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New Guideline for Travel Medicine



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Am Fam Physician. 2007 Sep 15;76(6):878-884.

Background: There have been significant advances in the field of travel medicine over the past 25 years. Travel medicine is primarily concerned with maintaining wellness in travelers by minimizing environmental risks and preventing infectious disease. This guideline, developed by the Infectious Diseases Society of America, focuses on the most common issues in travel medicine including appropriate immunization, traveler's diarrhea, and the prevention of malaria. The full guideline is available at http://www.journals.uchicago.edu/CID/journal/issues/v43n12/40908/40908.html.

Recommendations: A pretravel health risk assessment is vital to ensure a traveler's well-being. This should include the traveler's age, underlying health conditions, medication use, immunization history, and trip details (e.g., planned activities, length of stay, lodging). Information about potential health hazards at specific destinations is available at http://www.cdc.gov/travel.

Immunization status of travelers should be reviewed, and routine immunizations should be updated as needed. Although hepatitis A is largely self-limited, fulminant hepatitis and death is more common in patients older than 40 years; immunization should be considered for travelers who have not had the disease. Yellow fever immunization is strongly recommended for persons traveling to equatorial South America and Africa. Vaccination centers offering yellow fever immunization can be found at http://www2.ncid.cdc.gov/travel/yellowfever. Other immunizations (e.g., meningitis, rabies, Japanese encephalitis, typhoid, and tick-borne encephalitis) should be offered to persons at high risk based on the nature of travel. Table 1 gives an overview of immunization recommendations for travelers.

Table 1

Immunization Recommendations for Travelers

Immunization Recommendations

Routine immunizations (e.g., hepatitis B, influenza, measles, mumps, pertussis, pneumonia, rubella, tetanus-diphtheria)

Should be updated before travel if clinically indicated

Hepatitis A

Recommended for all travelers, especially if traveling to regions with poor sanitation and hygiene

Japanese encephalitis, rabies, tick-borne encephalitis, typhoid

Should be considered on a case-by-case basis, depending on the nature of travel and potential risk of exposure

Meningitis

Required for persons traveling to Mecca; recommended for travelers to sub-Saharan Africa (i.e., Senegal to Ethiopia), especially if traveling between December and June

Polio

One lifetime booster is recommended for adults traveling to high-risk regions, especially Asia and Africa

Yellow fever

Recommended for travelers to endemic regions (e.g., equatorial South America and Africa)

Table 1   Immunization Recommendations for Travelers

View Table

Table 1

Immunization Recommendations for Travelers

Immunization Recommendations

Routine immunizations (e.g., hepatitis B, influenza, measles, mumps, pertussis, pneumonia, rubella, tetanus-diphtheria)

Should be updated before travel if clinically indicated

Hepatitis A

Recommended for all travelers, especially if traveling to regions with poor sanitation and hygiene

Japanese encephalitis, rabies, tick-borne encephalitis, typhoid

Should be considered on a case-by-case basis, depending on the nature of travel and potential risk of exposure

Meningitis

Required for persons traveling to Mecca; recommended for travelers to sub-Saharan Africa (i.e., Senegal to Ethiopia), especially if traveling between December and June

Polio

One lifetime booster is recommended for adults traveling to high-risk regions, especially Asia and Africa

Yellow fever

Recommended for travelers to endemic regions (e.g., equatorial South America and Africa)

Diarrhea is the most common travel illness. All travelers should be counseled about dietary hygiene and precautions including drinking bottled or boiled water and avoiding undercooked and improperly prepared foods. Although antibiotic prophylaxis is not recommended for most travelers, physicians may consider providing a fluoroquinolone prescription for up to three days or azithromycin (Zithromax). This would allow for prompt self-treatment if a fever greater than 101.3° F (38.5° C) or bloody diarrhea develops. Afebrile persons with nonbloody stools can usually be self-treated with an antidiarrheal medication such as loperamide (Imodium).

Malaria is highly preventable, yet more than 1,300 cases are reported annually in travelers returning to the United States. Most malaria cases are caused by non-adherence with or inappropriate chemo-prophylaxis. Prevention should include wearing long-sleeved shirts and long pants and sleeping in areas protected with netting that is treated with permethrin or another insecticide. Travelers should use an insect repellent containing at least 20 percent N,N-diethyl-m-toluamide.

Prophylaxis for malaria is recommended for those traveling to high-riskareas (Table 2). Although chloroquine Aralen) is effective for the prevention of malaria when traveling to Central America, the Dominican Republic, and much of the Middle East, alternative medications should be used when traveling to areas where resistant Plasmodium strains are common. Physicians should consider malaria as the cause of fever in any patient who presents within one year of traveling to an endemic area, regardless of whether they received prophylaxis.

Table 2

Antimalarial Medication Recommendations by Destination

Destination Medication

Argentina and Paraguay, Central America, Haiti and Dominican Republic, Middle East

Chloroquine (Aralen): 500 mg every week, beginning one week pretravel and continuing until four weeks posttravel

Asia, South America (except Argentina and Paraguay), sub-Saharan Africa

Atovaquone/proguanil (Malarone): 250/100 mg every day, beginning one to two days pretravel and continuing until seven days posttravel [corrected]

or

Mefloquine (Lariam): 250 mg every week, beginning one week pretravel and continuing until four weeks posttravel*


note: Risk (including drug-resistant strains) may be restricted to regions of some countries; targeted recommendations are available at http://www.cdc.gov/travel.

*—Mefloquine is not recommended for travelers to western Cambodia and forested areas of Thailand-Cambodia and Thailand-Burma borders because of multidrug-resistant Plasmodium falciparum.

Table 2   Antimalarial Medication Recommendations by Destination

View Table

Table 2

Antimalarial Medication Recommendations by Destination

Destination Medication

Argentina and Paraguay, Central America, Haiti and Dominican Republic, Middle East

Chloroquine (Aralen): 500 mg every week, beginning one week pretravel and continuing until four weeks posttravel

Asia, South America (except Argentina and Paraguay), sub-Saharan Africa

Atovaquone/proguanil (Malarone): 250/100 mg every day, beginning one to two days pretravel and continuing until seven days posttravel [corrected]

or

Mefloquine (Lariam): 250 mg every week, beginning one week pretravel and continuing until four weeks posttravel*


note: Risk (including drug-resistant strains) may be restricted to regions of some countries; targeted recommendations are available at http://www.cdc.gov/travel.

*—Mefloquine is not recommended for travelers to western Cambodia and forested areas of Thailand-Cambodia and Thailand-Burma borders because of multidrug-resistant Plasmodium falciparum.

Source

Hill DR, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. December 15, 2006;43:1499–539.


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