Last-Minute Travelers

Introduction

It is never too late for a pre-travel consultation. Although travelers are encouraged to access pre-travel care ≥1 month before departure, healthcare professionals can and should provide services within days or even hours of departure. As defined by the World Health Organization, the last-minute traveler (LMT) is anyone departing for an international destination on short notice, typically ≤2 weeks. Some reports suggest that LMTs comprise up to 16% of a travel clinic population and include business travelers, relief workers, students, travelers visiting friends and relatives, travelers who planned a trip for some time but delayed seeking pre-travel care, and travelers unsuccessful at obtaining an earlier appointment. Regardless of the reason or time constraints, healthcare professionals should offer all travelers support for their upcoming trips.

Pre-travel visit priorities

Delivering pre-travel services to LMTs can be challenging. Typically, LMTs only have time for a single encounter. Clinics prepared to provide services to LMTs will need to have healthcare professionals trained to administer multiple simultaneous immunizations and to be aware of local 24-hour pharmacy resources for prescriptions and medical kit items. They should also be able to recommend resources at the destination for additional services not completed before departure. To accommodate last-minute appointments, clinics can offer dedicated hours or telemedicine services. Even with very limited time, every LMT should receive a full pre-travel assessment, all indicated vaccinations as time permits, and focused counseling to mitigate the major health and safety risks of their journey.

Vaccinations

Consider each traveler's itinerary, trip activities, risk for infection at the destination, and cumulative risk associated with repeat travel (see Vaccination and Immunoprophylaxis—General Principles chapter). Educate travelers about the value and safety of multiple simultaneous immunizations; emphasize preventive behaviors for travelers who might not be adequately protected if they are vaccinated immediately before travel or who do not have sufficient time to complete a vaccine series.

Routine vaccines

Most travelers who attended school in the United States received routine vaccinations as children. For travelers who are not up to date on vaccinations, provide initial or additional vaccine doses, such as influenza, respiratory syncytial virus, or measles-mumps-rubella vaccines, according to age recommendations and Advisory Committee on Immunization Practices (ACIP) schedules. Arrange for return visits as needed.

Recommended travel vaccines: single-dose protection

Even with limited time before departure, research supports the use of certain single-dose vaccines, if indicated, to initiate protection in LMTs. These include hepatitis A (monovalent), influenza, meningococcal (quadrivalent, ACWY), polio booster (inactivated), typhoid (injectable), tetanus-diphtheria, and cholera vaccines for select travelers.

Recommended vaccines: multiple doses needed

LMTs often cannot complete the schedule of vaccines requiring multiple doses to induce full protection. Carefully evaluate the need for these vaccines, factoring in destination, incidence, and disease severity. ACIP does not recommend single primary doses of multiple-dose vaccines because they may give a traveler a false sense of protection and lead to confusion about the need for and timing of additional doses.

If a traveler needs protection against hepatitis B, Japanese encephalitis (JE), rabies, or tick-borne encephalitis (TBE) vaccine, consider alternative approaches, including use of an approved, accelerated schedule or, depending on expected duration of stay and level of risk, identifying vaccination resources for the traveler at the destination. Travelers should be aware that vaccines received in some countries might be of substandard quality. Because travelers' level of protection will be unclear if they do not complete a full series of a multidose vaccination, provide preventive behavior counseling.

Coronavirus disease 2019

CDC advises all international travelers to be up to date with their COVID-19 vaccinations before travel.

Hepatitis B

Heplisav-B vaccine is approved for adults ≥18 years of age and requires only 2 doses separated by 1 month, a quicker regimen than for other hepatitis B vaccine formulations. For LMTs with imminent exposure (e.g., disaster relief workers), healthcare professionals can use an accelerated 3-dose vaccination schedule with Twinrix, the combination hepatitis A and hepatitis B vaccine, at 0, 7, and 21–30 days, plus a 12-month booster. Arrange follow-up visits for short-term travelers to complete the series and help extended-stay travelers identify resources at their destination to complete the schedule.

Japanese encephalitis

In the United States, the JE vaccine, IXIARO, has been approved for use with an accelerated schedule (days 0, 7; see Japanese Encephalitis chapter). For at-risk LMTs who cannot complete the full primary vaccine series ≥1 week before travel, counsel them to strictly adhere to insect precautions. Alternatively, help travelers identify reliable sources at their destination for IXIARO vaccination or internationally (but not domestically) available, single-dose JE vaccines, (e.g., Imojev [Sanofi Pasteur] or live attenuated SA 14-14-2 JE vaccine [Chengdu Institute of Biological Products]).

Rabies

In 2022, ACIP revised its recommendations for rabies vaccination and approved a 2-dose pre-exposure regimen given on days 0 and 7 (see Rabies chapter). This revised schedule has the advantage of being both less expensive and easier to complete prior to travel. There is, however, an absence of data on the duration of immunity for this 2-dose series beyond 3 years. As a result, travelers with a sustained risk for rabies exposure should either receive a third dose of vaccine after day 21 of the initial regimen up until year 3 or have a titer drawn after 1 year of the initial regimen.

Travelers with a recognized pre-exposure vaccination regimen should receive a 2-dose vaccine booster (days 0 and 3) if they have a rabies exposure. For travelers who started, but did not complete, a rabies pre-exposure vaccination regimen and had a potential rabies exposure, provide the same post-exposure prophylaxis as for a completely unimmunized person. Regardless of whether travelers are vaccinated or not, emphasize animal avoidance (see Zoonotic Exposures: Bites, Scratches, and Other Hazards and Rabies chapters). Encourage travelers to purchase insurance for evacuation or urgent post-exposure treatment (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). As warranted, suggest for long-stay travelers and those without sufficient funds the option to complete or receive the rabies pre-exposure vaccination series at their destination.

Tick-borne encephalitis

For LMTs traveling to a TBE-endemic area, the United States has approved a vaccine used in Europe for decades (see Tick-Borne Encephalitis chapter). For people aged 16 years and older with an assessed risk, TICOVAC is administered in a 3-dose series (day 0; 14 days to 3 months after dose 1; 5 to 12 months after dose 2). Two doses are considered protective if the traveler has >21 days before exposure. As warranted, offer longer-stay travelers the option to receive TBE vaccine doses at their destination. All travelers to TBE-endemic areas are advised to take precautions to avoid tick bites (see Mosquitoes, Ticks, and Other Arthropods chapter).

Required vaccines

Meningococcal

Quadrivalent (ACWY) meningococcal vaccine is required for all individuals 1 year of age and older traveling to the Kingdom of Saudi Arabia for religious pilgrimages. Hajj visas will not be issued without proof that applicants received meningococcal conjugate vaccine. Check the Kingdom of Saudi Arabia's Ministry of Health website for up-to-date information.

Yellow fever

Travelers who receive YF vaccine <10 days before entering a risk area are at risk of infection with YF virus. Documentation of vaccination against YF on the International Certificate of Vaccination or Prophylaxis (ICVP) becomes valid 10 days after administration. When proof of vaccination against YF is required by a country on the traveler's itinerary, and the LMT is planning to arrive before 10 days have elapsed, healthcare professionals can suggest the traveler rearrange the order of travel or reschedule the trip (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter, for a list of countries). Otherwise, the traveler risks being denied entry, quarantined, or revaccinated on arrival. In travelers for whom YF vaccine is contraindicated, YF vaccine Uniform Stamp Owners (healthcare professionals designated by their state or territorial health department to administer YF vaccine) can issue a medical waiver on the ICVP and a letter in lieu of vaccination (see Yellow Fever chapter, for more details).

Malaria and other mosquito-borne illnesses

Healthcare professionals must factor time until departure and local pharmacy supply when considering malaria chemoprophylaxis choices for LMTs, in addition to the usual considerations of cost, drug resistance at destination, itinerary, medical contraindications, drug-drug interactions, and patient preference. For travelers departing in ≤1 week, options for malaria chemoprophylaxis include atovaquone-proguanil or doxycycline, in addition to education about mosquito avoidance and follow-up for fever. Consider primaquine or tafenoquine only if time allows for glucose-6-phosphate-dehydrogenase (G6PD) screening; do not prescribe either of these drugs without first knowing the traveler's G6PD status (see Malaria chapter). Educating travelers about insect avoidance can help them to avoid arboviral infections at their destination and help to prevent local disease transmission at destination and upon return (see Mosquitoes, Ticks, and Other Arthropods chapter).

Risk-management health counseling

Pre-travel counseling is critical for LMTs. Determine travelers' knowledge and experience in managing travel health risks and focus on major risks of the trip and special issues for LMTs (Box 1.10.1). LMTs benefit most when provided with simple, prioritized messages about prevention and self-care. The last-minute visit is also an opportunity to educate about the importance of seeking care further in advance and also a chance to prepare LMTs for the "trip after this one."

Box 1.10.1

Special challenges

Travelers leaving in less than 48 hours

If travel is imminent, healthcare professionals can still provide telehealth or secure digital messaging for prevention counseling and recommendations for services at the destination. During the consultation, emphasize and reassure the LMT that many travel health risks can be prevented by adhering to healthy behaviors. The LMT can also be directed to their primary care provider if last-minute appointments are more readily available, the provider is comfortable with travel medicine, and the appropriate medications and vaccinations can be obtained through this option.

Travelers with preexisting medical conditions

LMTs with preexisting conditions might be at increased risk for acute episodes of comorbid conditions (see Travelers with Chronic Illnesses chapter). These travelers should carry a portable medical record (e.g., pertinent medical information kept on a flash drive, smartphone app, or in the cloud), know reliable sources for medical care at their destination, and purchase travel health insurance, trip insurance, and medical evacuation insurance (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). In addition, encourage these travelers to schedule without delay a pre-travel appointment or conversation with their treating healthcare professionals. Some conditions (e.g., immunosuppression, pregnancy) often require additional discussion or advance planning and could warrant delaying departure (see Immunocompromised Travelers and Pregnant Travelers chapters). For LMTs who are immunocompromised, timing of vaccination requires special consideration, and they should seek pre-travel services 3 to 4 months before their trip.

Extended-stay travelers

A last-minute consultation will not provide adequate time for a full medical and psychological evaluation or additional education for an expatriate. Advise extended-stay travelers to arrange an early consultation with a qualified healthcare professional at their destination.

Traveler requests: carrying vaccines or off-label dosing

Because of time constraints, some LMTs might ask to carry a vaccine abroad or for a vaccine to be administered off-label (e.g., different schedule, double dosing). Due to cold chain concerns, it is rarely advisable to provide travelers with a supplied vaccine. Healthcare professionals who administer a vaccine in a nonstandard manner can face medical-legal issues and induce a false sense of protection in the traveler.

Recurring last-minute travelers

Clinics that frequently see LMTs might want to address this as an administrative issue. The clinical practice could build flexibility into the schedule and proactively identify groups likely to travel last minute (e.g., college students, corporate employees, relief workers). For these travelers, the clinic might consider routine pre-travel visits or preemptive vaccinations for certain itineraries. For example, universities could alert academic departments with frequent travel to seek pre-travel services as soon as a trip is planned or when airline tickets are purchased. Occupational travel health clinics could establish policies to provide pre-travel care to all new hires who will participate in employee travel.