Media LLC and Shoreland, Inc, and research funding from Xcellerex Inc.

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Original articleInternational Travel by Persons With Medical Comorbidities: Understanding Risks and Providing Advice

Abstract

Objective

Patients and Methods

Results

Conclusion

Section snippets

Network and Study Sites

Data Collection

Demographic Characteristics

Discussion

Conclusion

Acknowledgments

Infect Dis Clin North Am

J Infect

Travel Med Infect Dis

Trans R Soc Trop Med Hyg

U.S. Travel Abroad Declined Two Percent in 2010

Health advice and immunizations for travelers

N Engl J Med

Advising the traveller

Medicine

Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey

J Travel Med

Travel health knowledge, attitudes and practices among United States travelers

J Travel Med

Vaccination and immunization against travel-related diseases in immunocompromised hosts

Expert Rev Vaccines

Travel patterns and risk behavior in solid organ transplant recipients

J Travel Med

Travels with HIV: the compliance and health of HIV-infected adults who travel

Int J STD AIDS

HIV infection and travel: pretravel recommendations and health-related risks

Top HIV Med

Traveling after heart transplantation

Clin Transplant

Travel immunization update for older adults

J Gerontol Nurs

International travel and exposure risks in solid-organ transplant recipients

Transplantation

Health preparations and travel-related morbidity of kidney transplant recipients traveling to developing countries

Clin Transplant

Health risks of travelers with medical conditions—a retrospective analysis

J Travel Med

Symptoms of infectious diseases in immunocompromised travelers: a prospective study with matched controls

J Travel Med

Travel patterns and risk behaviour of HIV-positive people travelling internationally

CMAJ

The practice of travel medicine: guidelines by the Infectious Diseases Society of America

Clin Infect Dis

Travel vaccines and elderly persons: review of vaccines available in the United States

Clin Infect Dis

Original article
International Travel by Persons With Medical Comorbidities: Understanding Risks and Providing Advice