Preparing Active Patients for International Travel

Carlos E. Jiménez, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 10 - OCTOBER 2003

In Brief: The risk of acquiring an illness when traveling internationally depends mostly on the area of the world to be visited. Today, with so many transportation options, increasing numbers of athletes are traveling abroad for training and competition, and leisure travelers are enjoying physically challenging adventure vacations—thus exposing themselves to potential medical problems. Primary care, sports medicine, and team physicians must be able to provide travelers with up-to-date information on immunization and chemoprophylaxis requirements, as well as other preventive medicine recommendations.

Many Americans are engaging in international travel for athletic training, competition, and leisure sports. However, many of the countries visited are underdeveloped or exotic, and travelers are exposed to many health hazards. Very few publications have addressed the travel-related health problems that are affecting international athletes. The Centers for Disease Control and Prevention (CDC) has reported several illness outbreaks among athletes at some sporting events, including the 2000 Eco-Challenge-Sabah multiexpedition race in Borneo, Malaysia.^1-4 As sporting venues become more distant, many adventurous and "x-treme" athletes will be facing new medical challenges.

Travel-related illnesses affect an estimated 20% to 70% of tourists, journalists, and relief workers, according to one clinical study⁵ and surveys done by travel medicine publications. The most common health problems affecting tourists include accidental trauma, traveler's diarrhea, respiratory illnesses, and skin disorders. Cardiovascular disease is the most common cause of death among all travelers; however, its incidence is similar to that of nontravelers.⁶ Malaria is another life-threatening travel disease, affecting approximately 30,000 tourists from North America and Europe each year.⁵ Clearly, prevention plays a major role in maintaining health while traveling.

Armed With Information

Sports medicine physicians must be able to prepare athletes for travel abroad by providing counseling about health risks, disease prevention, immunization, and prophylactic drugs. Alternatively, if clinicians do not feel comfortable dealing with travel issues, they may refer those athletes to specialized clinics where up-to-date information and recommendations can be obtained. Most high-profile athletes and teams participating in renowned sporting events, such as the Olympics or world meets, are provided appropriate medical support, many times including a traveling physician. However, most athletes travel abroad without physicians or even athletic trainers; therefore, this sector of the population is the one that will benefit the most from a good pretravel medical evaluation. Preparation is the watchword for the traveling athlete.

The initial pretravel assessment should ideally occur at least 6 weeks before departure to allow time for any required booster immunization and chemoprophylaxis.⁷ During this evaluation, the healthcare provider learns more about the athlete's medical and immunization history, travel itinerary, activities at each destination, accommodations, and trip duration. Using this information, the provider can research the intended travel area by using one or more of the available up-to-date published or Internet-based sources, such as the CDC Travel Health Information, the CDC Yellow Book, Travel Health Online, or World Health Organization (WHO) International Travel & Health.

The information retrieved should include the country's climate, current epidemics, the disease risk summary for each destination, and the recommended vaccinations and chemoprophylaxis for the proposed trip. An aware clinician can then counsel travelers about disease prevention, appropriate immunization and chemoprophylaxis, and recommendations for a travel first-aid kit (table 1).

Physicians treating competitive athletes need to alert their patients regarding the use of certain over-the-counter medications, such as decongestants and cold remedies, that may contain ephedrine, phenylephrine, or phenylpropanolamine as an active ingredient. Using sympathomimetic substances during intense exertion or hot weather may increase the risk of hyperthermia and other heat-related illnesses. Additionally, some of these substances are banned by many sports organizations, such as the National Collegiate Athletic Association, the International Olympic Committee, and the National Football League. Athletes could be disqualified or suspended from competition if they are found to have an illegal substance during drug testing.

A Shot of Prevention

Vaccines are generally divided into three categories: routine, required, and recommended.⁸ Routine vaccines (eg, diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella) are usually obtained during childhood, and these should be updated regardless of travel. Required immunizations are mandated by the WHO for entry into certain countries. Currently, yellow fever vaccine is the only one required. A list of the endemic countries in South America and Africa that require this vaccination can be found on the CDC and WHO Web sites.

Recommended vaccines are the ones offered to travelers to decrease the risk of contracting certain infectious diseases. Some of the most common infectious diseases can be prevented with proper immunization (table 2).

Hepatitis A is the most common travel-related disease that can be prevented by vaccination. The risk of infection is approximately 300 per 100,000 travelers per month in the tourist areas of developing countries, and it is five to seven times higher in nontourist areas. Most experts recommend that all athletes traveling to developing countries be immunized against hepatitis A. The two vaccines (Havrix and Vaqta) are a two-dose series that consist of an initial dose and a booster dose about 6 months later. The first dose provides over 94% active immunity protection after 4 weeks. After the booster dose, protective immunity lasts 10 to 20 years.^9,10

Hepatitis B vaccine is recommended for athletes who participate in sports that may involve contact with blood or body fluids, such as boxing, wrestling, and football. In addition, this vaccine is recommended for sexually active athletes. The three-dose vaccine is given initially, then 1 and 6 months later. Immunity develops in approximately 90% of patients after the second dose, and the third dose provides long-term protection. Accelerated vaccination can be performed at 0, 1, and 2 months for athletes with limited time before departure; however, a booster at 12 months is recommended to ensure long-lasting immunity.^9,10

Typhoid fever is caused by ingestion of food or water contaminated with Salmonella typhi. The CDC recommends typhoid vaccination for people traveling to endemic areas of Latin America, Africa, and Asia for longer than 3 weeks, or if the traveler plans to stay in rural areas. Three vaccines are currently available: a live oral vaccine consisting of four capsules taken on alternate days during 1 week, a single polysaccharide intramuscular injection, and a whole-cell subcutaneous injection with a booster given 4 weeks later. The first two types are preferred over the whole-cell vaccine because of fewer side effects.^9,10

Japanese B encephalitis is a potentially lethal viral illness transmitted by a mosquito of the Culex species in rural parts of tropical Asia. Travelers who anticipate spending more than 4 weeks in epidemic or endemic areas should be vaccinated. The vaccine is a three-dose series given over a 4-week period. The vaccine should be administered at least 2 weeks before departure to allow time to monitor for an adverse reaction that is prone to occur. Risk of Japanese encephalitis is rare among short-term travelers, and the vaccine is usually not recommended for them.^9,10

Meningitis epidemics occur frequently in sub-Saharan Africa from December to June, and also in northern India, Saudi Arabia, and Nepal. The meningococcal vaccine is recommended for travelers to areas where epidemics are occurring. The CDC usually updates most health departments and travel agencies about high-risk areas. The meningococcal polysaccharide vaccine is a single-dose injection that provides immunity against various serogroups of Neisseria meningitidis for about 3 years.^9,10

Rabies is a fatal encephalomyelitis transmitted by an animal bite. The preexposure rabies vaccine is recommended for athletes traveling to remote areas of Latin America, the Middle East, Africa, and Asia where immediate access to medical care for postexposure prophylaxis is not available. The vaccination consists of 3 weekly injections. Any traveler who might have been exposed to rabies, regardless of vaccination status, should always contact the local health authorities immediately.^9,10

Cholera and plague vaccines are available in the United States, but both have low efficacy. The risk for international athletes to contract plague or cholera is low; therefore, the vaccines are rarely indicated.

Traveler's Diarrhea

Diarrhea is the most common illness affecting travelers. The hallmark symptom is at least 3 unformed stools in 24 hours and one or more of the following symptoms: abdominal pain, cramps, nausea, vomiting, or bloody stools. The risk of acquiring traveler's diarrhea ranges from 20% to 30% among short-term travelers worldwide to as high as 80% among long-stay tourists.¹¹ The leading causative pathogens are bacteria, including Escherichia coli and species of campylobacter, shigella, and salmonella. Gastrointestinal viruses (eg, rotavirus, Norwalk) and parasitic infections (eg, Giardia lamblia) are less frequent causes. The traveler's destination is the most important determinant of risk. Developing countries in Latin America, Africa, the Middle East, and Asia are considered high risk. Several countries in Southern Europe and the Caribbean Islands are considered intermediate risk. Low-risk areas include the United States, Canada, northern Europe, Japan, Australia, and New Zealand.

Travelers should be instructed about ways to avoid diseases transmitted through food and water and about the importance of fluid replacement if diarrhea occurs. Prophylaxis is usually not indicated, but most travelers should carry an antimotility agent and an antibiotic for self-treatment. Loperamide hydrochloride can be used to treat mild diarrhea. If loperamide is not effective during the first 24 to 48 hours, the patient should begin taking a quinolone antibiotic (eg, ciprofloxacin, ofloxacin, levofloxacin, or norfloxacin) for up to 3 days.

Malaria

Malaria is a parasitic blood infection transmitted to humans through the bite of the Anopheles mosquito. It is the most frequent infectious cause of death for people traveling to countries in the tropics and subtropics. Worldwide, more than 300 million people are infected annually, and about 2 million die. Even if the exposure to a malarious area is brief, such as a one-night stay, the traveler should take protective measures. Malaria is characterized by symptoms of recurrent fever, chills, headaches, weakness, and lethargy. Symptoms can develop up to a year after travel. Therefore, travelers should immediately report malaria symptoms to their healthcare provider. Malaria is diagnosed by performing thick and thin blood smears. One negative blood smear does not rule out malaria, and, if symptoms persist, two additional smears should be performed 12 to 24 hours apart.

Four species of malaria exist: Plasmodium falciparum, P malariae, P vivax, and P ovale. Infection with P falciparum, the most virulent species, can result in death if not promptly treated. The best way to prevent malaria is to avoid the mosquito. The Anopheles mosquito feeds at night; therefore, maximum precautions should be taken from dusk to dawn. Effective defenses against malaria and other vector-borne illnesses include wearing permethrin-coated clothing that covers the arms and legs, applying insect repellent containing DEET (N,N-diethyl-3-methylbenzamide), and using bed nets.

Chemoprophylaxis is recommended for any traveler going to malarious regions (table 3). Chloroquine phosphate is the drug of choice in areas where there is no resistance to this drug, such as west of the Panama Canal zone in Central America, Mexico, Haiti, the Dominican Republic, and Egypt. In areas of chloroquine resistance, mefloquine hydrochloride, atovaquone with proguanil hydrochloride, and doxycycline hydrochloride are equally effective drugs of choice.⁵ All chemoprophylaxis drugs significantly decrease the risk of contracting malaria, but none guarantees 100% protection. Chemoprophylaxis should begin 1 week before patients travel to at-risk areas, except for doxycycline or atovaquone with proguanil, which should begin 1 day before travel. Patients receiving antimalarial prophylaxis should be advised about compliance and potential side effects.

Motor Vehicles and Driving

Accidental injuries cause 20% to 25% of all travel-related death, with motor vehicle accidents accounting for most of these fatalities.⁷ Travelers should be aware that the risk of motor vehicle–related death is generally many times higher in developing countries than in the United States. Motor vehicle injuries abroad result from a variety of factors, including frequent lack of seat belts or lack of their use, riding in nonpassenger areas (ie, the back of an open truck), and poor vehicle and road maintenance. In addition, trauma centers are essentially nonexistent in developing countries; therefore, an injury that could easily be handled locally in the United States may require that the patient be transported hundreds or thousands of miles away.

When abroad, travelers should consider letting a responsible native do the driving, or, when possible, select buses or trains as the main mode of transportation. However, if driving, travelers should be very careful and specifically request vehicles equipped with safety belts, working lights and windshield wipers, and brakes in good condition. Because a high proportion of crashes occur at night, travelers should avoid nonessential night driving, particularly in rural areas, and driving or riding with people while under the influence of alcohol or drugs.

Crossing Time Zones

Jet lag syndrome, characterized by daytime sleepiness, nighttime insomnia, poor concentration, malaise, gastrointestinal disturbance, and fatigue is among the most common complaints of travelers who fly across three or more time zones. Jet lag is caused by a disrupted circadian rhythm and sleep-wake cycle. While not a serious condition, jet lag can significantly impair competition and performance of an athlete for several days.

To minimize the effects of jet lag, athletes are encouraged to sleep well the night before departure, maintain good hydration (aircraft cabin pressure can cause dehydration), synchronize their watches with the destination time zone at departure, and carry personal relaxation materials, such as books, magazines, and music.^7,8 Eyeshades, earplugs, melatonin, and short-acting hypnotics, such as zolpidem tartrate, may help some travelers. Patients should be warned that alcoholic beverages exacerbate the drowsiness effect of hypnotic medications. After arrival, competitive athletes should allow 1 day of recovery for each time zone difference.

Motion Sickness

Bumpy bus rides, air travel, and ocean vessels are often associated with motion sickness. Symptoms include epigastric discomfort, sweating, pallor, nausea, dizziness, and vomiting. Motion sickness is caused by a mismatch of vestibular and visual sensations. Travelers may prevent motion sickness by:

• Eating a light meal no less than 3 hours before embarking;
• Focusing on the horizon;
• Sitting in a central location (eg, the front seat of a car, middle of a ship, or over the wings in an airplane);
• Limiting head and neck movements by reclining or leaning back against a firm surface;
• Avoiding visual stimuli (eg, reading or watching a movie);
• Increasing ventilation or exposure to fresh air;
• Avoiding alcoholic beverages or smoking; and
• Taking prophylactic medications before the trip.

The transdermal scopolamine patch is the most effective drug available and has fewer side effects. However, children, elderly patients, or people who have a history of glaucoma or prostatic enlargement should not use scopolamine. Other medications include dimenhydrinate, diphenhydramine hydrochloride, and meclizine hydrochloride. All of these medications cross the blood-brain barrier and can cause drowsiness. Acupressure with wristbands has generated a great deal of interest as a nonpharmacologic means of preventing motion sickness. To control nausea and vomiting, pressure is applied to the P6 acupuncture point located on the palmar side of wrist. Clinical trials are inconclusive regarding the true benefits of this treatment.

Altitude Illness

Athletes traveling to mountainous regions to train or compete should be aware of the signs and symptoms of altitude sickness. This illness is more common among travelers who ascend quickly, are younger, and have a history of altitude illness. Being in good physical shape is not protective against high-altitude illness.

Common symptoms of the mild form of altitude illness, also referred to as acute mountain sickness, include headache, insomnia, irritability, muscle aches, fatigue, nausea, anorexia, vomiting, and swelling of the face, hands, and feet. These can significantly impair athletic performance.

Use of alcohol and certain medications, such as sleeping pills and tranquilizers, increase the risks of altitude illness. The illness is more prevalent at elevations above 7,000 ft (2,134 m), and the incidence goes up at higher altitudes because of reduced barometric pressure and low oxygen levels. High-altitude pulmonary edema and high-altitude cerebral edema are more severe and emergent forms of altitude illnesses, but, fortunately, they occur less frequently.

Ascending slowly, eating a high-carbohydrate diet 1 to 2 days before ascent, remaining well hydrated, and avoiding intense training until acclimatized will help reduce or avoid the symptoms of altitude illness. For athletes flying on a tight schedule to altitudes of 10,000 ft (3,048 m) or more, acetazolamide may be beneficial, because this medication prevents or lessens the symptoms of altitude sickness by increasing the respiratory rate. However, it is also a diuretic and may cause dehydration. For prevention, the acetazolamide dosage is 125 to 250 mg twice a day beginning 1 day before the trip and continued for 48 to 72 hours.

Mild forms of altitude illnesses can be treated by staying a day or two at the altitude at which symptoms occur, then ascending cautiously. Symptomatic treatment includes nonnarcotic analgesics, such as ibuprofen for headache, prochlorperazine for nausea and vomiting, and acetazolamide to speed up acclimatization. Severe altitude illness is treated with immediate descent, oxygen, and dexamethasone.⁸

Sexually Transmitted Disease

Those who have unprotected sex during international travel are at a high risk for acquiring sexually transmitted diseases (STDs) such as gonorrhea, chlamydiosis, urethritis, syphilis, chancroid, herpes, human immunodeficiency virus, and hepatitis B and C. Travelers may feel less sexually inhibited in a foreign country, placing themselves at a greater risk for acquiring STDs. Counseling for travelers should include the benefits of abstinence and the consequences of acquiring an STD. If, however, a traveler chooses to engage in sexual activities, he or she can reduce the risk of acquiring an infection by judicious selection of partners and correctly using high-quality latex condoms. Avoiding alcohol and drugs, which may promote incautious behavior, is also wise.⁵

Severe Acute Respiratory Syndrome

First described in China in November 2002, severe acute respiratory syndrome (SARS) has spread to other countries, particularly in other parts of Asia and to Canada. SARS transmission occurs through respiratory droplets from infected patients. Symptoms include fever higher than 100.4°F (38°C), dry cough, shortness of breath, and difficulty breathing. SARS can cause death, particularly in people 65 and older.

At this time, no specific drug to prevent or treat the disease is known. The best way to avoid the virus is to minimize contact with individuals who have SARS and to minimize exposure to infectious droplets on surfaces. Frequent hand washing is an effective method of reducing the risk of SARS transmission. If traveling to an area where there have been recent cases of SARS, it is wise for patients to avoid crowded public conditions and unnecessary visits to healthcare facilities. Surgical masks have been used in potentially high-risk situations, such as in poorly ventilated, crowded facilities in SARS-affected areas, but no validation data on the effectiveness of these masks exist.

Travelers should always check with their healthcare provider regarding the emergence of new epidemics and infectious diseases, such as SARS, and stay informed about current travel alerts and health advisories. Information about travel alerts and advisories and CDC pretravel health recommendations can be found at www.cdc.gov/travel.

Other Illnesses and Posttravel Health Problems

Travelers are at increased risk of other illnesses or conditions, including infections such as marine envenomations, drowning, psychiatric illnesses, sunburn, and heat-related illnesses. The risks can be greatly reduced by following certain precautions (table 4). Some diseases might not manifest themselves immediately; for example, malaria might not cause symptoms for as long as 6 to 12 months after the person returns home. Therefore, if tourists become ill after coming home, they should inform their physicians about countries they visited during the preceding 12 months. A complete travel history will help physicians establish a correct diagnosis, even when facing a very rare disease.

Point of Departure

As more patients pursue sports and leisure activities in foreign countries, clinicians need to maintain a high index of suspicion for pathogens not normally seen in their home area. Healthcare providers who know where to find up-to-date information can counsel their traveling patients about required or recommended immunizations, malaria, diarrhea, STDs, motor vehicle safety, and a wide variety of health issues.

References

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2. Outbreak of leptospirosis among white-water rafters—Costa Rica, 1996. MMWR 1997;46(25):577-579
3. Update: Outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000—Borneo, Malaysia, 2000. MMWR 2001;50(2):21-24
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7. Reyes I, Shoff WH: General medical advice for travelers. Emerg Med Clin North Am 1997;15(1):1-16
8. Health information for International Travel 2001-2002. Atlanta, Centers for Disease Control and Prevention, 2001. Available at http://www.cdc.gov/travel/yb/index.htm. Accessed May 8, 2003
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10. Burger ET: Preparing adult patients for international travel. Nurse Pract 2001;26(5):13-23
11. Ramzan NN: Traveler's diarrhea. Gastroenterol Clin North Am 2001;30(3):665-678

Dr Jiménez is the director of the Presby Wellness and Fitness Center at Ashford Presbyterian Community Hospital in Condado, Puerto Rico. Address correspondence to Carlos E. Jiménez, MD, PMB 130, 35 Calle Juan C. Borbon, Suite 67, Guaynabo, PR 00969-5375; send e-mail to cejimenez@hotmail.com.

Disclosure information: Dr Jiménez discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.