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Travel Medicine

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Medical Author:

Mary D. Nettleman, MD, MS, MACP

Mary D. Nettleman, MD, MS, MACP

Mary D. Nettleman, MD, MS, MACP is the Chair of the Department of Medicine at Michigan State University. She is a graduate of Vanderbilt Medical School, and completed her residency in Internal Medicine and a fellowship in Infectious Diseases at Indiana University.

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Coauthor:

Kara Jacobs, MPH

Medical Editor:

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Why should travelers see a physician before they leave on a trip?

Travelers should see a physician before leaving for a trip if

• they are going to developing countries,
• they are visiting sites that are not on the usual tourist routes or traveling to high altitudes,
• they have chronic diseases that could be affected by travel,
• they are visiting countries that require vaccinations before they allow travelers to enter the country.

The goal of a pre-travel medical evaluation is to help travelers protect themselves against (1) common diseases that may be mild but that will disrupt their trip, and (2) less common diseases that may be serious or even fatal. All travelers need to be up to date on routine vaccines they would normally get if they were not traveling. For example, an annual influenza vaccination (flu shot) is recommended if traveling during influenza season. Travelers should also be up to date on tetanus vaccines. If a tetanus booster is needed, your physician may elect to use the Tdap vaccine that also provides continuing protect against adult pertussis. No vaccinations are required for re-entry into the United States after travel.

What diseases occur in travelers, and how can disease be prevented?

Travelers can pick up infections from contaminated food or water, from insect bites, animal bites, or from other people. Vaccinations, medications, and simple precautions can reduce or eliminate the risk of many of these travel-related infections. While infections are the most common problem for travelers, it is important to remember that the most common cause of death in travelers is motor vehicle accidents. Be sure to look both ways before crossing the street, don't get in the car if the driver is drunk, and use seat belts if available both at home and when traveling.

This review will cover diseases commonly encountered by travelers or those for which vaccinations are recommended. For a more complete discussion, please refer to the CDC travel medicine web site (http://www.cdc.gov).

Traveler's diarrhea

Traveler's diarrhea is the most common medical complaint in travelers, occurring in up to 50% of travelers to developing countries. It occurs when infectious organisms are inadvertently ingested by travelers, resulting in one to five days of loose stools. The stools are often watery and may be accompanied by abdominal cramps. Although not fatal, traveler's diarrhea can cause dehydration, vomiting, low-grade fever, and discomfort to the point that some travelers have to change their itineraries. It is important to note that traveler's diarrhea is not associated with bloody stools, severe abdominal pain, or high fever. These symptoms are suggestive of more serious conditions and should prompt medical attention.

Traveler's diarrhea is spread when bacteria or other infectious agents such as viruses are ingested. Traveler's diarrhea is most often spread through contaminated food or water, or by putting contaminated hands in the mouth. Even small amounts of contamination can cause infection. Although bacteria are the most common cause of traveler's diarrhea, there have been outbreaks of diarrhea on cruise ships caused by noroviruses. Noroviruses are very small (only visible on ultrathin-section electron microscopy) and spread readily from person to person.

Travelers can get diarrhea in most areas of the world, but some countries pose a higher risk. High-risk areas include most of Asia, the Middle East, Africa, and Central and South America. Risk is increased if the traveler is adventurous with his or her diet, eats foods from street vendors, or travelers to areas off the usual tourist routes.

Protective measures may help prevent or shorten the duration of traveler's diarrhea. All travelers should wash their hands often and understand basic food and water precautions (see below). However, it has been shown that even well-informed travelers often choose to eat foods that pose an increased risk of traveler's diarrhea. Therefore, travelers at risk should carry along an antimotility agent such as loperamide (Imodium; Kaopectate II; Imodium A-D; Maalox Anti-Diarrheal Caplets; Pepto Diarrhea Cont) and start taking it if they get symptoms. Bismuth subsalicylate (Pepto-Bismol) is also helpful.

Many physicians also recommend that travelers carry along an antibiotic to take in case they get diarrhea. Fluoroquinolones are the most commonly prescribed antibiotic; azithromycin (Zithromax, Zmax) or rifaximin (Xifaxan) are alternatives. Because bacteria are developing resistance to many antibiotics, many of the older antibiotics do not work well. If an antimotility agent (a drug that reduces gastrointestinal motility) and an antibiotic are started at the first sign of diarrhea, symptoms may be shortened to only a few hours instead of a few days. In rare cases, physicians might prescribe daily antibiotics or daily bismuth subsalicylate to prevent diarrhea, but this is not needed for most travelers. Affected people should stay hydrated. Pregnant women and children need special advice because many of these drugs are not appropriate for them.