Traveling Healthy To Foreign Lands

A five part series on how to ensure that international travelers keep healthy and prevent the introduction of disease into the United States.

Kenneth J. DiLuigi, RN, MS, CNS, COHN-S

As companies expand into foreign areas, international travel has become a way of life for many Americans. Education, counseling and proper immunization are the best ways to ensure a safe and healthy trip, as well as prevent the introduction of disease into this country. Nurses in occupational health, physician offices, infectious disease and primary care settings are in key positions to help patients assess risk associated with travel and ensure their health abroad.

I. Being Healthy In the Air

The air travel part of a trip, including eating, sitting and sleeping, seems easy, but individuals need to follow some basic guidelines to stay refreshed after flying. Airline food can be overcooked, salty and high in calories, despite notoriously small portions. A typical meal has between 600 to 900 calories -- 60 percent of those are from fat. Travelers can request special meals and snacks that are low in fat, cholesterol and calories. Vegetarian, low-salt and diabetic meals are also available. Most airlines require a minimum of 24-hours notice for special requests, but an order for special meals can be placed when reservations are made.

Travelers should avoid alcohol and caffeine, which hasten dehydration. Alcohol can also aggravate the head congestion that is associated with poor air circulation in planes. Instead, drink a glass of water or fruit juice during each hour of flight time. If you must have caffeinated beverages, it's best to take them in the morning when traveling west, and in the evening when heading east. In addition, you may wish to avoid the high-fat peanuts that the airlines usually pass out and opt for packing your own personal "goodie bag" with snacks high in protein, such as cheese or carbohydrate-high raisins or fruit.

Jet lag can be problematic when traveling long distances. Traveling north, south, or less than two time zones doesn't seem to disrupt the body's circadian rhythm, but when crossing several time zones, precautions are necessary. Travelers should reset their watch to destination time and follow routines for meals and sleep based on that time, and catnap when they can. Outdoor exercise upon arrival in a new time zone can help the body reset its internal clock.

Exercise on the flight is also an excellent way to help reduce jet lag and prevent such complications as leg cramps, ankle swelling, muscular stiffness and indigestion. On long flights, travelers should take hourly walks in the aisles, use layover time in airports for exercise, tighten and loosen abdominal muscles periodically, and if prolonged sitting cannot be avoided, use elastic stockings. Caffeine, including chocolate, cola, tea and coffee, should be avoided for three days before departure. However, ingesting it between 2 p.m. and 4 p.m. will least affect the body clock. Lastly, try not to stay up late the night before a flight.

II. Immunizations Are The Key To Healthy Travel

Examine the itinerary at least six months before departure to allow time for immunization and other precautions. Consider country destinations and length of stay, the season (wet, dry), the location (urban, rural), the type of accommodations (hotel, camping), and activities (work, visits to other than usual tourist areas). Generally underdeveloped areas are associated with greater risks of food and water-borne infections, places remote from populated cities and tourist attractions with greater exposure to contaminated water, and more tropical regions with insect-transmitted infections.

Regardless of itinerary, international travelers need up-to-date tetanus-diphtheria (TD) and measles-mumps-rubella (MMR) vaccines. A booster dose of adult tetanus-diphtheria (Td) is recommended every 10 years.

In addition, adult travelers may want to consider :

  • Influenza (FluShield) vaccine - recommended for adults 65 years or older and for other high-risk individuals.
  • Pneumococcal (Pnu-Immune 23) vaccine - recommended for adults 65 years or older and for other high-risk individuals.

Polio vaccines are maintained as either inactivated poliovirus vaccine (IPV), live oral poliovirus vaccine (OPV) or, a combination of IPV and OPV. IPV is recommended for adults who are traveling to polio-endemic areas and who are unvaccinated or whose polio immunization status is unknown. IPV is preferred because the risk of vaccine-associated paralysis following OPV is higher in adults than in children. The recommended schedule is two doses given at a 1 to 2 month interval and a third dose given 6 to 12 months after the second.

In some circumstances, time will not allow completion of a routine IPV schedule. If 8 weeks or more are available before protection is needed, three doses of IPV should be given at least 4 weeks apart. If 4 to 8 weeks are available before protection is needed, two doses of IPV should be given at least 4 weeks apart. If more than 4 weeks are available before protection is needed, a single dose of either OPV or IPV is recommended. In all instances, the remaining doses of vaccine should be given later, at the recommended intervals, if the person remains at increased risk.

Adults traveling to polio-endemic areas who have previously received one or more doses of either OPV or IPV, but who did not complete a primary series should be given the remaining required doses of either OPV or IPV, regardless of the interval since the last dose. It is not necessary to restart the series or add additional doses because of a prolonged interval between doses.

For persons who have received a complete series of polio vaccine (either IPV or OPV), an additional single dose of the OPV or IPV vaccine should be received by persons 18 years of age and older traveling to the developing countries of Africa, Asia, Middle East and the majority of the New Independent States of the former Soviet Union .

This additional dose of polio vaccine is necessary for travelers to risk areas only once in adulthood. These adults, being previously vaccinated, are not at increased risk of side effects, such as vaccine-associated paralytic polio. The need for further supplementary doses has not been established.

Persons born in, or after, 1957 should consider a second dose of measles vaccine before traveling abroad.

The Centers for Disease Control (CDC) maintains an International Travelers Hotline and a worldwide web site (http://www.cdc.gov) on the Internet for information about current standards and about world-wide disease activity.

Diseases transmitted by insects, such as mosquito-spread Yellow Fever and malaria, are still problematic.

Yellow Fever occurs in certain jungle locations of South America and Africa where the virus is maintained in a cycle among forests, mosquitoes and monkeys. In South America, sporadic infections occur almost exclusively in forestry and agricultural workers who are exposed occupationally in or near forests. In Africa the virus is transmitted in the moist savanna zones of West Africa during the rainy season, and infections occur principally among children. At intervals, massive outbreaks resulting in thousands of cases develop in urban locations and villages in the dry savanna of Africa.

Yellow Fever is a viral disease transmitted between humans by a mosquito. General precautions to avoid mosquito bites should be followed. These include the use of insect repellent, protective clothing, and mosquito netting. Yellow Fever is a very rare cause of illness in travelers, but most countries have regulations and requirements for Yellow Fever vaccination that must be met prior to entering the country.

Yellow Fever vaccine is the only vaccine that may be required for entry into certain countries of Africa and South America. After immunization an International Certificate of Vaccination is issued and will meet entry requirements for all persons traveling to or arriving from countries where there is active or a potential for Yellow Fever transmission. The certificate is good for 10 years. Most countries will accept a medical waiver for persons with a medical contraindication to vaccination (i.e., infants less than 4 months old, pregnant women, persons hypersensitive to eggs, or those with an immunosuppressed condition, such as HIV). CDC recommends obtaining written waivers from consular or embassy officials before departure.

Doctors or travelers can receive vaccine requirements based on their travel itineraries by contacting state or local health departments for the most recent recommendations or by checking the CDC Web site. The vaccine is obtained from Yellow Fever Vaccine Centers designated by your state health department. Consult your local health department for Yellow Fever vaccination sites near you. The CDC does not keep a list of registered Yellow Fever vaccination sites.

Malaria is prevalent in the tropical regions. Prophylaxis consists of a weekly dose of mefloquine (Lariam), if traveling to areas where chloroquine-resistant Plasmodium falciparum (causative agent of malaria) is present. In areas where P.falciparum is sensitive to chloroquine (Aralen), chloroquine should be taken one week before, during and four weeks after travel. People who travel to areas where drug-resistant P.falciparum is endemic and for whom mefloquine is not recommended may elect to use an alternative drug such as doxycycline (Vibramycin). Advise individuals to be vigilant for the flu-like symptoms of malaria, which may appear up to a year after exposure, and seek immediate medical attention.

Travelers can minimize risk by avoiding infectious mosquitoes. Warn them to stay in areas protected by screens or mosquito nets, to wear clothes that thoroughly cover the body, and to apply insect repellent to all exposed areas. The CDC recommends repellents that contain DEET (N, N-diethylmetatoluamide) in concentrations below 35 percent. For children, the concentration of DEET should be less than 8 percent. An application of permethrin-containing repellents by spray, or by soaking clothing and bednets, will repel insects for several weeks.

Food and waterborne diseases, such as typhoid fever, cholera, and Hepatitis A, can cause serious illnesses.

Vaccination against typhoid fever is recommended for travelers to areas where there is a recognized risk of exposure to Salmonella typhi, such as the Indian subcontinent, Asia, Africa and Latin America, and particularly for those visiting small cities or rural areas, or traveling for an extended period in areas with recognized risk. Three typhoid vaccines are currently available for use in the United States, one oral and two parenteral preparations. All three vaccines have been shown to produce 50 percent to 80 percent immunity.

A vaccine for cholera, only 50 percent effective for three to six months after vaccination, is also routinely prescribed. However, it is not recommended for infants under six months of age, or pregnant women. Currently, no country or territory requires cholera vaccination as a condition of entry. Local authorities, however, may continue to require documentation of vaccination against cholera. In such cases, a single dose of vaccine is sufficient to satisfy local requirements. The primary series -- two injections given one to four weeks apart -- is followed by a booster once every six months. The complete two-dose primary series is suggested only for special high-risk groups that work and live in highly endemic areas under less than adequate sanitary conditions.

The Hepatitis A virus infects people through the fecal-oral route or from contaminated water or food, especially shellfish. CDC recommends vaccination for travelers to all Japan, Australia, New Zealand, Northern and Western Europe and North America (excluding Mexico). However, when visiting areas of these excluded countries with intermediate or high endemicity of Hepatitis A, you may wish to consider the vaccination. The dosage of Hepatitis A vaccine may vary according to the person's age or, in the case of Havrix A, on a schedule determined by the manufacturer of the vaccine.

Japanese encephalitis or tick-borne encephalitis vaccines should be considered for long-term travelers to areas of risk.

Diseases transmitted through intimate contact pose a more limited risk. Most travelers are not routinely in jeopardy for Hepatitis B, which is transmitted through the exchange of blood and blood products, sexual activity, or contact with open skin lesions of infected persons. Hepatitis B vaccine should be considered for those who will live six months or more in areas where there are high rates of Hepatitis B such as Southeast Asia, Africa , the Middle East, the islands of the South and Western Pacific, and the Amazon region of South America.

Previously unvaccinated persons who will work in healthcare areas of high Hepatitis B endemicity or persons who anticipate intimate contact with the local population should be vaccinated. In addition, if it is likely that medical or dental treatment will be sought in local facilities, vaccination is recommended.

The Hepatitis B vaccine is highly effective, but doses need to be started six months before travel. In addition, serum titer levels for antibodies should be drawn to confirm effectiveness of the vaccine since 5 to 15 percent of the population will fail to develop a significant serum titer to the two available Hepatitis B vaccines.

All vaccines (except cholera and Yellow Fever vaccines) may be safely administered simultaneously without any decrease in effectiveness. Immune globulin (IG) may be simultaneously administered at different body locations with an inactivated vaccine such as DTaP, IPV, Hib, and Hepatitis A and Hepatitis B vaccines. However, IG diminishes the effectiveness of live-virus MMR and varicella vaccines if IG is given simultaneously. IG does not interfere with either OPV or Yellow Fever vaccine when given simultaneously.

III. Eating the Food & Drinking the Water

Poorly prepared and contaminated food is the major source of health problems in travelers in tropical and developing countries. A good rule to pass on is: "Boil it, cook it, peel it or forget it". All raw vegetables, which may be grown or washed with contaminated water, should be avoided. Completely peel all fruits and handle mangos with care. The stem of the mango emits a liquid that can cause a serious skin rash.

Travelers should stay away from all sauces, especially those served at room temperature. Also, fresh cheese and spicy foods are common sources of travelers' diarrhea. Dry or canned milk is preferable over fresh. If in doubt, hot soup, toast and hard-boiled eggs are generally safe. Most food, cooked and still hot, is probably safe, although cooking cannot guarantee disease-free fish.

Caught on tropical reefs rather than in the open ocean, tropical reef fish, red snapper, amberjack, grouper and sea bass can be toxic. And, never eat barracuda or puffer fish.

In many parts of the world, water, ice and even some bottled water can be hazardous. To reduce the chance of contracting water-borne diseases, advise travelers to drink only water from bottles with intact seals. They should also use bottled water to brush their teeth or rinse their mouths and contact lenses. However, locally bottled water, along with water that is advertised as "filtered", rather than purified, may be contaminated.

Travelers should also be wary of ice cubes, fruit juices and iced tea, which may be made out of or diluted with contaminated water. Several safe methods for purifying water are available. Prepare water on a daily basis rather than make large quantities at one time because it can be recontaminated during storage. Finally, individuals need to keep in mind that the alcohol in liquor will not kill bacteria.

Water can also contain parasites. Schistosomiasis infection begins when larvae of a flatworm, common to fresh water in many parts of the world, penetrate a person's broken or intact skin and migrate into the portal circulation. Adult worms eventually lodge in the bladder or intestines.

Salt water and water treated with chlorine or iodine is safe, but fresh water can be infested. Swimming or bathing in fresh water in rural areas should be avoided. Bath water should be heated to 122 degrees F (50 degrees C) for five minutes or treated with chlorine or iodine. If exposed, immediate and vigorous towel drying and application of alcohol may reduce risk. However, if infection is suspected, individuals need to seek a healthcare provider for screening and possible treatment with medication.

Traveler's diarrhea is usually acquired through ingestion of fecally contaminated food or water. Areas of high risk include Africa, the Middle East and Latin America. Although symptoms of diarrhea, nausea, bloating, urgency and malaise can last up to seven days, most episodes resolve on their own within a few days. The best way to avoid this problem is to be careful with food and beverage choices. Otherwise, oral fluids, soft drinks and salted crackers are recommended treatment. Severe dehydration may require the aid of a home-brewed rehydration drink of water, sugar, salt and baking soda or a commercial preparation such as Gatorade, which may be available abroad.

Antimicrobial drugs, such as doxycycline or trimethoprim/sulfamethoxazole (Bactrim, Septra), may shorten the length of the illness, but should not be used as preventive measures. Antidiarrheals, such as diphenoxylate (Lomotil) or loperamide (Imodium) are also inadvisable. While alleviating symptoms, these agents can diminish gastric motility and lead to intestinal obstruction. A healthcare provider needs to be consulted if diarrhea is severe, bloody or lasts more than a few days.

IV. What If You're Pregnant?

Travel for most women is safe through the second trimester. Long distance journeys are not recommended during the last trimester due to chances of early labor. Those travelers going to a hot climate may be exceptionally uncomfortable because of increased metabolism.

Unless sanctioned by their healthcare provider, pregnant women need to avoid areas at high altitude. Adjusting to the decrease in oxygen can be very taxing and dangerous to both mother and fetus due to hypoxemia. If it is absolutely necessary that she make the trip, advise the pregnant traveler to limit exertion for several days after arrival to minimize the risk of developing acute mountain sickness (AMS).

This condition is characterized by loss of appetite, nausea, vomiting, restlessness, headache, shortness of breath, scanty urine and psychological changes. Lastly, pregnant women should not fly in non-pressurized cabins at altitudes exceeded 10,000 feet above sea level, which is sometimes a problem in small private planes.

Other inappropriate destinations are developing regions of the world for which vaccinations would be necessary. Many of these locales may harbor dangerous infections that would affect the fetus, and for which no vaccines are available.

Women who are pregnant or who are likely to become pregnant within 3 months should not receive MMR or varicella vaccines. Yellow Fever or polio (OPV) vaccines should be given to pregnant women only if there is a substantial risk of exposure. If given during pregnancy, waiting until the second or third trimester minimizes theoretical concerns over possible birth defects.

Women in the second and third trimesters of pregnancy have been found to be at increased risk of complications from influenza. Because the currently available influenza vaccine is an inactivated vaccine, many experts consider influenza vaccination safe during any stage of pregnancy.

A study of influenza vaccination of more than 2,000 pregnant women demonstrated no adverse fetal affects associated with influenza vaccine. However, more data are needed. Some experts prefer to administer influenza vaccine during the second trimester to avoid a coincidental association with spontaneous abortion (miscarriage), which is common in the first trimester, and because exposures to vaccines have traditionally been avoided during this time.

No convincing evidence for risk to the unborn baby from inactivated viral or bacterial vaccines or toxoids administered to pregnant women has been documented. These vaccines include: Hepatitis A, Hepatitis B, rabies, injectable typhoid, meningococcal, pneumococcal, tetanus-diphtheria toxoid (adult formulation), and IPV. Immune globulin can be given to pregnant women.

Specific information is not available on the safety of cholera vaccine during pregnancy, therefore, it is prudent on theoretical grounds to avoid vaccinating pregnant women. Pregnant women should not be vaccinated against Yellow Fever because of a theoretical risk that the developing fetus may become infected from the live vaccine. All vaccines may be administered safely to children of pregnant women and to breast-feeding mothers.

V. Managing Illnesses While Traveling

The safest way to travel is to go prepared. First, pack a medical kit -- containing all of the things they need to help you "COPE" -- Credit card, Over-the-counter medications, Prescriptions, Eyeglasses (extra pair and duplicate prescription). Don't forget medical "jewelry" to alert others of special medical conditions should they be unable to do so.

Medic-Alert, at (800)-ID-ALERT, is open 24 hours a day and can be called collect from anywhere in the world. Interpreters are available to translate an individual's medical history to a foreign physician.

Before leaving the United States, check with your medical insurance company. Some medical insurance providers offer members a phone number that can be called from any location in the world to learn the name of the nearest participating facility.

Travelers should always consult the CDC Traveler's Hotline for the most current health information in any geographic region.

The International Association for Medical Assistance to Travelers (IAMAT) maintains a valuable directory of English-speaking physicians who have agreed to treat travelers for a set fee. To be eligible, a membership card can be obtained free of charge. The directory of IAMAT physicians lists participating doctors in 125 countries and their telephone numbers. The physicians agree to a set payment schedule for the first visit for members. Referrals, consultations, laboratory procedures, hospitalizations and other medical services are, of course, not subject to this fee schedule. To obtain more information and a membership, visit their Web site at http://www.sentex.netiamat/mb.html or, in the United States, call (716)-754-4833. The IAMAT also publishes disease-specific information, worldwide climatic and sanitary conditions, and required and suggested immunizations.

If individuals become ill while abroad, they can also look for a pharmacy. Overseas pharmacists often offer advice on minor illnesses. In addition, they probably would be able to direct you to an English-speaking medical facility. Lastly, depending on the country visited, medications that travelers are taking may not be available due to marketing constraints of the pharmaceutical manufacturer. Advise travelers to ensure that they carry an adequate supply of all medications in quantities that will suffice for the duration of their trip.

Travelers rarely anticipate serious accidents or injuries, however motor vehicle accidents are the leading cause of death to travelers in developing countries. The well-informed traveler needs to be aware of several options should an emergency arise. International SOS, the U.S. State Department (American Embassy), and Overseas Emergency Center, all offer emergency assistance and evacuation.

Nurses and other healthcare providers can offer much information to prepare and guide patients who are planning to make overseas journeys. Educated travelers embark with the knowledge to make wise health decisions to enhance their travel, reduce the inconvenience and perhaps save their own lives.

Kenneth J. DiLuigi, RN, MS, CNS, CEN, CFRN, CNAA, COHN-S is a Clinical Nurse Specialist in Occupational & Environmental Medicine for the Global Environmental Engineering, Safety & Industrial Hygiene group at Wyeth-Ayerst Pharmaceuticals in King of Prussia, Pennsylvania. He is also a part-time Emergency Nurse and Flight Nurse for Tenet Healthcare Systems in Philadelphia, Pennsylvania.

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