Foreign Travel

Travelers should be current on all routine immunizations, including COVID-19. Some countries require specific vaccinations (see table Vaccines for International Travel). The Centers for Disease Control and Prevention (CDC) website provides general travel and up-to-date immunization information and malaria chemoprophylaxis requirements (also available from the CDC's malaria hotline: 855-856-4713).

Patients should be advised to check the website of their nation's health agency (eg, CDC in the United States) as well as the destination countries' health agencies for possible health requirements related to COVID-19.

Dengue fever is a mosquito-borne viral infection endemic to the tropical regions of the world in latitudes from about 35° north to 35° south. Global cases of dengue fever are increasing. Outbreaks are most prevalent in Southeast Asia but also occur in the Caribbean, including Puerto Rico and the US Virgin Islands, Oceania, and the Indian subcontinent; more recently, dengue incidence has increased in Central and South America.

In the United States, the dengue vaccine CYD-TDV is approved for use in children and adolescents 9 to 16 years of age who have laboratory-confirmed previous dengue virus infection and are living in an area where dengue is endemic, but is not recommended or available for travelers. (See CDC: Dengue Vaccine Recommendations for information regarding the manufacturer discontinuing this vaccine.) The FDA is evaluating another dengue vaccine candidate (TAK-003) for the prevention of the viral disease caused by any serotype. TAK-003 is approved for use in Indonesia, the European Union, and the United Kingdom.

CDC: Prevent Mosquito Bites). These measures also offer protection from other insect-transmitted diseases including Zika and chikungunya.

Influenza is common in international travelers; hence annual influenza vaccines are indicated for all travelers.

Malaria is endemic in much of Africa, Asia, Latin America, and other regions. The CDC provides information about specific countries where malaria is transmitted (see Yellow Fever and Malaria Information, by Country), types of malaria, and resistance patterns.

Travelers to endemic regions should take preventive measures for malaria, including chemoprophylaxis. Although the RTS,S/AS01 (RTS,S) malaria vaccine is recommended for children living in regions with moderate to high Plasmodium falciparum malaria transmission, this vaccine is not recommended for travelers to those regions.

SchistosomiasisSchistosoma mansoni, S. haematobium, S. intercalatum) or 20 mg/kg 3 times per day for 1 day (S. japonicum, S. mekongi).

Traveler’s diarrhea (TD) is the most common health problem among international travelers. TD is usually self-limited, typically resolving in 5 days; however, 3 to 10% of travelers with TD may have symptoms lasting > 2 weeks, and up to 3% of travelers have TD lasting > 30 days. TD lasting < 1 week requires no testing. For persistent TD, laboratory testing is done.

Self-initiated treatment is indicated for moderate to severe symptoms, especially if vomiting, fever, abdominal cramps, or blood in the stool are present. Treatment of traveler's diarrhea< 2 years); replacement of fluids; and, in older people and small children, electrolytes (eg, oral rehydration solution).

Measures that may decrease the risk of TD include

• Drinking and brushing teeth with bottled, filtered, boiled, or chlorinated water

• Avoiding ice

• Eating freshly prepared foods only if they have been heated to steaming temperatures

• Eating only fruits and vegetables that travelers peel or shell themselves

• Avoiding food from street vendors

• Washing hands frequently

• Avoiding all foods likely to have been exposed to flies

Road traffic crashes are the most frequent non-natural cause of death of international travelers. Travelers should at all times use a seat belt in vehicles and a helmet when cycling. Travelers should avoid motorcycles and mopeds and avoid riding on bus roofs or in open truck beds.

Drowning is another common cause of death while abroad. Travelers should avoid beaches with turbulent surf and avoid swimming after drinking alcoholic beverages.

The most common medical problem after travel is

• Persistent traveler's diarrhea

The most common potentially serious diseases are

• Malaria

• Hepatitis A and B

• Typhoid fever

• Sexually transmitted infections, including HIV infection

• Amebiasis

• Meningitis

People can also acquire lice and scabies after being in crowded living conditions or places where hygienic measures are poor.

Some diseases become evident months after a traveler has returned home; a travel history with exposure risks is a useful diagnostic clue when patients present with a puzzling illness. The International Society of Travel Medicine (www.istm.org) has lists of travel clinics. Many of these clinics specialize in assisting travelers who are ill after their return home. For health care professionals, the Centers for Disease Control provides assistance and information to help patients returning from travel abroad.