HEALTH ADVICE for

INTERNATIONAL
TRAVEL
Renato M. Espinoza, MD, MHPEd
Dr Francisco Q Duque Medical Foundation
Lyceum Northwestern University
College of Medicine
Preventive Health and Community Medicine

Objectives:
1.

Examine the profile of the people who need/want to travel,

where they go and the purpose of their journey.
Overall health assessment
Immunization history

2.

Facilitate the full readiness of people before take-off.

Self-preparation for the travel and stay
Anticipation of needs in the area of destination

3.

Identify the common health threats and concerns in their

particular destination.
Common causes of illness or death
Specific environmental risks

4.

Gain knowledge and develop skills in managing urgent

problems anticipated in the area.
First aid measures
Coordination with public health authorities

World Tourism Organization

In 1999, an estimated 80 million travelers from industrialized countries (US/Canada, Europe,
Japan, and Australia/New Zealand) visited developing areas of the world, where the risks of
infectious diseases, many of them, vaccine-preventable, has increased. Some of the reasons
for travel are; search of exotic vacation places, to conduct business, government or
humanitarian services in the remote areas of the world. Studies show that 35-64% of short-term
travelers report some health impairment, usually caused by an infectious agent. These
infectious processes account for 1-4% of deaths among travelers.
Cardiovascular diseases and traumatic injuries (motor vehicle accidents, drowning, aircraft
accidents) are the most frequent causes of death, accounting for 50% and 22%, respectively.
Most travel-related illnesses are preventable by immunizations, prophylactic medications, or
pretravel health education. Included in HE should be mention of the role of hand hygiene in
reducing the transmission of pathogenic organisms. If hand washing with soap and water is not
feasible and hands are not visibly soiled, alcohol-based hand gels may be considered for use by
travelers to reduce travel-related infections. In a recent study, hand gels were shown to reduce
respiratory illness transmission in the home.
Health recommendations for international travel are based primarily on individual risk
assessment and any requirements mandated by public health authorities of the countries the
traveler plans to visit.
The risk of acquiring illness depends on these the area of the world visited, the length of stay,
activities and location of travel within the areas, and the underlying health of the traveler.
Therefore, it is important to inform the health advisor the following: travel itinerary and the
sequence in which countries will be visited and transited, the length of stay in each country, the
style of travel, whether be rural or urban, the reason for travel and the travelers underlying
health state, allergies or previous immunizations. In female visitors, it is to be revealed whether
she is planning pregnancy, or is pregnant or breast-feeding.
Recent reports stated travels from cruise ship has been a factor in influenza outbreaks.

World Tourism Organization

In 1999, an estimated 80 million travelers from industrialized countries
(US/Canada, Europe, Japan, and Australia/New Zealand) visited
developing areas of the world, where the risks of infectious
diseases, many of them, vaccine-preventable, has increased.
Some of the reasons for travel are:
1.
search of exotic vacation places,
2.
to conduct business,
3.
government or humanitarian services in the remote areas of the
world.
Studies show that 35-64% of short-term travelers report some health
impairment, usually caused by an infectious agent. These infectious
processes account for 1-4% of deaths among travelers.

World Tourism Organization

Infectious processes account for 1-4% of deaths among travelers.
Cardiovascular diseases and traumatic injuries (motor vehicle
accidents, drowning, aircraft accidents) are the most frequent causes of
death, accounting for 50% and 22%, respectively.
Most travel-related illnesses are preventable by immunizations,
prophylactic medications, or pre-travel health education.
Included in the health education should be mention of the role of
hand hygiene in reducing the transmission of pathogenic organisms. If
hand washing with soap and water is not feasible and hands are not
visibly soiled, alcohol-based hand gels may be considered for use by
travelers to reduce travel-related infections. In a recent study, hand gels
were shown to reduce respiratory illness transmission in the home.

World Tourism Organization

Health recommendations for international travel are based primarily on

individual risk assessment and any requirements mandated by public health
authorities of the countries the traveler plans to visit.
The risk of acquiring illness depends on these the area of the world visited,
the length of stay, activities and location of travel within the areas, and the
underlying health of the traveler. Therefore, it is important to inform the health
advisor the following: travel itinerary and the sequence in which countries will
be visited and transited, the length of stay in each country, the style of travel,
whether be rural or urban, the reason for travel and the travelers underlying
health state, allergies or previous immunizations. In female visitors, it is to be
revealed whether she is planning pregnancy, or is pregnant or breast-feeding.
Recent reports stated travels from cruise ship has been a factor in influenza
outbreaks.

IMMUNIZATIONS
Immunizations for international travel can be
categorized as:
1. Routine childhood and adult vaccinations (DT,
polio, tetanus, MMR)
2. Required those needed to cross international
borders as required by International Health
Regulations (yellow fever, meningococcal
disease)
3. Recommended according to risk of infection
(typhoid, hepatitis A, rabies)

Categories of Pre-travel Immunizations

ROUTINE
Childhood
immunizations

REQUIRED
Yellow fever
Meningococcal
disease

Adult
immunizations

RECOMMENDED
Tetanus
Poliomyelitis
Measles
Hepatitis A
Hepatitis B
Typhoid fever
Meningococcal meningitis
Rabies
Japanese encephalitis
Influenza
Typhus
Tuberculosis
Cholera

ROUTINE IMMUNIZATIONS
Travel is an excellent opportunity for the
practitioner to update an individuals childhood
or adult immunizations. These immunizations
are discussed in the guide for adult and the
recommendations of the Advisory Committee for
Immunization Practices (ACIP).
Included are : diphteria/tetanus, measles,
mumps, polio, rubella, Hemophilus influenza
type b, hepatitis B, varicella and influenza.

REQUIRED IMMUNIZATIONS
Each year, the WHO updates a list of immunizations by country. Health
Information for International Travel published biennially by the Centers for
Disease Control and Prevention, combines data from this list with
information obtained directly from ministries of health.
In accordance with the International Health Regulations, required
vaccinations must be recorded in the document, International Certificate of
Vaccination and validated by a stamp issued by the state health
departments.
YELLOW fever is the only vaccination designated by WHO as required for
entry into specific countries.
WHO also recognizes the Saudi Arabian requirement for meningococcal
vaccine ( A,C,Y,W-135) for pilgrims visiting Mecca for Hajj or Umrah.
In 1988, WHO eliminated the requirement for cholera vaccine for travelers,
however there are occasional reports that health officials at international
borders may still seek evidence of immunization.
No vaccinations are required for entry to the US.

Yellow Fever
Yellow fever, which occurs only in tropical Africa, certain countries in South
America, Panama, and Trinidad and Tobago, can be prevented by a single
subcutaneous injection of a live attenuated virus vaccine.
A certificate of yellow fever vaccination is valid for 10 years after a 10-day
waiting period.
Not recommended for infants less than 9 months of age,
immunocompromised patients, and during pregnancy.
Pregnant individuals and HIV-positive with CD4 counts greater than 200
should discuss immunization with their health care provider if they are at
high risk of getting infection.
Vaccine is not also given to persons with egg allergies, because the vaccine
is grown in chick embryos.
Contraindicated to patients with history of thymus disorder or dysfunction
(myasthenia gravis, thymoma, thymectomy, or DiGeorge syndrome)
Travelers who are not qualified to receive the vaccine should present a letter
from a physician, stating of the contraindication and has been counseled
about measures to prevent mosquito bites (bednets and the use of insect
repellents)

MENINGOCOCCAL MENINGITIS
Meningococcal meningitis poses a sporadic or epidemic riskmost
notably to pilgrims to Saudi Arabia during Hajj, and travelers to subSaharan Africa.
Incidence is greatest among those who have a direct close contact
with indigenous populations in overcrowded conditions in high risk
areas.
Because of lack of established surveillance and timely reporting of
from these countries, travelers to the meningitis belt during the dry
season should be advised to receive meningococcal vaccine,
especially if prolonged contact with the local population is likely.
Single dose of quadrivalent polysaccharide A/C/Y/W-135 vaccine is
protective for 3-5 years in adults and older children.
Not effective in children younger than 2-3 years of age.
The vaccine was recently licensed in the US for use in adolescents
and adults aged 11-55years.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

1. tetanus
Serosurveys in the US indicate that prevalence of immunity to
tetanus declined with increasing age.
Tetanus immunization must be kept up-to-date; it is protective for at
least 10 years.
Because diphteria is endemic in many countries, and became a
widespread problem several years ago in eastern Europe, tetanus
immunization should be given in combination with diphteria vaccine,
either as Td for adults or as DTaP(diphteria-tetanus-acelullar
pertussis) for children less than 7 years of age.
Some physicians vaccinate adult travelers at 5-10year intervals to
avoid the need for a booster or tetanus immune globulin if a person
has a tetanus-prone wound within five years.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

2. poliomyelitis
All travelers to countries where polio is or has recently been
endemic should be immunized adequately.
Although polio has been eliminated from the western hemisphere, it
remains endemic in India, Pakistan, Nigeria, Egypt, and Afganistan.
Beginning 2003, cases of polio have been reported from several
countries in sub-Saharan Africa and more recently, Indonesia and
Yemen, where polio had recently been eliminated thru global efforts.
These cases had been linked to outbreaks in northern Nigeria,
where eradication efforts were interrupted.
Individuals who have written documentation of having completed the
primary series of at least 3 doses require only one lifetime booster
dose of enhanced-potency inactivated polio vaccine or oral live
attenuated vaccine.
The live vaccine is no longer available in the US.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

3. measles
Indigenous transmission of measles has been interrupted in the Western
Hemisphere.
Recent cases in the United States have been imported or epidemiologically linked to
international travel. Half of these cases were in returning residents and the other half
in foreign visitors, including adoptees.
Measles remain a common infection outside the Western Hemisphere particularly in
developing countries.
All international travelers, including those who are infected with HIV(except those who
are severely immunocompromised) should have documented measles immunity.
Recommended for all persons traveling abroad born after 1956 who do not have
documentation of physician-diagnosed laboratory evidence of measles immunity, or
documented evidence of two prior doses live measles virus vaccine.
Children may be immunized as early as 6 months of age.. In such cases they should
receive MMR vaccine at 12-15 months and again at entry to kindergarten or first
grade.
A dose of MMR vaccine can be considered for persons born in 1956 or earlier whose
history of measles disease is uncertain.
Contraindications to the vaccine: the pregnant and immunocompromised other than
HIV-infected individuals.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

4. Hepatitis A
Hepatitis A is one of the most frequently reported vaccine preventable
infections of the travelers.
Although most infants and young children are asymptomatic when infected,
they do pose a health risk to others because of the ease of fecal-oral spread
of the virus. Mortality to this infection increases with age.
Risk of travelers from industrialized countries to developing countries has
been estimated to 3-6 per 1000 persons per month for the average nonimmune business traveler, increasing to 20 per 1000 per month for the
traveler who ventured off the usual tourist routes prior to widespread use of
vaccines.
HA vaccination is recommended for all travelers to the developing world, as
even in major tourist destinations the purity of water and the cleanliness of
food and food preparations cannot be guaranteed.
Inactivated HA virus vaccine is given in two separate doses 6-12 months
apart. These vaccine will provide protection of 25yrs for adults and 14-20yrs
in children.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

5. hepatitis B

Persons working in areas of high or intermediate hepatitis B virus

endemicity for 6 months or longer have infection rates of 2-5% per year.
Short-term travelers are also at risk for infection if:

they engage in unprotected sexual contact or injection drug use with residents
of these areas,
receive medical care that involves parenteral exposure,
after vehicular accidents or blood exposures,
engaging in medical procedures or disaster relief activities.

Low risk areas for HB include Western Europe and parts of Central and
South America.
Many travel health experts advise that all travelers receive this vaccine,
as it is virtually impossible to predict who may be involved in an accident
leading to injury that would require needle insertion or who may engage
in risk-taking behaviors.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

6. typhoid fever

More than half of the approximately 400 cases of typhoid fever reported
each year in US are acquired during foreign travel. All countries are
considered typhoid-endemic regions except; Canada, Japan, and
countries in Europe and Oceania.
Risk was particularly high for the travelers returning to their homeland to
visit and stay with relatives and friends in 6 countries, namely; India,
Pakistan, Mexico, Bangladesh, the Philippines, and Haiti.
The typhoid vaccines available are the

live, attenuated multidose oral vaccine developed from the Ty21a strain of
Salmonella typhi
Vi capsular polysaccharide vaccine administered intramuscularly in a
single dose.

The regimen must be completed at least one week before travel with
booster after 5-7 years. Oral vaccine is administered one capsule on
alternate days for 4 doses and should not be given concurrently with
antibiotics.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

7. meningoccocal meningitis
Meningococcal meningitis poses a sporadic or epidemic riskmost
notably to pilgrims to Saudi Arabia during Hajj, and travelers to subSaharan Africa.
Incidence is greatest among those who have a direct close contact
with indigenous populations in overcrowded conditions in high risk
areas.
Because of lack of established surveillance and timely reporting of
from these countries, travelers to the meningitis belt during the dry
season should be advised to receive meningococcal vaccine,
especially if prolonged contact with the local population is likely.
Single dose of quadrivalent polysaccharide A/C/Y/W-135 vaccine is
protective for 3-5 years in adults and older children.
Not effective in children younger than 2-3 years of age.
The vaccine was recently licensed in the US for use in adolescents
and adults aged 11-55years.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

8. rabies
Only a few cases of rabies have been reported in travelers, and no
data are available on the risk of infection. However, pre-exposure
vaccine is recommended to persons who might be at increased
occupational or avocational risk for exposure and for extended stays
in much of the developing world.
Children are at particular risk because of their usual carefree
attitude towards petting stray animals and the fact that they do not
usually report that they had been bitten.
Modern cell culture vaccines such as the human diploid and purified
chick embryo cell vaccines are inactivated products that are more
immunogenic and less reactogenic than earlier neural tissue rabies
vaccines.
Persons in high-risk categories are; cavers, veterinarians and
rabies laboratory workers.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

9. Japanese encephalitis
The estimated risk of JE in highly endemic areas during transmission
season can reach 1 per 500 persons per month.
From 1978 thru 2004, documented case reports 24 US travelers.
Among patients who develop clinical disease, case fatality rate may be
as high as 30%, with severe neurologic sequelae in 50% of the survivors.
The vaccine should be reserved for those traveling in endemic areas,
especially when there is rural exposure in rice and pig farming areas
during summer months.
Because of serious adverse reactions to the vaccine (generalized
itching, respiratory distress, angioedema and anaphylaxis) can occur in
some individuals up to 1 week after immunization, if possible, the traveler
should receive the last dose of vaccine 10 days before departure.
The primary series consists of three injections on days 0, 7, and 30.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

10. influenza
The risk for exposure to influenza viruses can occur throughout the
year in tropical and subtropical countries.
The attack rate is1.2 2.8% in travelers of all age groups, making
influenza the most common vaccine-preventable disease affecting
travelers.
ACIP recommends influenza vaccination before travel for persons at
high risk for complications if they travel to the tropics, with large
groups at any time of the year.
Travel to the Southern Hemisphere entails a high risk from April thru
September.
An inactivated parenteral vaccine and a live, attenuated vaccine
(LAIV), administered by nasal spray are currently given in US
travelers and to healthy persons aged 5-49 years.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

11. typhus
Since typhus is rarely seen in travelers,
routine immunization is not recommended.
Typhus vaccine is not available in the US

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

12. tuberculosis
TB has now become the number one killer infectious disease globally.
Each year, approx 9 million persons become ill from TB; of these two million
die.
Persons who will live for prolonged periods in developing countries and
those who will have close contact with local residents are at an increased
risk of exposure.
The efficacy of Bacille-Calmette-Guerin (BCG), a live vaccine derived from a
strain of Mycobacterium bovis, is highly regarded as the greatest help in
preventing severe complications of tuberculosis in children.
Side effects = draining abscesses at the site of injection or disseminated
infection.
It is recommended that travelers who will stay longer than 6 months should
have baseline tuberculin skin test placed before travel and repeated at 1-yr
to 2-yr intervals if risk continues.

RECOMMENDED IMMUNIZATIONS
TETANUS
POLIOMYELITIS
MEASLES
HEPATITIS A
HEPATITIS B
TYPHOID FEVER
MENINGOCOCOCAL MENINGITIS
RABIES
JAPANESE ENCEPHALITIS
INFLUENZA
TYPHUS
TUBERCULOSIS
CHOLERA

13. cholera
Cholera has continued to remain an important cause of severe
diarrheal disease globally, especially with its recent spread in the
1990s into Central and South America.
In 1991, the rate of cholera among Japanese travelers rose to 13
per 100,000 people in those returning from Indonesia.
The standard phenol-killed whole cell cholera vaccine requires 2
injections and confers a maximum protection of only 50% for 3-6
months, thus, it is generally not recommended because of the brief
and incomplete immunity it confers.
New oral vaccines provide 60-80% protection for about 6 months to
1 year, but are not effective against new serotypes 0139, which
spread rapidly thru Asia in the mid-1990s. These vaccines are not
yet available in the US.

Timing of Vaccines
More often, travelers visit their physician only a short time before their
anticipated date of departure. When necessary, inactivated vaccines may be
administered simultaneously at separate sites with separate syringes.
Theoretically, live vaccines should be administered 30 days apart because
of possible impairment of the immune response. However this restriction
does not apply to OPV, MMR, and varicella.
Ideally, Ig administration should be delayed until administration of of certain
live attenuated vaccines because of the possible reduction in antibody
response. This caveat does not apply to OPV or yellow fever vaccines but
does apply to MMR and its component vaccines.
Killed or inactivated vaccines usually pose no danger to the
immunocompromised host, although the immune response to these
vaccines may be suboptimal; also these vaccines are not usually
contraindicated during pregnancy.
Regardless of how long a vaccination schedule has been interrupted, there
is no need to restart a primary series of immunizations.
Finally, all immunization should be recorded in the international certificate of
vaccination booklet and carried with the passport.

Accessory Health Problems

destination-related
concerns

MALARIA

The most recent national data available from Canada reveal 369 cases in
2004, 1089 imported cases in the US in 2004, and 1747 in the United
kingdom in 2006.
The risk of Malaria per month of stay without prophylaxis is

highest in sub-Saharan Africa and Oceana

intermediate in Haiti and the Indian subcontinent
low for travelers to Southeast Asia and to Central and South America

Sub-Saharan Africa is also the most common region of acquisition

reported among travelers in the surveillance systems cited above and via
the GeoSentinel Surveillance Network, a global network thru the
International Society for Travel Medicine and CDC with 30 sites on 6
continents.
Detailed recommendations for the prevention of malaria are available
from CDC 24hrs/day from voice information service (1-877-FYI-TRIP; 1877-394-8747) or on the Internet at http://www.cdc.gov/travel

Malaria: PERSONAL PROTECTION MEASURES

Anopheles mosquitoes, the vectors of malaria, are exclusively
nocturnal in their feeding habits; protection from mosquito bites from
dusk till dawn is highly effective in reducing infection.
Wear protective clothing (long-sleeved shirts and long pants) when
outside during evening hours.
Insect repellants (DEET) and pesticide (permethrin) are highly
efficacious at protection against mosquito bites.
DEET is the most effective and best studied insect repellant
currently in the market. It is of minimal adverse effects and is
recommended even in children older than 2 months of age.
Bed net impregnated with permethrin is also effective in cases when
the travelers can not stay in air-conditioned quarters.
A pyrethroid-based flying insect spray should be used to clear the
bed net and room of mosquitoes.

Malaria: CHEMOPROPHYLAXIS
Personal protection measures greatly reduce but not eliminate risk of
malaria, thus the need for pharmacologic prophylaxis in high risk places.
Most antimalarials are only suppressives, acting on the erythrocytic stage of
the parasite beyond the liver phase, thereby preventing the clinical
symptoms of disease but not infection.
Travelers must be informed that any febrile illness that occurs during or up
to 1 year after a trip to a malaria-endemic area should be evaluated
immediately by a health care professional.
Drugs used: mefloquine, chloroquine, atovaquone/proguanil, primaquine.
Regardless of the chemoprophylactic regimen recommended, it is important
for travel health advisors to tell the travelers;
a, globally, there is no uniformity in concerning malaria
chemoprophylaxis recommendations.
b. they are likely to meet other travelers and health care providers
overseas who give conflicting advice regarding the optimal regimen for
malaria chemoprophylaxis.

TRAVELERS DIARRHEA

Diarrhea is the most frequent health impairment among travelers with

these common complaints, in addition to loose stools and fecal
urgency are abdominal cramps, nausea, vomiting, and general
malaise.
The most common etiologic agents at most destinations are: ETEC,
EAEC, Shigella spp, salmonella spp, Campylobacter spp, Vibrio
parahemolyticus (ASIA), rotavirus (Latin America) and protozoa.
When counseling travelers about diarrhea, health care providers
must consider several issues:

FOOD and WATER precautions

Hand Hygiene
Chemoprophylaxis
Self-treatment of illness
IMMUNIZATION

VECTOR-BORNE DISEASES

Although Malaria is the most important vector-borne infection in

travelers,others also require careful attention.
These are:
Dengue fever which is an increasing problem particularly in the
Carribean, Central and South America, and Southeast Asia. It is
transmitted by Aedes mosquito which prefers an urban and indoor
habitat, bites during the day particularly in the early morning and
late afternoon. Therefore, its important to take insect precautions
during the day, in addition to those required between dusk and
dawn for malaria.
Tick-borne encephalitis is acquired by the bite of an infected tick
ot ingesting unpasteurized dairy products in endemic foci
between latitude 39 and 65 degrees.
Other common cases includemite-borne typhus, loiasis,
relapsing fever, bartonellosis, and plague.

SEXUALLY TRANSMITTED
INFECTIONS
DURING AN INTERNATIONAL TRAVEL, INDIVIDUALS
OFTEN FEEL A SENSE OF ANONIMITY, MAY BE LESS
SEXUALLY INHIBITED, AND MAY THEREFORE PUT
THEMSELVES AT GREATER RISK FOR ACQUISITION OF
STD
The risk is increased by exposure to multiple or professional
partners.
Safer sexual practices, including the use of condoms throughout
intimacy, are particularly important in the era of HIV/AIDS.
Immunization against hepatitis B is a must for those who may
engage in casual sex while abroad.

SOIL- AND WATERBORNE DISEASE

Schistosomiasis, a helminthic disease infects over 200 million
people in parts of South America, the Carribean, Africa, the Middle
East and Southeast Asia.
It can be avoided by advising travelers to stay out of slow-moving,
fresh water in developing countries in the areas of the world as
stated above.
Swimming in the ocean or freshwater pools without snails is safe.
Barefoot walking exposes the traveler to a variety of hazards,
including tungiasis, snake bites, cutaneous larva migrans from
cat and dog hookworms, human hookworm infection, and
strongyloidiasis.
Sandals provide only partial protection so that closed footwear is
better.

ADAPTATION to the ENVIRONMENT

Excessive sun exposure can cause erythema and sunburn,
chemical hypersensitivity, eye damage, bleaching of the skin, and
predisposition toward skin cancers including malignant melanoma.
The least potent sunscreen that should be used is one with a sun
protection factor (SPF) of 15, offering 93% protection.
Adaptation to a hot climate can take from 1 to several weeks,
depending on the ambient temperatures and humidity.
Clothing should be made of natural fibers such as cotton and linen
to allow air to circulate.
Light fabrics reflect light and are preferable to dark colors.
In hot weather and in the absence of strenuous exercise, the
average person must replace at least 1 liters of fluid per day.
In excessive sweating, it is important to replace salt by adding extra
salt to food

ILLNESS AFTER RETURN

It is more exception than the rule for the physician
to ask Where have you been? of travelers who
become ill after their return.
Before departure, travelers must be warned that if
they become ill on their arrival, they should
immediately inform their physicians of their trip.
This advice is particularly important for febrile
travelers, since no antimalarial drug guarantees
full protection regardless of how carefully they
have followed recommended precautions.

KEY MESSAGES

In a comprehensive health advice to international travelers,

advisor must know the travel itinerary and the sequence in
which countries be visited; the length of stay; the reason for
travel; the style of travel; and the medical history of the
traveler.

In the inquiry about present health status, it is important to

note the immunizations received, food allergies and
medication idiosyncrasies, and if female,
obstetric/gynecologic informations.

Travelers must be warned on risks of travel, educate on selfcare and personal protection measures.