By the Way . . . the Last-Minute International Traveler

Abstract

Evidence has consistently revealed international travelers are increasing in numbers every year as more folks travel for business, pleasure, humanitarian reasons, and medical tourism. Clinicians who consistently counsel travelers are well acquainted with the last-minute traveler who would benefit from a travel health assessment, vaccine administration, and health and safety information to manage travel-related issues while en route and upon arrival. Instruction in travel emergencies and packing tips, with advice to be able to address common travel issues associated health matters, are important strategies for the traveler to understand and better navigate his or her journey. To also serve the traveler are two excellent mobile apps from the Centers for Disease Control, free to the traveler, that are designed to contain travel and vaccine documents and to provide guidance in choosing foods and beverages while abroad. The occupational health nurse’s role is to support and reassure the traveler. Even at the last minute, travel health risks can be significantly reduced by the traveler obtaining vaccines and observing healthy practices.

Case scenario: An otherwise healthy 64-year-old American male employee presented to the occupational health office to let the staff know he would be out of the office on vacation. In a “by the way” discussion, he disclosed he was leaving in the morning for Belize with his wife and teenage daughter for a week of snorkeling, fishing, and visiting the Mayan ruins. When asked if he and his family had scheduled a travel consult, he replied, “no, what for? We are staying in a 5 star resort.”

Introduction

Last-minute travelers may include folks who are leaving on short notice (such as some business travelers or immigrants returning home for a family emergency) or may refer to people who have planned a trip for some time but postponed seeking pretravel care (Rosselot, 2017). In this case scenario, the production worker was not part of the corporate association that would proactively identify him as a business traveler and recommend him for a travel health assessment. Furthermore, this worker did not consider that a travel health consultation would be of any benefit. He presumed the more expensive the trip, coupled with the superior (5 star) rating of accommodations, the more adequate the defense for deterring disease for his family and himself.

According to the Centers for Disease Control and Prevention (CDC; 2017), Americans made more than 73 million trips internationally in 2015 and that number is expected to increase as more folks are traveling for business, pleasure, volunteerism, health care, or to visit friends and relatives. Nearly 1 billion people worldwide traveled internationally in 2013, and approximately 50% became ill or were injured while overseas, and some required medical care upon arriving home (Keystone, Freedman, Kozarsky, Connor, & Northdurft, 2013). However, being aware of the hazards and the strategies to reduce or eliminate the risks allows travelers to remain healthy abroad and to fully enjoy the pleasures of travel.

Ideally, a travel health consult should be scheduled 4 to 6 weeks before the journey, so there is adequate time for education and vaccinations. A pretravel consultation encompasses an individual risk assessment focusing on the traveler’s health and history of previous travel, future travel plans, medical and surgical history, last eye and dental examinations, and current medications. The traveler should be asked about routine and travel vaccines and previous experience with illnesses related to travel (Chen, Hochberg, & Magill, 2017).

Vaccines

All travelers should be current on routine vaccines, including influenza, and last-minute travelers particularly should be encouraged to obtain hepatitis A, typhoid, polio (inactivated), cholera, and quadrivalent (ACWY) meningococcal meningitis vaccines depending on their destination as evidence indicates there may be partial protection, even if the dose is given as the traveler steps onto the plane (Rosselot, 2017). Malaria risk can also be mitigated at the last minute as several location-appropriate antimalarial drugs can be initiated as late as the day before the journey (Arguin & Tan, 2017). Special care should be provided to those who are planning a pregnancy or are currently pregnant or breastfeeding as vaccines and malaria prophylaxis may need to be managed differently and airlines and cruise ships may impose restrictions on how late in the pregnancy a woman is permitted to travel (Morof & Carroll, 2017). The occupational health nurse can refer to the CDC’s website for guidance on vaccination requirements for their traveling workers at their “Traveler’s Health” webpage: https://wwwnc.cdc.gov/travel/page/clinician-information-center.

En Route

Travelers who are at risk of deep-vein thrombosis (over 40 years; body mass index [BMI] ⩾ 30 kg/m²; taking hormonal contraceptives or hormone replacement therapy; currently pregnant or in the postpartum period; family or personal history of deep-vein thrombosis; active cancer; serious heart, lung, or bowel disease; and recent surgery, hospitalization, trauma, or limited mobility) and traveling for long distances should be cautioned to select an aisle seat on the aircraft when possible to facilitate mobility in the cabin (Reyes, Beckman, & Abe, 2017). In addition, they should be encouraged to perform stretching exercises of the lower legs and toes hourly while seated and wear below-knee graduated compression stockings (GCS) providing 15 to 30 mm Hg of pressure at the ankle.

Travel Safety

Many of the health risks encountered internationally are not vaccine or medication avertable. Clinician time is well spent on educating travelers regarding personal safety, including motor vehicle accidents, the leading cause of injury and death in travelers (Steffen & Grieve, 2013). Travelers should be cautioned never to drink and drive, to always wear seat belts, and to don helmets if riding a bicycle or motorcycle. If hiring a local driver, choose a driver authorized by the hotel. Remind travelers it is essential to look carefully both ways when crossing the street as traffic patterns often flow in the opposite direction from what is familiar at home. Avoid night driving as emergency response may be limited or unavailable.

Instruction on water safety is crucial. Factors contributing to the risk of drowning include lack of knowledge with local water currents and locales, inability to swim, and the absence of lifeguards on duty. Rip currents can be especially perilous, as are sea animals such as urchins, jellyfish, coral, and marine lice. Alcohol use is also considered a contributing factor to both drowning and boating mishaps (Sleet, Ederer, & Ballesteros, 2017). Caution travelers to avoid swimming alone or in unfamiliar waters. Travelers should also be reminded to wear life jackets during water recreational activities and swim with a buddy. Fresh water swimming should be avoided as parasitic infections may result.

Food and beverage consumption can add to the risk for illness to travelers. Raw foods, such as meat and seafood, pose the greatest threat and should be avoided. In areas where sanitation is questionable, salads, uncooked vegetables, raw fruits that cannot be peeled, unpasteurized fruit juices, and dairy products should be omitted, unless they can be washed under safe running water. Boiling water–prepared coffee and tea are considered safe if served hot. Factory-sealed cans or bottles are also acceptable, but if stored in ice water, the water should be wiped away before drinking the beverage. Bottled water should be used for drinking, preparing, and cooking food and brushing teeth (Griffin, Hlavsa, & Yoder, 2017).

The chief medication for prevention of traveler’s diarrhea (TD) is bismuth subsalicylate, which is the active ingredient in Pepto-Bismol and Kaopectate. Connor (2017) noted either medication (taken daily as either 2 oz. of liquid or 2 chewable tablets 4 times per day) lessened the incidence of TD by approximately 50%. Connor also indicated that prophylactic antibiotics are not recommended for most travelers as they do not protect against nonbacterial pathogens. In addition, antibiotics can remove protective microflora from the bowel, which can increase the risk of infection from resistant bacterial pathogens.

An additional adjunct to assist the traveling worker in prevention of TD, and available at no cost, is a valuable online application (app) developed by the CDC, “Can I Eat This?” When downloaded to a mobile device, a traveler can get on the spot advice about the safety of food and beverages worldwide.

Insect precautions and sun protection are essential. If applying both sunscreen and insect repellant, apply the sunscreen first, followed by insect repellant containing DEET or picardin. Instructing workers to avoid animals is critical as even a small bite or scratch can be a portal for rabies and last-minute travelers do not meet the 21-day accelerated rabies prophylaxis schedule (Torresi & Kollaritsch, 2013). Immediate medical care is necessary to treat any animal inflicted wound, even if it appears insignificant. Travelers should be reminded not to carry food in their backpacks as animals, especially monkeys, can become aggressive when seeking a snack.

Travel Emergencies and Insurance

Information on trip and medical evacuation insurance should be provided, with options to purchase this online, with little advanced notice required. These policies ensure air transportation to United States standards of medical care. The occupational health nurse can inform travelers about the State Department’s Smart Traveler Enrollment Program (STEP; https://step.state.gov/step). Registering for this free service allows U.S. citizens and nationals traveling and living abroad to enroll their trip with the nearest U.S. Embassy or Consulate and receive important information from the embassy in an emergency, whether natural disaster, civil unrest, or family situation. A second CDC app called “TravWell” can be downloaded to a mobile device before leaving home, storing the itinerary, passport, and important travel documents, should they become lost or stolen. TravWell will also store the traveler’s list of medications and immunizations.

Packing Tips

Finally, the occupational health nurse ought to remind travelers of the basics including frequent hand washing or using an alcohol-based sanitizer; packing any prescription medications plus over-the-counter medications (e.g., aspirin or acetaminophen, decongestant, eye drops, antidiarrheal such as Pepto-Bismol, antacid of choice, hydrocortisone cream, Benadryl to treat congestion and assist with sleep) in carry-on luggage. Travelers should also include Band-Aids, an extra pair of glasses or contact lenses, and a plastic bag that can be filled with ice to treat a sprain. Green tea bags and bouillon packets are also useful for rehydration if needed. An inexpensive rubber door stop inserted on the inside of the hotel room door can provide an additional measure of security.

The occupational health nurse’s role is to support and reassure the traveler. Even at the last minute, travel health risks can be significantly reduced by the traveler observing healthy practices. Ultimately, the decision to receive a vaccine is solely in the hands of the traveler, similar to individuals who chose (or not!) to take their blood pressure or cholesterol medicines. Nevertheless, the opportunity to provide guidance during a teachable moment is key.

Follow-up: This worker declined vaccinations but did accept the advice regarding travel health. This employee was advised to schedule a post journey trip appointment to assess his health and to discuss future travel plans. He was referred to the CDC’s Traveler’s Health Website for further information.