Purpose
Introduction
The pre-travel consultation offers a dedicated time to prepare travelers for health concerns that might arise during their trips. During the pre-travel consultation, healthcare professionals can conduct a risk assessment for each traveler, communicate risk by sharing information about potential health hazards, and manage risk by various means. Managing risk might include giving immunizations, emphasizing to travelers the importance of taking prescribed malaria prophylaxis and other medications (and highlighting the risks of not taking them correctly), and educating travelers about steps they can take to address and minimize travel-associated risks. The pre-travel consultation also serves a public health purpose by helping limit the role that international travelers may play in the global spread of infectious diseases.
The travel medicine specialist
Travel medicine specialists have in-depth knowledge of immunizations, health risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine specialist is indicated for all international travelers and is particularly important for those with a complicated health history, pregnant women, anyone taking special risks (e.g., traveling at high altitude, working in refugee camps), or those with prolonged or complicated itineraries. Healthcare professionals aspiring to be travel medicine specialists can benefit from the resources provided by the International Society of Travel Medicine (ISTM) and might consider specialty training and certification (see Travel Medicine Resources for Healthcare Professionals chapter).
Components of a pre-travel consultation
Effective pre-travel consultations require attention to the traveler's health background and incorporate the itinerary, trip duration, travel purpose, and activities planned during travel, which all factor into the health risk associated with travel (Box 1.1.1). The pre-travel consultation is the best opportunity to educate the traveler about health risks at the destination and how to mitigate them. The typical pre-travel consultation does not include a physical examination, and a separate appointment with the same or a different healthcare professional might be necessary to assess fitness for travel. Because travel medicine clinics are not available in some communities, primary care physicians should seek guidance from travel medicine specialists to address areas of uncertainty. The Centers for Disease Control and Prevention (CDC) Travelers' Health website has country-specific recommendations and links to an interactive web-tool, Pre-Travel Providers' Rapid Evaluation Portal from Global TravEpiNet, to guide primary care physicians through a pre-travel consultation.
Personalize travel health advice by highlighting likely exposures and reminding the traveler of ubiquitous risks (e.g., injury, foodborne and waterborne infections, vector-borne diseases, respiratory tract infections, blood-borne infections, and sexually transmitted infections). Balancing the importance of precautions with an appreciation of the positive aspects of the journey can lead to a more meaningful pre-travel consultation. In addition, pay attention to the cost of recommended interventions. It is important to recognize that some travelers are unable to afford all the recommended immunizations and medications, and to prioritize interventions in these situations (see Travel Health Advice for Resource-Limited Travelers chapter).
Assess individual risk
Traveler characteristics and destination-specific risk provide the background to assess travel-associated health risks. Such characteristics include personal health background (e.g., past medical history, special conditions, immunization history, medications); prior travel experience; trip details, including itinerary, timing, reason for travel, travel style, and specific activities; and details about the status of infectious diseases at the destination. Certain travelers also might confront special risks. Recent hospitalization for serious problems might lead to a decision to recommend delaying travel. Air travel is contraindicated for patients with certain conditions. For instance, patients should not travel by air <2 weeks after an uncomplicated myocardial infarction or <10 days after thoracic or abdominal surgery (see Travelers with Chronic Illnesses chapter). Consult relevant healthcare professionals most familiar with the traveler's underlying conditions.
Other travelers with specific risks include those who have chronic illnesses (see Travelers with Chronic Illnesses chapter), are immunocompromised (see Immunocompromised Travelers chapter), or are pregnant (see Pregnant Travelers chapter). Travelers visiting friends and relatives (see Visiting Friends and Relatives: VFR Travel chapter), long-term travelers (see Long-Term Travelers and Expatriates chapter), and travelers with small children (see Traveling Safely with Infants and Children chapter) also face unique risks. More comprehensive discussion on advising travelers with additional health considerations is available in Travelers with Additional Considerations. Determine whether recent notices for outbreaks or other safety concerns have been posted for the traveler's destination by checking information available on CDC Travelers' Health, U.S. Department of State, and other resources.
In addition to recognizing the traveler's characteristics, health background, and destination-specific risks, discuss anticipated exposures related to special activities. For example, river rafting could expose a traveler to schistosomiasis (see Schistosomiasis chapter) or leptospirosis (see Leptospirosis chapter), and spelunking in Central America could put the traveler at risk for histoplasmosis. Eating food from street vendors (see Food and Water Precautions for Travelers chapter) increases the risk for travelers' diarrhea (see Travelers' Diarrhea chapter). Flying from lowlands to high-elevation areas and trekking or climbing in mountainous regions introduces the risk for altitude illness (see High Altitude Travel and Altitude Illness chapter). Inquire about plans for specific leisure, business (see The International Business Traveler chapter), and healthcare-seeking activities (see Medical Tourism chapter).
Communicate risk
Once destination-specific risks for a particular itinerary have been assessed, communicate them clearly to the traveler. Health-risk communication is an exchange of information in which the healthcare professional and traveler discuss potential health hazards for the trip and any available preventive measures. Communicating risk is one of the most challenging aspects of a pre-travel consultation because travelers' perceptions of and tolerance for risk can vary widely. (For a more detailed discussion, see Perspectives: Travelers' Perception of Risk chapter).
Manage risk
Vaccinations
Vaccinations are a central component of pre-travel consultations, and the risk assessment forms the basis of recommendations for travel vaccines (see Vaccination and Immunoprophylaxis—General Principles chapter). Consider whether the patient has sufficient time to complete a vaccine series before travel (see Last-Minute Travelers chapter). The purpose of travel, season, duration, and specific destination within a country will inform the need for vaccines. At the same time, the pre-travel consultation presents an opportunity to update routine vaccines (Table 1.1.1).
Pay attention to vaccine-preventable diseases for which immunity might have waned over time or after a recent immunocompromising condition (e.g., after a hematopoietic stem cell transplant). Asking whether travelers plan to travel again in the next 1–2 years can help justify receipt of an immunization at the current visit for travel over several years (e.g., rabies pre-exposure, Japanese encephalitis, tick-borne encephalitis) rather than only the upcoming trip. When a traveler's time until departure does not allow for conventional dosing of vaccines, accelerated dosing schedules can be offered for certain vaccines (e.g., Japanese encephalitis, rabies, hepatitis B). Provide travelers with a record of administered immunizations (including the International Certificate of Vaccination or Prophylaxis [i.e., Yellow Card]) and instructions to follow up as needed to complete a vaccine series. Advise travelers against obtaining medication and vaccine series in other countries; although, when necessary, completing a vaccine series at an established travel medicine center in the destination country may be considered for select vaccines.
Table 1.1.1: The Pre-Travel Consultation, Vaccines to Update and Consider1
| Routine Vaccines | |
|---|---|
| Vaccine | Travel-Related Occurrences and Recommendations |
| COVID-19 (see COVID-19 chapter) | International travelers should be up to date according to current recommendations. |
| Haemophilus influenzae type b | Organism ubiquitous worldwide; may cause meningitis. |
| Hepatitis B | Recommended for travelers visiting countries where HBsAg prevalence is ≥2%. Vaccination can be considered for all international travelers, regardless of destination, depending upon individual behavioral risk and potential for exposure. Routine vaccination is recommended for all persons aged through 59 years as well as one-time screening for all adults aged ≥18 years. |
| Human papillomavirus | Causal relationship with travel is unknown (see Sex and Travel chapter). |
| Influenza (see Influenza chapter) | Greater transmission from October–March in the Northern Hemisphere and April–September in the Southern Hemisphere; year-round transmission can occur in tropical areas. Outbreaks have occurred on cruise ships (see Cruise Ship Travel chapter). Current-season vaccine is recommended for all travelers. Novel influenza viruses (e.g., avian influenza viruses H5N1 and H7N9) can be transmitted to travelers visiting areas where these viruses are circulating; vaccines against avian influenza are unavailable, hence travelers should avoid animal contact, consumption of unpasteurized dairy, or undercooked animal products in these areas. |
| Measles, mumps, rubella (see Measles [Rubeola] chapter) | Infections are common in countries and communities that do not immunize children routinely, including parts of Europe. Outbreaks have occurred in the United States because of infection in returning travelers. Vaccination is recommended for all international travelers ≥6 months old without documented immunity. |
| Meningococcal disease (serogroups A, C, W, and Y) (see Meningococcal Disease chapter) | Outbreaks occur regularly in Sub-Saharan Africa in the meningitis belt during the dry season, generally December–June, although transmission can occur at other times for those with close contact with local populations. Outbreaks have occurred with Hajj pilgrimage. The Kingdom of Saudi Arabia requires the quadrivalent vaccine for pilgrims (see Saudi Arabia: Hajj and Umrah Pilgrimages chapter). |
| Pneumococcal | Streptococcus pneumoniae is ubiquitous worldwide. The vaccine protects against bacteremia, meningitis, and pneumonia. |
| Polio (see Poliomyelitis chapter) | Unimmunized or under-immunized travelers can become infected with either wild poliovirus or vaccine-derived poliovirus. Recommendations and requirements for polio vaccination may be in place for countries with wild poliovirus circulation for their residents, long-term visitors, and international travelers. A single lifetime booster dose may be given to adults who received a complete polio vaccination series as children and are traveling to a destination with increased risk. |
| Rotavirus | Common in developing countries, although not a common cause of travelers’ diarrhea in adults. The vaccine is only recommended for young children. |
| Respiratory syncytial virus | Transmission occurs globally and year-round. There are now 3 vaccines that are approved for adults ≥60 years and during pregnancy. A monoclonal antibody, nirsevimab, is recommended for newborns and infants. |
| Tetanus, diphtheria, pertussis | Rare cases of diphtheria have been attributed to travel. Pertussis has occurred in travelers whose immunity has waned. |
| Varicella | Infections are common in countries that do not immunize children routinely, as in most low- and middle-income countries. |
| Zoster | Travelers may experience varicella zoster reactivation, but causal relationship is difficult to establish. |
| Travel Vaccines | |
|---|---|
| Vaccine | Travel-Related Occurrences and Recommendations |
| Cholera (see Cholera chapter) | Infections in travelers have been rare. Vaccination can be considered for those traveling to an area with active cholera transmission in the last 12 months. |
| Hepatitis A (see Hepatitis A chapter) | Hepatitis A is one of the most common vaccine-preventable diseases acquired during travel. Pre-vaccination serologic testing for hepatitis A immunity before vaccination is not routinely recommended but may be considered in specific settings to reduce costs by not vaccinating people who are already immune. Travelers to countries with high or intermediate hepatitis A endemicity should be vaccinated, receive immunoglobulin, or receive vaccine plus immunoglobulin based on their age and underlying conditions. |
| Japanese encephalitis (see Japanese Encephalitis chapter) | Rare cases have occurred, estimated at <1 case/1 million travelers to endemic countries. However, the severe neurologic sequelae and high fatality rate warrant detailed review of trip plans to assess the level of risk. Vaccination is recommended for persons moving to an endemic country, longer-term (e.g., ≥1 month) travelers to endemic areas, and frequent travelers to endemic areas. Shorter-term (e.g., <1 month) travelers with an increased risk and travelers to endemic areas who are uncertain about their specific travel duration, destinations, or activities may also receive vaccine. |
| Rabies (see Rabies chapter) | Rabies pre-exposure immunization simplifies post-exposure immunoprophylaxis; rabies immunoglobulin might be difficult to obtain in many destinations. Travelers with occupational or recreational activities that may potentially place them at risk and who may have difficulty obtaining safe post-exposure prophylaxis may be offered vaccine. |
| Tick-borne encephalitis (TBE) (see Tick-Borne Encephalitis chapter) | Cases have been identified in travelers, with an estimated risk of 1/10,000 person-months. Endemic areas are expanding in Europe. Travelers moving or traveling to a TBE-endemic area and who are likely to have extensive exposure to ticks based on planned outdoor activities and itinerary should consider vaccination. |
| Typhoid (see Typhoid and Paratyphoid Fever chapter) | The highest risk is for travelers going to South Asia (e.g., Bangladesh, Pakistan, and India), areas where drug-resistant isolates have been increasing. Vaccine should be recommended to travelers to areas in which there is a risk of exposure; risk is greatest in developing countries where travelers may have prolonged exposure to potentially contaminated food and drink. |
| Yellow fever (see Yellow Fever chapter) | Risk occurs in defined areas of Sub-Saharan Africa and the Amazonian regions of South America (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter). Some countries require proof of vaccination for entry. For travelers visiting multiple countries, sequence of country entry can affect yellow fever vaccination requirement. Vaccine should be offered to eligible travelers to endemic areas, with a particular emphasis on absolute and relative contraindications to the vaccine. |
Notes
Abbreviation: HBsAg, hepatitis B surface antigen.
1Based on Advisory Committee on Immunization Practices guidelines, if available; current as of January 2024.
Malaria prevention
Malaria continues to cause substantial morbidity and mortality in travelers, with those visiting friends and relatives abroad accounting for the majority of cases. From 1973 to 2018, the annual number of U.S. malaria cases reported to CDC has increased; therefore, healthcare professionals should carefully assess travelers' risk for malaria and recommend preventive measures during the pre-travel consultation. For travelers going to malaria-endemic countries, discuss malaria transmission, ways to reduce risk, including mosquito-bite avoidance, recommendations for prophylaxis, symptoms of malaria, and the need for prompt medical care if symptoms develop. (Additional information on malaria is available in Yellow Fever Vaccine and Malaria Prevention Information, by Country and Malaria chapters.)
Self-treatable conditions
Despite healthcare professionals' best efforts, some travelers will become ill (see Post-Travel Evaluation of the Ill Traveler chapter). Obtaining reliable and timely medical care during travel can be problematic in many destinations (see What to Do When Sick Abroad chapter). Consequently, consider prescribing certain medications in advance to enable the traveler to treat common health problems. Box 1.1.2 provides a list of some of the most common situations for which travelers find self-treatment useful.
Travel medicine specialists need to recognize conditions for which travelers might be at risk and provide information about appropriate self-diagnosis and treatment. Keys to a successful self-treatment strategy include: sharing a simple disease or condition definition; recommending or prescribing treatment; and educating the traveler about the expected outcome of treatment. It is important to assess the traveler's ability to manage the self-treatment plan. As an example, for travelers' diarrhea: inform travelers that most symptoms can be managed with fluid replacement plus loperamide or bismuth subsalicylate; consider prescribing travelers antibiotics they can carry with them for use in the event of incapacitating diarrhea (see Travelers' Diarrhea chapter); and tell them to seek medical attention if symptoms persist for 24–36 hours or are particularly severe, such as high fevers, dehydration, or bloody diarrhea.
With some activities in remote settings (e.g., trekking), the only alternative to self-treatment would be no treatment (see Adventure Travel chapter). Pre-travel counseling might result in a more accurate self-diagnosis and treatment than relying on local medical care in some areas. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in certain countries makes it important for travelers to bring quality manufactured drugs with them from a reliable supplier.
Encourage travelers to carry a travel health kit with prescription and nonprescription medications and review each traveler's medication list for possible drug-drug interactions (see Medication and Vaccine Interactions in Travel Medicine chapter; more detailed information for healthcare professionals and travelers is included in Travel Health Kits). Travelers with Additional Considerations, has supplementary travel health kit information for travelers who have additional health needs and considerations.
Address special health risks
Travelers with underlying health conditions require additional attention to health issues related to the destination and activities (see Travelers with Chronic Illnesses chapter). For instance, travelers with a history of cardiac disease should carry medical reports, including a copy of a recent electrocardiogram. Asthma can flare in a traveler visiting a polluted city or from physical exertion during a hike; recommend that travelers discuss with their primary healthcare professional a plan for treatment and carry necessary medication in case of asthma exacerbation. Travelers should be aware of the risks associated with medical tourism (e.g., infection, procedure complications) with specific counseling for any traveler planning to seek health care during travel (see Medical Tourism chapter). Advise travelers to identify any allergies or serious medical conditions on a bracelet or a card to expedite medical care in emergency situations (see Severely Allergic Travelers chapter). Section 5 provides more information on preparing for and obtaining health care abroad. Instruct travelers on how to obtain travel medical insurance (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter) and direct them to resources that provide lists of reputable medical facilities at their destination, such as:
Educate to change behavior
The pre-travel consultation provides another setting to remind travelers of basic health and safety practices during travel, including frequent handwashing, wearing seatbelts, using car seats for infants and children, wearing a helmet while riding a motorcycle or bicycle, safe sexual practices, and communicable disease prevention. Organize topics into a checklist and place priority on the most serious and frequently encountered issues (Box 1.1.3). In addition, address general noninfectious issues (e.g., jet lag, sunburn). Written information is essential to supplement verbal advice and enables travelers to review the instructions from their clinic visits. CDC's Travelers' Health website provides educational material. By giving advice on health risks and self-treatable conditions, healthcare professionals can minimize travelers' need to seek medical care while abroad and possibly help them return to good health faster.
Box 1.1.1
Box 1.1.2
Box 1.1.3
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