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• Section 1 - Maps & Travel Medicine
• Section 2 - The Pretravel Consultation

Improving the Quality of Travel Medicine Through Education & Training

Cdc yellow book 2024.

Author(s): Suraj Arshanapally, Jessica Allen Tchoukalov

Individuals planning international travel benefit from a pretravel visit dedicated to health-related travel recommendations. Such consultations with clinicians can help travelers remain healthy during and after travel.

Recent outbreaks of infectious diseases (e.g., Zika, coronavirus disease 2019 [COVID-19]) demonstrate the role of international travel in the geographic spread of disease. These outbreaks highlight the need to equip more clinicians with travel medicine training to ensure they can properly educate and advise travelers and prevent travel-related disease spread.

Travel Medicine Education & Training

The pretravel consultation is most effective when the clinician has experience and training related to travel medicine and can provide travelers with up-to-date information and guidance. In the United States, many types of health care professionals, ranging from infectious disease specialists to family medicine practitioners, offer travel medicine care and counseling. Travel medicine professional organizations offer training opportunities and certification programs for clinicians. This training is available via in-person courses or e-learning (e.g., webinars, workshops, online courses). Outlined below are several organizations that provide travel medicine-related trainings and education.

Travel Medicine-Related Professional Organizations

Aerospace medical association.

The  Aerospace Medical Association (AsMA) represents professionals in the fields of aviation, space, and environmental medicine who take care of air and space travelers. AsMA publishes the journal Aviation, Space, and Environmental Medicine; hosts an annual scientific meeting; and offers continuing medical education and certification in aerospace medicine–related topics.

American Society of Tropical Medicine and Hygiene

Formed in 1951 through the merger of predecessor organizations dating back to 1903, the  American Society of Tropical Medicine and Hygiene (ASTMH) has a subsection, the American Committee on Clinical Tropical Medicine and Travelers’ Health, that focuses exclusively on tropical and travel medicine. ASTMH publishes The American Journal of Tropical Medicine and Hygiene, a peer-reviewed scientific journal; hosts the ASTMH annual meeting; hosts an electronic distribution list; and maintains a tropical and travel medicine consultant directory.

In addition, ASTMH offers the CTropMed examination, which leads to a  Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health . CTropMed is open to clinicians with a current professional health care license who have passed an ASTMH-approved tropical medicine diploma course or who have sufficient tropical medicine experience. ASTMH also hosts an annual intensive update course in clinical tropical medicine and travelers’ health, designed to prepare clinicians planning to take the CTropMed examination.

Infectious Diseases Society of America

The  Infectious Diseases Society of America (IDSA) is the largest organization representing infectious disease clinicians in the United States. IDSA has many active members with expertise in tropical and travel medicine. In 2006, IDSA published evidence-based guidelines on the practice of travel medicine in the United States. IDSA publishes travel-related research in 3 journals: The Journal of Infectious Diseases, Clinical Infectious Diseases, and Open Forum Infectious Diseases. IDSA also co-sponsors the annual  IDWeek meeting and the online  Emerging Infections Network (EIN), a provider-based sentinel network to assist public health authorities with emerging infectious disease surveillance.

International Society for Infectious Diseases

The  International Society for Infectious Diseases (ISID) was organized in 1986 and has approximately 80,000 members in 201 countries. Like IDSA, ISID does not specifically focus on travel medicine. However, its international reach, particularly in low-resource countries, makes travel medicine an important topic in ISID and makes ISID a valuable source of information for infectious diseases clinicians in many overseas travel destinations.

ISID publishes the International Journal of Infectious Diseases and hosts the biennial International Congress on Infectious Diseases and the International Meeting on Emerging Diseases and Surveillance. In addition, ISID hosts the  Program for Monitoring Emerging Diseases (ProMED)—an open-source electronic system for reporting emerging infectious diseases and toxins, including outbreaks— and the  EpiCore  global outbreak surveillance system.

International Society of Travel Medicine

The  International Society of Travel Medicine (ISTM) is a multinational organization dedicated to promoting healthy, safe, and responsible travel and movement of all people crossing borders by facilitating advancement of epidemiologic surveillance and research, education, and service in travel and migration medicine. ISTM was founded in 1991 and has over 4,000 members worldwide. ISTM publishes the peer-reviewed Journal of Travel Medicine and hosts the TravelMed listserv, where members share information. ISTM also maintains a  directory of domestic and international travel medicine clinics affiliated with ISTM members in 90 countries. ISTM hosts committees that address pressing issues in travel medicine (e.g., digital communications and publications); special interest and professional groups, including groups for travel medicine nurses and travel medicine pharmacists; the biennial Conference of the International Society of Travel Medicine; and annual regional sub-meetings.

In addition, ISTM provides an online learning curriculum and offers the  Certificate in Travel Health (CTH) Examination; passing the examination is one of several required elements for health care professionals (including physicians, nurses, and pharmacists) who provide travel health advice and who participate regularly in travel medicine professional development to receive ISTM certification. ISTM also provides an annual intensive update course in travelers’ health designed to prepare clinicians planning to take the CTH exam.

Wilderness Medical Society

Organized in 1983, the  Wilderness Medical Society (WMS) focuses on adventure travel, including wilderness travel and diving. WMS publishes the journal Wilderness and Environmental Medicine, and has developed practice guidelines for emergency care in wilderness settings. WMS hosts annual meetings, a world congress, and subspecialty meetings. In addition, WMS offers courses leading to certification in advanced wilderness life support and courses leading to the Diploma in Mountain Medicine (DiMM). WMS also offers a wilderness medical curriculum that, when successfully completed, qualifies members for fellowship in the Academy of Wilderness Medicine.

In addition to the above-mentioned organizations, the World Health Organization maintains a  list of regional and national societies of travel medicine on its website.

The following authors contributed to the previous version of this chapter: Keun Lee, Stephen M. Ostroff

Bibliography

Chiodini JH, Anderson E, Driver C, Field VK, Flaherty GT, Grieve AM, et al. Recommendations for the practice of travel medicine. Travel Med Infect Dis. 2012;10(3):109–28.

Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;42(12):1499–539.

Kozarsky PE, Steffen R. Travel medicine education—what are the needs? J Travel Med. 2016;23(5):taw039. LaRocque RC, Jentes ES. Health recommendations for international travel: a review of the evidence base of travel medicine. Curr Opin Infect Dis. 2011;24(5):403–9.

Leder K, Bouchard O, Chen LH. Training in travel medicine and general practitioners: a long-haul journey! J Travel Med. 2015;22(6):357–60. Ruis JR, van Rijckevorsel GG, van den Hoek A, Koeman SC, Sonder GJ. Does registration of professionals improve the quality of travelers’ health advice? J Travel Med. 2009;16(4):263–6.

Schlagenhauf P, Santos-O’Connor F, Parola P. The practice of travel medicine in Europe. Clin Microbiol Infect. 2010;16(3):203–8.

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What to Know About the C.D.C. Guidelines on Vaccinated Travel

In updated recommendations, the federal health agency said both domestic and international travel was low risk for fully vaccinated Americans. But travel remains far from simple.

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By Ceylan Yeginsu

The Centers for Disease Control and Prevention updated its guidance for fully vaccinated Americans in April, saying that traveling both domestically and internationally was low risk.

The long-awaited recommendations were issued by federal health officials after a series of studies found that vaccines administered in the United States were robustly effective in preventing infections in real-life conditions.

One is considered fully vaccinated two weeks after receiving the single dose of the Johnson & Johnson vaccine, or two weeks after receiving the second dose of the Pfizer-BioNTech or Moderna shots.

If you decide to travel, you might still have some questions. Here are the answers.

Will I still need to wear a mask and socially distance while traveling?

Yes. Under federal law, masks must be worn at airports in the United States, onboard domestic flights and in all transport hubs. The C.D.C. says that as long as coronavirus measures are taken in these scenarios, including mask wearing, fully vaccinated Americans can travel domestically without having to take a test or quarantine, although the agency warns that some states and territories may keep their local travel restrictions and recommendations in place.

For those wishing to travel internationally, a coronavirus test will not be required before departure from the United States unless mandated by the government of their destination. Vaccinated travelers are still required to get tested three days before travel by air into the United States, and are advised to take a test three to five days after their return, but will not need to self-quarantine.

Can I go abroad?

Yes, but only to countries that will have you.

More than half the world’s countries have reopened to tourists from the United States, including the countries of the European Union , which on June 18 added the United States to its “safe list” of countries, meaning that American travelers can now visit. While the European Union aims to take a coordinated approach to travel this summer, member states will be allowed to set their own requirements for travelers from individual countries based on their own epidemiological criteria, which means they may require testing or vaccination.

Some places like Turkey, Croatia and Montenegro had already been welcoming Americans with negative test results. Greece joined that growing list in May, ahead of most European countries, opening to fully vaccinated tourists and other foreigners with a negative test.

Many Caribbean nations have reopened to American tourists, but each has its own coronavirus protocols and entry requirements.

Here’s a full list of countries Americans can currently travel to.

What about domestic travel? Is it free and clear to cross state borders?

If you are fully vaccinated, the C.D.C. says you can travel freely within the United States and that you do not need to get tested, or self-quarantine, before or after traveling. But some states and local governments may choose to keep travel restrictions in place, including testing, quarantine and stay-at-home orders. Hawaii , for instance, still has travel restrictions in place.

Before you travel across state lines, check the current rules at your destination.

How are they going to check that I’m fully vaccinated?

Right now, the best way to prove that you have been vaccinated is to show your vaccine card .

Digital vaccine and health certificates showing that people have been vaccinated or tested are in various stages of development around the world and are expected, eventually, to be widely used to speed up travel.

The subject of “ vaccine passports ” is currently one of the most hotly debated topics within the travel industry, with questions over the equity of their use and concerns over health and data privacy.

In early April, Gov. Ron DeSantis of Florida issued an executive order that would ban local governments and state businesses from requiring proof of vaccination for services.

And in March, the European Union endorsed its own vaccine certificate , which some countries are already using, with more expected to adopt it by July 1.

But what about my kids? What’s the guidance on traveling with unvaccinated people?

The C.D.C. advises people against travel unless they have been vaccinated. If you must travel, the agency recommends testing one to three days before a trip and following all coronavirus guidance at your destination.

In May, the F.D.A. expanded its emergency use authorization of the Pfizer-BioNTech coronavirus vaccine to include adolescents between 12 and 15 years of age.

All air passengers aged two and older coming into the United States, including fully vaccinated people, are required to have a negative Covid-19 test result taken no more than three days before they board their flight.

What is my moral obligation to the places I visit where most people are not vaccinated?

The United States inoculation rollout has been among the fastest in the world, but there is a stark gap between its rapid rollout and the vaccination programs in different countries. Some nations have yet to report a single dose being administered.

Many countries are currently seeing a surge in new cases and are implementing strict coronavirus protocols, including mask mandates in public spaces, capacity limits at restaurants and tourist sites and other lockdown restrictions.

It is important to check coronavirus case rates, measures and medical infrastructure before traveling to your destination and not to let your guard down when you get there. Even though you are fully vaccinated, you may still be able to transmit the disease to local communities who have not yet been inoculated.

You can track coronavirus vaccination rollouts around the world here.

Follow New York Times Travel on Instagram , Twitter and Facebook . And sign up for our weekly Travel Dispatch newsletter to receive expert tips on traveling smarter and inspiration for your next vacation.

Ceylan Yeginsu is a London-based reporter. She joined The Times in 2013, and was previously a correspondent in Turkey covering politics, the migrant crisis, the Kurdish conflict, and the rise of Islamic State extremism in Syria and the region. More about Ceylan Yeginsu

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Understanding CDC Travel Health Notices

The U.S. Centers for Disease Control and Prevention (CDC) uses Travel Health Notices (THN) to “inform travelers and clinicians about current health issues that impact travelers’ health, like disease outbreaks, special events or gatherings, and natural disasters, in destinations around the world.”

On April 13, 2022 the CDC announced significant changes to the Travel Health Notices (THN) specific to COVID-19. The structure of the 4 level system will reserve the highest level-'Level 4: Do Not Travel' for only special circumstances such as a healthcare infrastructure collapse or extreme spikes in case counts of COVID-19 levels. This change resulted in 89 countries being removed from the "Level 4: Do Not Travel" list.

CDC Travel Health Notices for Levels 1, 2, and 3 will continue to be based on a 28-day incidence or case counts.

The 4 COVID-19 Travel Health Notice levels are: 

Level 4 – Special Circumstances/Do Not Travel

Level 3 – High Level of COVID-19

Level 2 – Moderate Level of COVID-19

Level 1 - Low Level of COVID-19

Level Unknown: Unknown Level of COVID-19

Read more from the CDC on how COVID-19 Travel Health Notices are determined here .

The CDC's standard (non-COVID-19)  Travel Health Notice system  has 3 levels: 

Warning Level 3 – Avoid all non-essential travel 

Alert Level 2 – Practice Enhanced Precautions 

Watch Level 1 – Practice Usual Precautions 

This standard THN system will remain in use alongside the C OVID-19 specific travel health notices introduced by the CDC in 2020. 

COVID-19 vaccines currently appear as recommended vaccines on CDC Country Information pages . When COVID-19 vaccines were authorized under an Emergency Use Authorization process, they were not listed on Country Imformation pages by the CDC. Now that the COVID vaccines are authorized under general use guidelines per the FDA, they have been added to a list of recommended vaccines on CDC Country pages.

Colleges, universities, and provider organizations consider CDC Travelers Health Notices and other information provided by the CDC (e.g., vaccinations and immunizations) in their evaluation of the relative health and safety of an education abroad location. 

Visit CDC Travelers Health COVID-19 Homepage  

Some other sources are:

• WHO Efficiency of Care
• Global Health Security Index assessment
• Harvard Metrics on Case Rates
• WHO current COVID infection rates/spread 
• Our World in Data Daily Positive Test Rates
• European Centre for Disease Prevention and Control 14-day cumulative number of COVID-19 cases per 100 000
• CIEE Health Risk Index
• ISOS (COVID-19) Impact Rating  

NAFSA Education Abroad Health and Safety  

Crisis Management for Education Abroad

Outbound Immigration and Logistical Considerations for Education Abroad During the COVID-19 Pandemic  

Government Connection: Understanding CDC Travel Health Notices  

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CDC Updates COVID Travel Guidance for 120 Countries Ahead of Summer

Images By Tang Ming Tung / Getty Images

Key Takeaways

• The Centers for Disease Control and Prevention has updated its COVID travel guidance for more than a hundred countries.
• The CDC classifies travel to each country by level of COVID-19 risk.
• Infectious disease experts say it's relatively safe to travel internationally now, provided you're vaccinated and avoid high-risk countries.

The Centers for Disease Control and Prevention (CDC) has issued new COVID-19 travel guidelines for more than 120 countries.

The updated advice offers detailed information on specific countries for travelers who are vaccinated and for those who aren't. The CDC specifically assigns risk levels to each country based on the number of cases per 100,000 people.

To use the new guidance , travelers can search by the name of the country they’re interested in visiting and then learn whether its COVID-19 risk is very high, high, moderate, low, or unknown.

The CDC also offers detailed advice on what to do to stay safe in that particular country, broken down by whether you’re vaccinated or unvaccinated.

The new guidance arrives as COVID-19 cases dip to low levels previously seen at the start of the pandemic in March 2020.  As vaccination increases and cases drop, travel among Americans is picking up speed.

Just days after the CDC's updated guidance, the Transportation Security Administration (TSA) announced that it screened more than 2 million passengers on the same day for the first time since March 2020.

What the Risk Levels Mean

The CDC divides up countries based on four levels of risk.

Level 4: Very High Risk

Countries that are classified as very high-risk have more than 500 new cases per 100,000 people over the past 28 days. The CDC recommends against traveling to these countries, which currently include Brazil, India, and Iraq.

Level 3: High Risk

These countries have 100 to 500 cases per 100,000 residents. The CDC specifically recommends avoiding nonessential travel to these countries—including Mexico, Russia, and Iran—for people who are unvaccinated.

Level 2: Moderate Risk

Level 2 countries have 50 to 99 cases per 100,000, and currently include Finland, Cambodia, and Kenya. The CDC suggests that people who are unvaccinated and at increased risk of severe illness from COVID-19 avoid these countries.

Level 1: Low Risk

Level 1 countries are nations with less than 50 COVID-19 cases per 100,000 people, and include Australia, Israel, and Singapore. The agency still recommends that you get vaccinated before you travel to one of them.

What This Means For You

The CDC breaks down which countries are considered high and low risk for travel right now. If you decide to travel internationally, first check the risk level of the country you’re interested in visiting, and don’t forget to wear a mask on your journey.

Is International Travel Safe Right Now?

Infectious disease experts say your safety depends on your vaccination status. “For a fully vaccinated individual, international travel is low-risk,” infectious disease expert  Amesh A. Adalja, MD , senior scholar at the Johns Hopkins Center for Health Security, tells Verywell.

“If you’re fully vaccinated, I think international travel is OK,” Thomas Russo, MD , professor and chief of infectious disease at the University at Buffalo in New York, tells Verywell. “But one should be a little more cognizant of countries that have variants of concern, like India.”

While Russo says that “the consequences for fully vaccinated individuals might not be as bad” as they would be for those who aren't vaccinated, there is still a chance that they can bring the variants back home after traveling. “We’re trying to minimize importing those strains,” he says.

But there are “issues related to air travel in general,” Stanley Weiss, MD , professor of medicine at the Rutgers New Jersey Medical School, tells Verywell. “There is the issue of yourself and those near you, in screening areas, waiting areas, and on the plane."

Weiss points out that you can be exposed to COVID for long periods of time on international flights. And there's “a considerable period of time” where everyone may not always be masked.

Ultimately, “the decision to take an international trip currently is really a risk/benefit consideration that is dependent upon one's own risk tolerance,” Prathit Kulkarni, MD , assistant professor of medicine in infectious diseases at Baylor College of Medicine, tells Verywell.

He recommends being mindful of the risk level of the country you’re interested in visiting. “If it is possible to defer a trip to a country with very high transmission currently until transmission slows down a bit, that is likely preferred,” Kulkarni says.

It’s important to keep in mind that “you may not be able to get reasonable healthcare if you get sick” while visiting a higher risk area, John Sellick, DO , an infectious disease expert and professor of medicine at the University at Buffalo in New York, tells Verywell.

Adalja agrees. “Traveling to a very high-risk area, even when fully vaccinated, probably is not going to be a very fun trip if a country is spiraling out of control because of COVID-19 cases and hospitals in crisis,” he says.

How to Stay Safe When You Travel

“Sometimes there are extenuating circumstances necessitating travel; In this case, prevention steps are the best way to reduce risk,” Kulkarni says. That includes wearing a mask in the airport and on the plane and practicing good hand hygiene, Sellick adds.

Be aware, too, that you may have to get tested or quarantine—even if you’re fully vaccinated—because of regulations in place in other countries, Adalja says.

Weiss recommends bringing extra masks along for the trip and keeping a spare on you at all times. “You need enough with you to enable you to change them,” he says.

Overall, public health experts stress the importance of getting vaccinated before you travel. “It’s the most important thing you can do,” Russo says.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page .

Centers for Disease Control and Prevention. How CDC determines the level for COVID-19 travel health notices .

Centers for Disease Control and Prevention. COVID-19 travel recommendations .

Centers for Disease Control and Prevention. Trends in number of COVID-19 cases and deaths in the US reported to CDC, by state/territory .

Transportation Security Administration. TSA surpasses 2 million daily travelers screened .

By Korin Miller Miller is a health and lifestyle journalist with a master's degree in online journalism. Her work appears in The Washington Post, Prevention, SELF, Women's Health, and more.

More From Forbes

Cdc guidelines on needing the vaccine for travel.

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Do you need the coronavirus vaccine for travel or not? That's a common question these days whether you stay within the United States or travel internationally. Here is the latest Centers for Disease Control and Prevention (CDC) guidance for traveling.

People wearing face masks are seen on the National Mall in Washington, D.C., the United States, on ... [+] Sept. 6, 2021. The total number of COVID-19 cases in the United States topped 40 million on Monday, according to data from the Johns Hopkins University. (Photo by Liu Jie/Xinhua via Getty Images)

Delay Travel Until Fully Vaccinated

The CDC currently recommends that all Americans become fully vaccinated against Covid-19 before traveling domestically or internationally. You are considered fully vaccinated 14 days after your final shot. Recovering from Covid-19 within the last three months also qualifies.

It's also possible to start taking booster shots approximately eight months after receiving the second dose of the Pfizer or Moderna mRNA shots to keep your fully vaccinated status.

In addition to being fully vaccinated, the CDC recommends these precautions:

• Wearing a mask during travel (it's federal law for commercial transit)
• Observing state and local recommendations
• Wear a mask in crowded outdoor spaces in high transmission areas
• Also, consider wearing a mask when in close contact with those who are unvaccinated
• Get a diagnostic test 3-5 days after returning from international travel

While the coronavirus vaccine receives most of the attention, it's essential to decide if you need to get other travel vaccines your destination requires or recommends. The Yellow Fever vaccine is a classic example.

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After traveling, you don't have to self-quarantine but should self-monitor for potential symptoms.

Travel Guidelines For The Unvaccinated

While the CDC discourages travel if you're only partially vaccinated or fully vaccinated, travel isn't prohibited. If possible, only travel for essential reasons and delay nonessential travel until receiving both shots and waiting 14 days to start your trip.

However, the CDC recommends additional safeguards to prevent transmission risk.

You should plan on getting a diagnostic test before traveling:

• Pre-arrival test within 1-3 days of travel
• Post-travel test 3-5 days after returning home

Several destinations require a negative pre-arrival test to enter. One United States destination with this requirement is Hawaii to waive the 10-day quarantine.

In addition to getting an additional test, the CDC recommends self-quarantining for up to 10 days:

• Ten days if you don't get a post-travel test
• Seven days if you receive a negative post-travel test on days 3-5

Additional Travel Mandates

While the CDC doesn't require Americans to be fully vaccinated to travel locally or to another country, a growing number of nations have vaccine mandates for visitors.

For example, the European Union doesn't mandate vaccines for foreign visitors but recommends each nation have this requirement. Iceland, Italy, Germany, and other countries have this policy.

Multiple countries across the globe also require all fully vaccinated travelers to have a negative pre-arrival test to waive the quarantine. Non-vaccinated travelers must also have a negative test but are more likely to observe a mandatory self-quarantine.

Mandatory United States Re-Entry Test

When returning from international travel, the vaccinated and unvaccinated must have a negative test result to re-enter the United States without quarantine.

When To Stay Home

Regardless of your vaccination status, there are several instances when the CDC requires you to stay home:

• Known exposure to Covid-19
• Are you currently sick or exhibiting symptoms
• Test positive for Covid-19

The Center also discourages traveling with another person who is sick with Covid-19.

Commercial transportation providers and entry agents will most likely have you and other travelers complete a health questionnaire. If you state yes to one of the above traits, you can expect to self-quarantine until you test negative and are symptom-free.

While the CDC doesn't require you to be fully vaccinated to travel, they discourage traveling for the unvaccinated and partially vaccinated. When traveling, it's essential to follow the current safety guidelines and keep potential exposure to a minimum whether you're vaccinated or not.

Related Articles:

• New Europe-U.S. Travel Restrictions
• New Travel Warnings Issued From CDC
• TSA Mask Mandate Extends Into 2022

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Health Guidelines for Travel Abroad

a CMO, SAC Health System, 250 South G Street, San Bernardino, CA 92410, USA

b Family Medicine Residency Program, Loma Linda University, 1200 California Street, Suite 240 Redlands, CA 92374, USA

Norman Benjamin Fredrick

c Family and Community Medicine and Public Health Sciences, Global Health Center, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033, USA

Leesha Helm

d Department of Family Medicine, Pennsylvania State University College of Medicine, Penn State Health, PGY-3, 500 University Drive, Hershey, PA 17033, USA

Jeffrey Cho

Most travel medical care is provided by patients’ primary care physicians; only 10% of international travelers visit a travel clinic. The main purposes for travel include vacationing, visiting friends and family, business, and for educational purposes. The purposes of the pretravel consultation are to estimate risk and provide recommendations to mitigate risk.

• • Primary care providers manage the majority of travel medical care. The purpose of the pretravel visit are risk assessment and mitigation.
• • Encourage travelers to enroll in the Smart Traveler Enrollment Program for travel advisories.
• • The Centers for Disease Control and Prevention travel website offers destination-specific, point-of-care resources for clinicians and travelers.
• • Travelers who are visiting friends and relatives are a high-risk group.
• • The most common syndromes in returning travelers are gastrointestinal, febrile, and dermatologic.

Introduction

Most travel medical care is provided by patients’ primary care physicians; only 10% of international travelers visit a travel clinic. The main purposes for travel include vacationing, visiting friends and family, business, and for educational purposes.

Pretravel consultation

The purposes of the pretravel consultation are to estimate risk and provide recommendations to mitigate risk.

Traveler background

The initial pretravel assessment should focus on specific aspects regarding the health background of the traveler ( Box 1 ). A full history and physical examination, including a review of immunizations, allergies, medications, and chronic medical conditions should be explored. Special attention and tailored recommendations should be given to those with chronic disease states, including congestive heart failure, diabetes, mental health issues, and immunocompromised states. It is important to note recent hospitalizations and surgeries and to assess the risk associated with traveling after these events. Prior travel history may provide clues regarding intolerance to certain antimalarials or other medications.

Box 1

Risk assessment, medical history.

• • Medications
• • Allergies
• • Immunizations
• • Chronic disease states
• • Mental health
• • Hospitalizations
• • Surgeries
• • Pregnancy or breastfeeding
• • Previous travel
• • Previous use of antimalarials, antibiotics
• • Plans for repeat travel in next 1 to 2 years

Trip itinerary

• • Location
• • Dates and season
• • Activities, mass gatherings
• • Reasons for travel
• • Accommodations
• • Travel insurance

Trip specifics

Review the itinerary of the traveler, including types of travel, the reason for travel, and accommodations. Country-specific risks and travel advisories should be discussed in detail with the traveler by reviewing resources like the Smart Traveler Enrollment Program ( https://step.state.gov/ ) . By assessing these specific aspects, the provider can obtain a wealth of knowledge that can be synthesized to help the traveler manage possible risks.

Travel recommendations to reduce risk

Preparedness for exacerbations of chronic disease states.

Travel can be stressful and demanding for individuals with chronic disease states. Before travel, clinicians should direct travelers to recommendations provided by national associations related to their chronic medical states for travel guidelines. In addition, travelers should be directed to check in with the US embassy or consulate in their area of travel to clarify any restrictions on medications with which they may need to travel.

Travel Insurance and International Health Care

Many health insurances do not provide adequate coverage for international travel, including repatriation and medical evacuation. 1 The following resources can be used to help travelers make a decision regarding the need for travel insurance, travel health insurance, and medical evacuation insurance.

• • Department of State ( www.travel.state.gov )
• • International Association for Medical Assistance to Travelers ( www.iamat.org )

Accessing Local Reputable Medical Facilities

The International Association of Medical Assistance to Travelers maintains a list of clinics available to members: www.iamat.org/doctors_clinics.cfm . In addition, the Joint Commission International maintains a list of accredited, certified health care facilities: www.jointcommissioninternational.org .

Medications for chronic conditions and prevention of disease states specific to regions of travel should be procured before initiation of travel. Individuals with preexisting conditions or allergies should consider wearing a medical alert bracelet or card in their wallet. See Table 1 for a list of suggested travel health kit items.

Table 1

Health kit item checklist

Abbreviation: HIV, human immunodeficiency virus.

Providers should recommend travelers carry documentation of the following:

• • Health insurance, supplemental insurance,
• • Proof of vaccinations,
• • List of medications and preexisting conditions, and
• • Contact card with emergency contact, location of travel, hospitals and clinics, US embassy or consulate number, health care provider contact information.

Important Travel Risks

The World Health Organization has cited that, among deaths in travelers, 18% to 24% are caused by injuries, whereas only 2% are caused by infectious disease. 1

Motor vehicle safety

Among US travelers in foreign countries, motor vehicle accidents are the leading cause of death, making up approximately 27% of all nonnatural deaths in 1 study. 1  Contributing factors include lack of familiarity with infrastructure in the area of traveled, lack of seat belt use, alcohol use, travel fatigue, poor visibility, and increased risk for road-related accidents. 1 Prevention strategies include using seatbelts and child safety seats, avoiding night-time driving, increasing awareness of driving hazards, using helmets when driving motorcycles or motorbikes, avoiding alcohol or cellphone use before or during driving, using marked taxis for travel, avoiding travel in overcrowded buses, and remaining alert while crossing streets. 1

Drowning is the fourth leading cause of death of international US travelers. 1 Avoidance of swimming alone and the use of a life jacket with water-related activities should be encouraged. Swimming should be avoided when local water conditions or currents are unknown and if a traveler has recently used alcohol.

Crime and violence

Of nonnatural death causes in foreign travelers, 21% can be attributed to crime and violence. 1 Clinicians should encourage travelers to familiarize themselves with crime trends in the areas they are traveling to. Information can be accessed from the Overseas Security Advisory Council website ( www.osac.gov ) . Travelers can also familiarize themselves with security updates by accessing the Department of State’s Bureau of Consult Affairs recommendations for travel safety at http://travel.state.gov . Special precaution should be taken to protect against pickpocketing and individuals should attempt to keep money worn under clothing secured to the neck or waist. Travelers should limit traveling alone or at night time, keep all valuables secure, keep all doors and windows locked, use recommended safe modes of transportation, and avoid resistance if confronted in a robbery. The nearest US embassy should be contacted if concerns related to crime, violence, accidents, medical concerns, or specific travel questions arise.

Counterfeit, adulterated, or expired medications

Travelers should be educated about the risks of procuring medications while traveling including but not limited to medication side effects secondary to use of inappropriately compounded medications, counterfeit medications, and use of uncommon medication additives. 1 Clinicians should recommend obtaining all medications before travel to ensure that individuals are using authentic medications with known side effects and appropriate dosing.

Infections While Abroad

Immunizations.

Maintenance of an accurate immunization history is necessary to provide adequate protection for the traveler. Immunization records should be obtained and reviewed and, if unreliable, titers for measles, mumps, rubella, and hepatitis A should be obtained. Sufficient time should be taken before travel to ensure travel-specific vaccines can be administered and appropriate immunity achieved ( Table 2 ). The risks and benefits of immunizations should be discussed. In addition, vaccines with waning immunity should be addressed as well, especially in the case of immunocompromised travelers. Assessing return travel to similar areas with the next 1 to 2 years from the initial trip will help clinicians to assess the need for specific immunizations. Travelers should be given an updated immunization record to travel with. Country-specific recommendations for vaccines can be accessed by clinicians at the Centers for Disease Control and Prevention (CDC) travel website ( https://wwwnc.cdc.gov/travel ).

Table 2

Travel vaccines, including routine vaccines of high priority in travelers

Abbreviations: IM, intramuscularly; MPSV4, meningococcal polysaccharide vaccine.

Several important diseases are transmitted by mosquitos, of which malaria is among the most important. Most of the 1700 cases of malaria diagnosed in the United States annually are among returned travelers. 1 Box 2 outlines strategies for malaria prevention.

Box 2

Strategies to prevent malaria.

• Long-sleeved pants, shirts, and socks
• Permethrin-treated clothing
• Permethrin-treated bed nets
• Mosquito repellants (≥20% DEET)
• Chemoprophylaxis

From dawn to dusk, mosquitoes that transmit Dengue, Yellow Fever, Zika, and Chikungunya are active and bite whereas, from dusk to dawn, mosquitoes that carry malaria, West Nile, and Japanese encephalitis are active. Providers should review the CDC’s Malaria Maps, and Malaria Information by Country Table and take note of the special considerations mentioned on the drug selection guide: https://www.cdc.gov/malaria/travelers/drugs.html .

Antimalarials should always be purchased before travel, because in some countries drugs that are sold may be counterfeit. 1 Clinicians should also warn travelers that if symptoms of malaria occur, including flulike illness while traveling or after returning home, immediate medical attention should be sought. Antimalarials alone do not prevent transmission and should be used in conjunction with preventive measures, including repellants for skin and clothing in addition to appropriate clothing and mosquito netting. 1 , 6

Traveler’s diarrhea

Traveler’s diarrhea often occurs suddenly with loose, frequent stools in about 30% to 70% of travelers. 7 Poor food handling practices are thought to put travelers at highest risk for traveler’s diarrhea. Preventative measures include specific food and beverage selection, frequent handwashing, frequent use of alcohol-based hand sanitizers with greater than 60% alcohol content, and consideration of vaccination against typhoid and hepatitis A. 8 Table 3 contains recommendations for traveler’s diarrhea treatment based on severity.

Table 3

Treatment of traveler’s diarrhea based on severity

Respiratory illness

Respiratory illness occurs in 20% of returning travels, with upper respiratory infections being the most common respiratory illness. Risks include exposures in hotels, cruise ships, aircrafts and tour group. Individuals with comorbidities including asthma and chronic obstructive pulmonary disease are at higher risk for respiratory illnesses. 1 Prevention tips include minimizing contact with individuals with cough or congestive symptoms, frequent handwashing, and vaccination before travel. Viral etiologies such as rhinovirus, are more common causal agents, although coronaviruses (Middle East respiratory syndrome in the Arabian Peninsula) and avian influenza (Asia) should also be included in a clinician’s differential. 1 Viral causes can also put individuals at risk for superimposed bacterial infections.

Bloodborne illness

Travelers should be cautioned against obtaining tattoos and piercings in low-income areas of the world, because the risk of human immunodeficiency virus and hepatitis C transmission secondary to use of unclean needles is high in these areas. 1

Exposure to human immunodeficiency virus

Travelers should be cautioned about the risk of human immunodeficiency virus specifically associated with certain practices, including needle sharing, risky sexual behaviors, or exposure in a health care setting. In the case of health care workers or individuals who plan to be involved with high-risk behaviors, the physician should discuss having postexposure prophylaxis available to them in case of exposure. Preexposure prophylaxis can reduce the risk of human immunodeficiency virus infection by up to 70%. 1 Immediate attention by a physician should be sought out if concern for exposure arises to ensure appropriate counseling and the possible need for postexposure prophylaxis.

Sexual health

Travelers should be cautioned against high-risk sexual activities that may lead to the transmission of sexually transmitted infections, unwanted pregnancy, or bloodborne infections. Consistent contraceptive methods should be used in a traveler who does decide to be sexually active. Health care resources overseas should be provided for travelers, including reputable clinics to seek out if concerns for sexually transmitted infections and/or pregnancy arise.

Venous Thrombosis and Embolism

Travelers at increased risk for development of deep venous thrombosis who are traveling long distances should be advised to walk as often as possible, use appropriately fitted compression stockings that provide 15 to 30 mm Hg at the ankle, hydration, and to perform calf exercises as often as possible. The use of aspirin for deep venous thrombosis prevention is not recommended. 1

When traveling between time zones, travelers can often develop a mismatch between their natural 24-hour circadian rhythm and the time of day. When traveling through more than 3 time zones, sleep-related difficulty, mood changes, mental clarity, and gastrointestinal disturbance can occur with jet lag. During the pretravel assessment, the clinician can discuss this in detail with the traveler and set expectations. Changes to diet and physical activity, sunlight exposure, the use of melatonin and melatonin-receptor analogs, consideration of hypnotic medications with discussion of risks and benefits, and a combination of these therapies can be discussed with the traveler before initiation of travel. Avoidance of alcohol as a sleep aid should be discussed with travelers as well as encouraging hydration during the trip.

Special populations

Immunocompromised travelers.

According to the 2018 CDC Yellow Book, immunocompromised travelers make up 1% to 2% of travelers seen in US travel clinics. 1 The immunocompromised status may be due to a medical condition, medication, or treatment. Common examples are noted in Box 3 .

Box 3

Examples of immunocompromised travelers.

• Chronic oral steroids greater than or equal to 20 mg per day of prednisone or equivalent
• Posttransplant on medication
• Renal failure on dialysis
• Current or recent (<3 months) chemotherapy
• Chronic liver disease
• Human immunodeficiency virus infection with a CD4 count of less than 200
• Autoimmune diagnosis on biologics

Special points to remember for immunocompromised travelers:

• • Response to vaccines may be limited.
• • Live vaccines are contraindicated in severely immunosuppressed individuals.
• • Increased risk of foodborne and waterborne infections ( Salmonella , Shigella , Campylobacter , Giardia , Listeria , and Cryptosporidium ).
• • Avoid swallowing water during water-based activities.
• • Avoid eating raw seafood.

Traveling while pregnant

Key points for pregnant travelers 1 :

• • Obstetric emergencies are sudden and can be life threatening. Having an emergency plan and access to appropriate obstetric care is recommended.
• • Before booking, check with the airline or cruise ship regarding any limitations on travel. Some limit travel based on gestational age.
• • During air travel the cabin is pressurized to 6000 to 8000 feet. This will not affect a fetus in a normal pregnancy, but could cause fetal problems in women with cardiovascular conditions, sickle cell disease, or severe anemia (hemoglobin <8 g/dL).
• • During air travel, frequent stretching, walking, and isometric exercises are recommended to decrease risk of deep venous thrombosis, which is increased in pregnancy.
• • Treatment of choice for traveler’s diarrhea is hydration and, if indicated, azithromycin.
• • Owing to the risk of birth defects, the CDC recommends that pregnant women do not travel to areas where Zika is present. If travel cannot be avoided, avoidance of mosquito bites is extremely important. More information can be found at the CDC Zika website ( http://www.cdc.gov/zika/pregnancy/index.html ).
• • Most live virus vaccines are contraindicated during pregnancy except for yellow fever, for which pregnancy is considered a precaution by the Advisory Committee on Immunization Practices.
• • Malaria is more serious in pregnant than in nonpregnant women and puts both the mother and the fetus at risk. Malaria chemoprophylaxis is highly encouraged. Chloroquine and mefloquine (depending on the region) are the drugs of choice. Doxycycline and primaquine are contraindicated due to possible effects on the fetus, whereas atovaquone-proguanil lacks available safety data.

Traveling with Children

According to the CDC, an estimated 1.9 million American children travel internationally each year. 1 Typically, children are exposed to the same risks as adults, but the consequences can be more severe and children are less likely to receive travel advice than adults.

The most common health problems among child travelers were 1 :

• • Diarrheal illnesses,
• • Dermatologic diagnosis (animal/insect bites, cutaneous larva migrans, sunburn),
• • Febrile illnesses (malaria), and
• • Respiratory disorders.

Key points when traveling with children 1 :

• • Diarrheal diseases are more common and can be more likely to cause dehydration. Treatment should focus on oral rehydration solution and if indicated antibiotics for traveler’s diarrhea. Children should be given a nonfluoroquinolone such as azithromycin, which can be given as a single daily dose (10 mg/kg) for 3 days.
• • Car crashes and drowning are the leading 2 causes of death in children while traveling. Car seats are often not available so parents should bring their own. Life vests should always be used around water.
• • Avoidance of mosquito and other bug bites is critical, especially in malaria endemic areas. Repellents with DEET should not be used on infants less than 2 months and after 2 months, only repellents with 30% or less DEET should be used.
• • Malaria prophylaxis is also recommended for children in malaria endemic areas. Dosing will need to be adjusted based on weight. Doxycycline should not be given to children less than 8 years old because of the risk of teeth staining, and atovaquone-proguanil should not be used in children weighing less than 5 kg.
• • Rabies is more common in children owing to less fear in approaching animals. If there is exposure to any animal bite, seek medical care immediately. Consider rabies vaccine if planning to spend more than 3 months in endemic area.

Visiting Friends and Relatives

A traveler who is returning home to visit friends or relatives is considered a visiting friends and relatives traveler. Today, visiting friends and relatives travelers make up more than one-half of all international travelers. 1 They are least likely to seek pretravel advice and more likely to develop problems while traveling because they typically stay longer at a destination, eat local food in people’s homes, and often do not take the same precautions as other travelers.

Key points for visiting friends and relatives travelers 1 :

• • Malaria risk is 8 to 10 times higher than for a non-visiting friends and relatives traveler. Malaria immunity weans after living outside of a malaria endemic region, so when returning to the endemic region, malaria prophylaxis and mosquito bite avoidance is recommended. Malaria prevention medication should be started several weeks before international travel.
• • Foodborne illnesses are more common and any immunity to local bacteria can also wean with time after living outside the community. Avoidance of food at room temperature, raw fruits and vegetables, tap water, and ice from tap water is recommended.
• • These travelers are also at increased risk of tuberculosis and sexually transmitted diseases.

Posttravel assessment

General approach.

Worldwide, 8% of travelers develop illnesses severe enough to seek a health care provider. 1 The majority of travelers present to primary care for posttravel illnesses. Data gathered from a directed history can elucidate the cause of a traveler’s symptoms. Knowledge of the travel itinerary and incubation periods is essential to narrowing down a differential diagnosis based on geography and timing after travel.

Common Syndromes

According to a large-scale study by GeoSentinal, a global surveillance network, the most common syndromes in returned travelers are gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%). 9

Gastrointestinal Illness

Many cases of traveler’s diarrhea can be treated empirically, and 80% to 90% of cases are bacterial. See Table 4 for top infectious causes of persistent traveler’s diarrhea. Azithromycin should be preferentially used in travelers returning from South and Southeast Asia owing to the increasing resistance to fluoroquinolones. 7 Severe symptoms, including fever, tenesmus, and gross blood, should prompt further testing, including stool culture. If stool is tested for ova and parasites, 3 or more stool specimens should be collected to increase sensitivity. 7 Some organisms, such as Cryptosporidium and Cyclospora , require specific testing. Testing for Clostridium difficile should be performed if the traveler recently used antibiotics or malaria chemoprophylaxis. A minority of travelers have persistent diarrhea lasting more than 2 weeks, which can be from (1) persistent infection or an untreated coinfection, (2) postinfectious processes like postinfectious irritable bowel syndrome, which can be diagnosed using the Rome criteria, or (3) unmasking of a previously undiagnosed gastrointestinal disease. 7

Table 4

Top infectious causes of persistent traveler’s diarrhea listed in decreasing order of frequency in each column

Febrile Illness

Fever in a returned traveler needs to be evaluated immediately owing to the potential for a rapidly progressing, life-threatening illness like malaria. Those who arrive from areas where malaria is endemic should be evaluated with thick and thin blood films and malarial antigen tests, if available. Blood smears should be repeated if suspicion is high and initial smears are negative. Other important causes to consider include dengue fever, enteric fever (typhoid, paratyphoid), and rickettsial diseases (eg, African tick bite fever), among others. It is also important to keep in mind other common causes of fever including influenza, which occurs year round in tropical climates. See Table 5 for the top febrile illnesses to consider in returned travelers based on location. Those with fever accompanied by alarming symptoms should be thoroughly evaluated as soon as possible, which may be best conducted in the emergency department. In 25% to 40% of patients with fever, no specific cause was identified. 9 , 10

Table 5

Top febrile illnesses to consider in returned travelers based on location

Dermatologic Conditions

Rashes are common in returned travelers. One of the most common skin findings is the classic pruritic migratory serpiginous rash of cutaneous larva migrans. 11 Exposure occurs when skin (eg, bare feet) comes in contact with contaminated sand or soil. Animal bites and scratches, most commonly received from dogs and monkeys, are also common in returned travelers and may require rabies postexposure prophylaxis in up to 12% of cases. 9 See Box 4 for the top tropical dermatologic conditions to consider in returned travelers.

Box 4

Top 10 tropicala dermatologic conditions to consider in returned travelers.

• 1. Cutaneous larva migrans
• 2. Arthropod bite
• 3. Myiasis (bot fly, tumbu fly)
• 4. Injuries including animal bites
• 6. Cutaneous leishmaniasis
• 7. Tungiasis
• 8. Swimmer’s itch
• 9. Rickettsial infection
• 10. Dengue fever

a Many cosmopolitan causes (eg, cellulitis) excluded from this list.

Screening Asymptomatic Returned Travelers

Currently, there are no CDC guidelines for asymptomatic returned travelers.

Special circumstances section

Altitude illness.

Altitude illness is most common at altitudes of 8200 feet (2500 m) or more, although it can occur at lower elevations. 1 The main issue in altitude sickness is hypoxemia, which is exacerbated during sleep. Respiratory depressants such as alcohol and sleep medications should be avoided; acetazolamide and stimulants may speed acclimatization. Moderate-to-vigorous physical activity can exacerbate hypoxemia and should be avoided for the first 48 hours. Physical conditioning does not predict acclimatization. Contraindications to traveling to altitude include severe heart or lung disease, sickle cell anemia, high-risk pregnancy, and cerebral pathology.

There are 3 altitude syndromes: acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Treatment involves immediate descent, medications ( Table 6 ), oxygen supplementation, and pressurization bags if rapid descent is not feasible.

Table 6

Common medications for altitude illness

Abbreviations: AMS, acute mountain sickness; BID, twice per day; HACE, high altitude cerebral edema; HAPE, high altitude pulmonary edema; PO, by mouth.

SCUBA Diving

SCUBA-related illnesses can be divided into 2 categories: barotrauma and decompression illness. The primary risk factors are dive depth, bottom time, and speed of ascent. 1 Decompression illness can occur even when all precautions are taken. The Divers Alert Network is a resource that can be accessed by both divers and health care providers at http://www.diversalertnetwork.org/ or at their 24-hour emergency hotline (919-684-9111).

Motion Sickness

Motion sickness is not a true pathology, but a normal response to the external stimulation that is created by the vestibular system. The most common forms are sea sickness, motor vehicle sickness, and air sickness. It has been noted to be more common in women and less common in frequent travelers either owing to habituation or self-selection. See Box 5 and Table 7 for recommendations for motion sickness prevention and management.

Box 5

Recommendations to prevent motion sickness, table 7.

Common preventive medications for motion sickness

Abbreviation: PO, by mouth.

Mass Gatherings

Defined as at least 1000, but can be more than 25,000, people gathered at a specific location for a specific purpose. 1 Often these gatherings can strain the local resources and increase the risk of disease transmission among the attendees. Common challenges among attendees are hypothermia, heat exhaustion, dehydration, sunburn, but worsening of underlying chronic diseases (eg, heart failure, diabetes) also occurs. And at times there can be other dangers such as unsafe transportation, stampedes, collapse of structures, fire, terrorism and other forms of violence. See Box 6 for examples of mass gatherings.

Box 6

Mass gathering examples.

• Measles exposure at amusement parks in the United States.
• Meningitis (meningococcal vaccine is required for the Hajj) and respiratory infections (Coronavirus) among Hajj pilgrims.
• Concern for Zika at Rio, Brazil Olympics.
• Exposure to flu during sports events, concerts, conventions.

Disclosure Statement: The authors have nothing to disclose.

Malaria and Travelers for U.S. Residents

Quick links.

• Prophylaxis Guidelines for Malaria in “Off-the-Radar” Areas
• Travel to West Africa? Don’t Neglect Malaria Prevention
• Mosquito Repellent Fact Sheet
• Prescribing Information for Malaria Prevention Drugs
• Yellow Book Malaria Section New!
• Blog: CDC Malaria Hotline—When the Caller is Ill Abroad

This information is intended for travelers who reside in the United States. Travelers from other countries may find this information helpful; however, because malaria prevention recommendations and the availability of antimalarial drugs vary, travelers from other countries should consult health care providers in their respective countries. For more health recommendations for international travel, visit the CDC Yellow Book .

Every year, millions of US residents travel to countries where malaria is present. About 2,000 cases of malaria are diagnosed in the United States annually, mostly in returned travelers.

Travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. However, all travelers to countries where malaria is present may be at risk for infection.

Obtain a detailed itinerary including all possible destinations that may be encountered during the trip and check to see if malaria transmission occurs in these locations. The Malaria Information by Country Table  provides detailed information about the specific parts of countries where malaria transmission does or does not occur. It also provides additional information including the species of malaria that occur there, the presence of drug resistance, and the specific medicines that CDC recommends for use for malaria prevention in each country where malaria transmission occurs on CDC’s Malaria maps.

Prevention of malaria involves a balance between ensuring that all people who will be at risk of infection use the appropriate prevention measures, while preventing adverse effects of those interventions among people using them unnecessarily. An individual risk assessment should be conducted for every traveler, taking into account not only the destination country, but also the detailed itinerary, including specific cities, types of accommodation, season, and style of travel. In addition, conditions such as pregnancy or the presence of antimalarial drug resistance at the destination may modify the risk assessment.

More on: Malaria Risk Assessment for Travelers

Based on the risk assessment, specific malaria prevention interventions should be used by the traveler. Often this includes avoiding mosquito bites through the use of repellents or insecticide treated bed nets, and specific medicines to prevent malaria.

More on: Preventing Mosquito Bites While Traveling

If malaria prevention medicines will be needed for the traveler, the  Malaria Information by Country Table lists the CDC-recommended options. For many destinations, there are multiple options available. Factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug-drug interactions), the cost of the medicines, and the potential side effects.

More on: Tips on Choosing the Right Drug for an Individual Traveler

The Drugs for Malaria Prevention table  provides prescription dosing information for both adults and children.

In some countries (including those with malaria risk), drugs may be sold that are counterfeit (“fake”) or substandard (not made according to United States standards). Such drugs may not be effective. Antimalarial drugs should always be purchased before traveling overseas!

For details and specific warnings, see Counterfeit and Substandard Antimalarial Drugs

This picture shows some things that travelers can use to protect themselves against malaria: malaria pills; insect repellent; long-sleeved clothing; bednet; and flying insect spray. (Not shown, but also protective: air conditioned or screened quarters.)

The interventions used to prevent malaria can be very effective when used properly, but none of them are 100% effective.

Malaria is always a serious disease and may be a deadly illness. Travelers who become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after returning home (for up to 1 year) should seek immediate medical attention and should tell the physician their travel history.

Travelers who are assessed at being at high risk of developing malaria while traveling should consider carrying a full treatment course of malaria medicines with them. Providing this reliable supply of medicine (formerly referred to as standby or emergency self-treatment) will ensure that travelers have immediate access to an appropriate and high quality medicine if they are diagnosed with malaria while abroad. Depending on the medicine they are using for prevention, this could either be atovaquone/proguanil or artemether/lumefantrine.

More on: Malaria Treatment (United States)

Travelers are often surprised to learn that even if they adhered to all of the prevention advice and did not become sick with malaria, recent travel to a place where malaria transmission occurs is an exclusion criterion for blood donation.

More on: Prevention of Blood Transfusion-Associated Malaria

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The Pretravel Consultation

The pretravel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pretravel consultation are to:

• Perform an individual risk assessment.
• Communicate to the traveler anticipated health risks.
• Provide risk management measures, including immunizations, malaria prophylaxis, and other medications as indicated.

The Travel Medicine Specialist

Travel medicine specialists have in-depth knowledge of immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for all travelers, and is particularly important for those with a complicated health history, special risks (such as traveling at high altitudes or working in refugee camps), or exotic or complicated itineraries. Clinicians who wish to be travel medicine providers are encouraged to join the International Society of Travel Medicine (ISTM) and consider specialty training and certification.

Components of a Pretravel Consultation

Effective pretravel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-1 ). The pretravel consultation is the major opportunity to educate the traveler about health risks at the destination and how to mitigate them. The typical pretravel consultation does not include a physical examination; a separate appointment with the same or a different provider may be necessary to assess a person’s fitness to travel. Because travel medicine clinics are not available in some communities, primary care physicians should seek guidance (by phone or other communication, if available) from travel medicine specialists to address areas of uncertainty.

Travel health advice should be personalized, highlighting the likely exposures and also reminding the traveler of ubiquitous risks, such as injury, foodborne and waterborne infections, vectorborne disease, respiratory tract infections, and bloodborne and sexually transmitted infections. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pretravel consultation. Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the recommended immunizations and medications, a situation that requires prioritizing interventions. (See Prioritizing Care for the Resource-Limited Traveler later in this chapter.)

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks (Table 2-1 ). Certain travelers may confront special risks. Recent hospitalization for serious problems may lead the travel health provider to recommend delaying travel. Air travel is contraindicated for certain conditions, such as <3 weeks after an uncomplicated myocardial infarction and <10 days after thoracic or abdominal surgery. The travel health provider and traveler should consult with the relevant health care providers most familiar with the underlying illnesses. Other travelers with specific risks include travelers who are visiting friends and relatives, long-term travelers, travelers with small children, travelers with chronic illnesses, immunocompromised travelers, and pregnant travelers. More comprehensive discussion on advising travelers who have additional health considerations is available in Chapter 5. Providers should determine whether recent outbreaks or other safety notices have been posted for the traveler’s destination; information is available on the CDC and US Department of State websites, and in various other resources.

In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, the exposures related to special activities also merit discussion. For example, river rafting could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk of histoplasmosis. Flying from lowlands to high-altitude areas and trekking or climbing in mountainous regions introduces the risk of altitude illness. Therefore, the provider should inquire about plans for specific leisure, business, and health care–seeking activities.

Communicate Risk

Once destination-specific risks for a particular itinerary have been assessed by the provider, they should be clearly communicated to the traveler. The process of risk communication is a 2-way exchange of information between the clinician and traveler, in which they discuss potential health hazards at the destination and the effectiveness of preventive measures, with the goal of improving understanding of risk and promoting more informed decision making. Risk communication is among the most challenging aspects of a pretravel consultation, because travelers’ perception of and tolerance for risk can vary widely. For a more detailed discussion, see Perspectives : Travelers’ Perception of Risk in this chapter.

Manage Risk

Immunizations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. For example, providers should consider whether there is sufficient time before travel to complete a vaccine series; the purpose of travel and specific destination within a country will inform the need for particular vaccinations. At the same time, the pretravel consultation presents an opportunity to update routine vaccines (Table 2-2 ). Particular attention should be paid to vaccines for which immunity may have waned over time or following a recent immunocompromising condition (such as after a hematopoietic stem cell transplant). Asking the question, “Do you have any plans to travel again in the next 1–2 years?” may help the traveler justify an immunization for travel over a number of years rather than only the upcoming trip, such as rabies preexposure or Japanese encephalitis. Travelers should receive a record of immunizations administered and instructions to follow up as needed to complete a vaccine series.

Another major focus of pretravel consultations for many destinations is the prevention of malaria. Malaria continues to cause substantial morbidity and mortality in travelers. Since 1973, the annual number of US malaria cases reported to CDC has shown an increasing trend; therefore, pretravel consultation must carefully assess travelers’ risk for malaria and recommend preventive measures. For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, recommendations for prophylaxis, and symptoms of malaria.

Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. For example, a traveler with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma may flare in a traveler visiting a polluted city or from physical exertion during a hike; travelers should be encouraged to discuss with their primary care provider how to plan for treatment and bring necessary medication in case of asthma exacerbation. Travelers should be counseled on how to obtain travel medical insurance and how they can find reputable medical facilities at their destination, such as using the ISTM website ( www.istm.org ), the American Society of Tropical Medicine and Hygiene website ( www.astmh.org ), or the State Department Travel website ( https://travel.state.gov/content/travel/en/international-travel/before-you ...). Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

The pretravel consultation also provides another setting to remind travelers of basic health practices during travel, including frequent handwashing, wearing seatbelts, using car seats for infants and children, and safe sexual practices. Topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues (Table 2-3 , Box 2-1 ). General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement oral advice and enable travelers to review the instructions from their clinic visits; educational material is available on the CDC Travelers Health webpage ( www.cdc.gov/travel ). Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad and possibly lead to faster return to good health.

Self-Treatable Conditions

Despite providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pretravel counseling may 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 the developing world makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Chapter 6, Perspectives : Avoiding Poorly Regulated Medicines and Medical Products during Travel ).

Travel health providers need to recognize the conditions for which the traveler may be at risk, and educate the traveler about the diagnosis and treatment of those conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:

• “Travelers’ diarrhea” is the sudden onset of abnormally loose, frequent stools.
• Most cases will resolve within 2–5 days, and symptoms can be managed with loperamide or bismuth subsalicylate.
• For diarrhea severe enough to interrupt travel plans, an antibiotic can be prescribed that travelers can carry with them (see Travelers’ Diarrhea section in this chapter).
• The traveler should feel better within 6–24 hours.
• If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.

To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:

• Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.
• A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.
• Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.

The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book or discussed below.

• Travelers’ diarrhea ( Chapter 2 , Travelers’ Diarrhea)
• Altitude illness ( Chapter 3 , High-Altitude Travel & Altitude Illness)
• Jet lag ( Chapter 8 , Jet Lag)
• Motion sickness (Chapter 8, Motion Sickness )
• Respiratory infections ( Chapter 11 , Respiratory Infections)
• Skin conditions such as allergic reactions or superficial fungal infections ( Chapter 11 , Skin & Soft Tissue Infections)
• Urinary tract infections: common among many women; carrying an antibiotic for empiric treatment may be valuable
• Vaginal yeast infections: self-treatment course of patient’s preferred antifungal medication can be prescribed for women who are prone to infections, sexually active, or who may be receiving antibiotics for other reasons (including doxycycline for malaria chemoprophylaxis)
• Occupational exposure to HIV (Chapter 9, Health Care Workers , Including Public Health Researchers and Laboratorians)
• Malaria self-treatment (see Chapter 4 , Malaria)

In sum, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. Providers should review medication lists for possible drug interactions. More detailed information for providers and travelers is given in Chapter 6, Travel Health Kits; supplementary travel health kit information for travelers with specific needs is given in Chapter 5.

Box 2-1. Summary of sexual health recommendations for travelers

Before travel.

• Obtain recommended vaccinations, including those that protect against sexually transmitted infections.
• Get recommended tests for HIV and treatable STDs. Be aware of STD symptoms in case any develop.
• Check condom packaging and expiration dates.
• Review local laws about sexual practices and obtain contact information for medical and law enforcement services.
• If pregnant or considering pregnancy, review whether Zika virus infection is a risk at destination.

During Travel

• Use good judgment in choosing consensual adult sex partners.
• Use condoms consistently and correctly to decrease the risk of HIV and STDs.
• If indicated, be prepared to start taking medications for HIV postexposure prophylaxis or unintended pregnancy within 72 hours after a high-risk sexual encounter.
• Never engage in sex with a minor (<18 years old), child pornography, or trafficking activities in any country.
• Report suspicious activity to US and local authorities as soon as it occurs.

After Travel

• To avoid exposing sex partners at home, see a clinician to get recommended tests for HIV and treatable STDs.

Bibliography

• Freedman DO, Chen LH, Kozarsky P. Medical considerations before travel. N Engl J Med. 2016 July 21;375:247–60.
• Hatz CFR, Chen LH. Pre-travel consultation. In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. pp. 31–6.
• Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
• International Society of Travel Medicine. Body of knowledge for the practice of travel medicine—2012. Atlanta: International Society of Travel Medicine; 2012 [cited 2018 Feb 18]. Available from: www.istm.org/bodyofknowledge .
• Kozarsky PE, Steffen R. Travel medicine education—what are the needs? J Travel Med. 2016 Jul 4;23(5).
• Leder K, Chen LH, Wilson ME. Aggregate travel vs. single trip assessment: arguments for cumulative risk analysis. Vaccine. 2012 Mar 28;30(15):2600–4.   [PMID:22234265]
• Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, et al. GeoSentinel surveillance of illness in returned travelers, 2007–2011. Ann Intern Med. 2013 Mar 19;158(6):456–68.   [PMID:23552375]
• Schwartz BS, Larocque RC, Ryan ET. In the clinic: travel medicine. Ann Intern Med. 2012 Jun 5;156(11):ITC6:1–16.   [PMID:22665823]
• Steffen R, Behrens RH, Hill RD, Greenaway C, Leder K. Vaccine-preventable travel health risks: what is the evidence—what are the gaps? J Travel Med. 2015;22(1):1–12.
• Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1):S57–S74.

Lin H. Chen, Natasha S. Hochberg

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