Travel Medicine in Primary Care: The Pre-Travel Consultation

This transcript has been edited for clarity. 
Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr Paul Nelson Williams. 
Paul, when I’m planning to travel, what should I think about? I want some general tips to start off here. 
Paul N. Williams, MD: Let’s say a patient presents to your office who is going to be traveling to someplace exotic, at least to us. What sort of history should you take and how can you counsel them best? We talked to the great Dr Boghuma Titanji about travel medicine.
 In general, we tend to focus on the destination and the potential infections you can get in that destination. But you actually have to think of the substrate that you’re treating, meaning the patients themselves and what risk factors they are bringing to the party. Most of the mortality that happens with travel is not really related to infectious stuff; it’s because you didn’t look left when crossing the street, or you had a heart attack because you were going to have a heart attack anyway.
This risk-reduction counseling involves reminding patients to take their medications with them, having contingency plans for illness or injury, and probably getting traveler’s insurance. It’s some of the most useful advice that you can give in addition to counseling and planning for the infectious disease risks.
A person’s behavior might be different when they’re traveling. Some might engage in higher-risk sexual activity, for example. It’s completely within your wheelhouse as a primary care doctor to consider prescribing pre-exposure prophylaxis, do some good counseling, and even consider post-exposure prophylaxis for the appropriate patient. There is such a thing as sex tourism, and your patient may not share that with you. Assume that the patient might be more sexually active, and make the offer to protect them from those risks as much as you’re able to. 
The other infectious disease that we should focus on is malaria and how we can counsel patients about those risks. 
Watto: When I see a patient for a pre-travel visit, my mind immediately goes to mosquitoes and malaria. You are right about missing the bigger picture if you’re not talking to them about their underlying comorbidities and their behaviors while they’re traveling.
One behavior that people should be doing is using insect repellent, insecticide-treated bed nets, and wearing the appropriate clothing to protect them from both the sun and the bugs while they are traveling. It’s hard to avoid being bit by mosquitoes, as Dr Titanji said. Even if the traveler is from an endemic area— she mentioned that she’s from Cameroon, but she’s been out of the country for more than 6 months and has lost her immunity to malaria, so she needs to take prophylaxis when she travels there. People are often a little more cavalier if they grew up in the area they are traveling to, but they are actually at risk. 
For malaria prevention, if the patient is leaving soon, a prescription for a daily antimalarial medication is probably the way to go because you only need to start the drug a day or two before travel. Doxycycline, atovaquone-proguanil, and primaquine are potential agents to use. Primaquine is contraindicated in G6PD deficiency. The prevention drugs are typically continued for 7 days after the patient returns home.
The weekly medications, which include mefloquine and chloroquine, have to be started roughly 2 weeks before travel and continued for 4 weeks after they return. In some cases, the timing and the patient’s comorbidities will dictate which medication is preferred.
Paul, are you giving patients who are planning to travel to certain countries a prescription for artemether-lumefantrine (the drug used to treat malaria) in case they become infected during travel? If the patient has a fever upon return from an endemic area, malaria is likely. 
Williams: I have not had the opportunity to do so. 
Watto: On the podcast, we go into the ins and outs of all the drugs. Primary care physicians should feel comfortable prescribing these medications, especially if the patient is in a pinch. 
When I travel, I’m all about that street food, and staying with a local family and eating what they eat. Am I at risk for traveler’s diarrhea? 
Williams: Those are the behaviors that potentially increase your risk for traveler’s diarrhea. As part of the pre-travel encounter, in addition to the counseling around what medications to take and what shots to get, it’s also important to remind patients to wash their food with bottled water. Use bottled water for everything — not just for drinking, but also for brushing your teeth, for rinsing off anything that may come in contact with your gut. Make sure the water comes from a safe source. 
Street food is the romantic part of traveling and a way to engage with culture, but it’s also a great way to be exposed to the local microbiome, which means it’s your chance to get sick as well. So, just engage at risk. I can’t fully endorse it, but I can understand the temptation.
Watto: When I inevitably get traveler’s diarrhea from eating street food, I am going to take ciprofloxacin, right? Is there any resistance to it out there? Is it still first-line treatment?
Williams: I originally thought about ciprofloxacin as a long time de facto treatment for traveler’s diarrhea. But actually, it’s azithromycin. It’s reserved for moderate to severe cases of traveler’s diarrhea. The mild cases are annoying but not disruptive to activities. Once it becomes disruptive to day-to-day plans, that’s when you drift into “moderate” territory.
And blood in the stool means you’ve drifted into severe diarrhea, basically dysentery. It’s reasonable to give an antibiotic just in case for those circumstances, but it’s going to be azithromycin, not ciprofloxacin. 
Watto: Let’s pretend I’m a 75-year-old man. I’m pretty sick at baseline. I’m traveling to a country for which I need the yellow fever vaccine. I’m just going to go get it, right? No risk to me? 
Williams: What’s important here is which country the patient is traveling to. Some countries do require proof of a vaccine or at least a good medical reason to not have received it. But it’s a vaccine with risk, including death. The risk is higher with older age and other comorbidities. Patients need to be counseled accordingly because these risks are real.
The yellow fever vaccine can’t be given at the primary care office or pharmacy, only in a licensed travel clinic. Getting this done requires a little bit of organization and arrangement in advance, so make sure you are aware of which countries require the yellow fever vaccine. 
Although patients can’t get the yellow fever vaccine in the primary care office, they can get the other vaccines, such as hepatitis A, hepatitis B, or tetanus. These are generally cheap because they are preventive medicine, but the yellow fever vaccine, given at a travel medicine or vaccine clinic, can be expensive. 
We heard lots of great tips during the full podcast episode. I definitely recommend that you listen to it.