Travel Medicine

Vaccines, Prophylaxis, and Self-Treatment

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“The world is a book and those who do not travel read only one page,” said St Augustine. There are so many held in captivity in our world – some by culture, some by tyranny, some by poverty, and some by limitations of their own choices. With observation and experience of the world around us comes great understanding. The growth we acquire by eyewitness of another culture, person, and geography broadens our abilities. As we move to new and different experiences and contacts, we write more pages in our book, deepen empathy, perspective, and tolerance. Where would we be if travelers such as Christopher Columbus and Amerigo Vespucci had never set sail? These are some of the reasons I choose to provide Travel Medicine services.

The patient who seeks pre-travel screening should be clear on their itinerary and purpose of travel. It is important for the provider to be up-to-date on outbreaks and any worldwide epidemics, restrictions, or military uprisings. Prophylaxis and vaccinations are specific to the area of travel and activities. For example, those traveling to an endemic area for Japanese Encephalitis Virus need the costly and multiple injection vaccine series if they would be staying >1 month and/or with significant exposure to pigs and livestock. Travelers to areas with outbreaks in infectious diseases, such as H5N1/H7N9 Avian Influenza, Ebola virus, Dengue or SARS, need to be counseled on the risk, protection, and avoidance. Rarely, travel should be postponed or reconsidered. In addition to this, a patient must share all their health problems and information, including if they could be pregnant, have immunodeficiency, take medications, and any concerns with the travel medicine specialist. This will assist in avoiding medical complications, drug interactions, and behaviors that may have risk associated.

There are three areas all travelers will need addressed. One is vaccinations. All vaccines need to be updated (TDAP, Pneumovax, Influenza, and one adult Polio vaccine). Special considerations are necessary if the traveler has not received all the vaccine primary series as a child. If the traveler is going to an area with Meningiococus or Yellow Fever, these vaccines should be administered. Most will need Typhoid (I prefer the oral live attenuated vaccine for better efficacy and longer duration of immunity) and Hepatitis A series. Hepatitis B is only recommended if potential blood or sexual exposure is anticipated. Other occasional vaccines are tied to the traveler’s specific risk exposures.

The second area to address is prophylaxis, where the major issue is Malaria. The prescriber must discern resistance to anti-malarial therapy in the region(s) of travel, the patient’s ability to comply with any one regimen, medical co-morbidities, age, drug interactions, and cost. For example, an individual with even mild arrhythmias should take caution in using Mefloquine. It would not be wise to dose a medication once a week if the patient cannot keep up with that dosing regimen. No regimen is useful if the patient cannot afford the medication. In some cases, episodic treatment, where minimal exposure is anticipated and the traveler can comply with insect repellent use, is appropriate. There is more that can be transmitted transdermally than just Malaria and Yellow Fever. Therefore, clear instructions on insect repellent use and mosquito netting for sleep is necessary where indicated. Further considerations, such as altitude sickness for selected patients traveling to high elevations are individualized.

The third consideration is self-treatment for illnesses that may frequently develop during travel. Most patients are taking a relatively short trip spanning a week or two. If a simple infection of the lungs, urine, or skin develops, a significant amount of travel days could be spent seeking healthcare in a foreign country. Sending travelers with options to self-treat a mild infection is very reasonable. Additionally, information about traveler’s diarrhea, toxic megacolon, how to self-treat with/without Pepto-Bismol and/or antibiotics should be given in written format to be available at the time of need. It is difficult to remember the great amount of information given to a traveler in this setting, making simple written instructions very helpful. Sleep agents, anti-histamines, anti-diarrheal agents, and motion sickness medications are examples of other self-treatment options to consider. The practice of Travel Medicine is complicated, must be individualized, and requires active effort to be aware of emerging information worldwide.

Why See a Travel Medicine Specialist?

When the traveler is seen by a skilled Travel Medicine specialist for pre-travel evaluation, there are very few issues that develop upon their return. Although many do not understand why they should see a specialist before traveling, after their visit the benefits become very clear. Travelers to my office watch a five-minute video revealing the many infectious diseases they can be exposed to throughout the world. Meeting with the physician for further specific counseling and screening allows questions and concerns to be addressed. As a Yellow Fever Vaccine Center, my office is able to move travelers quickly through their needed vaccinations and have prophylaxis and self-treatment medications sent to their pharmacy of choice. Once established, there is ease and accessibility for any posttravel problems.

I am fortunate to have established my practice in Bowling Green, Kentucky. As an honor graduate of Western Kentucky University, I always held the area as an ideal prospect for residence. My husband and I met at WKU and trained in medicine together. As the time approached to choose a job, we realized that this region was totally underserved for our specialties – endocrinology and infectious diseases. Recently, Bowling Green has been listed as one of the top places ideal for retirement. After 25 years here, that is an added bonus.

Over the past 25 years in south central Kentucky, the need for a Travel Medicine specialist has not waned. In the past five years, I have seen many more travelers, approximating a four-fold increase. Certainly, the economy has become global, the people integrated, and the world our pages to turn.

THE PRACTICE OF TRAVEL MEDICINE IS COMPLICATED, MUST BE INDIVIDUALIZED, AND REQUIRES ACTIVE EFFORT TO BE AWARE OF EMERGING INFORMATION WORLDWIDE.

Rebecca D. Shadowen, MD, FSHEA, is with Medical Specialists of Central Kentucky and is the director of Infection Control and the Hospital Epidemiologist at the Medical Center and Greenview Regional Hosptial in Bowling Green, Kentucky. She is board certified in internal medicine and infectious diseases and specializes in infectious diseases, healthcare epidemiology, and travel medicine.