Charisse Ann Suliguin Pasay, Philippines
Millions travelled for tourism, migration, employment, business, education and humanitarian aid each day prior to COVID-19. Despite a greater chance of acquiring infections, only a handful of travelers seek pre-travel health advice. Those who actually do have difficulty adhering to the advice owing to a perception of minimal risk of infection.
The environment abounds with a plethora of infectious diseases. Newspapers and the internet are ripe with news on existing infectious diseases, of emerging and re-emerging viruses and of decades-old epidemics – information that only scratch the surface. It is generally recognized that infectious diseases remain a leading cause of deaths worldwide. Known sources are pathogenic bacteria, viruses, parasites and fungi that spread from person to person or from animals to humans.
These diseases are closely monitored by epidemiologists and scientists alike because of their potential impact to public health. Dedicated surveillance networks provide data on the incidence of infectious diseases per population and describe travel-related disease patterns and risks. It is up to the travel medicine specialist to interpret the relevance of this data to the traveler, a skill beyond the scope of a primary care physician.
Travel medicine focuses on the health issues related to global travel. This includes vaccinations, epidemiology, region-specific travel medicine, pre-travel management, travel-related illness and post-travel management. The goal is to provide adequate and complete education and preparation in all stages of travel. From pre-travel, to preventing one from getting an exotic disease, to post-travel when one may bring an unwanted illness to his loved-ones, family members, friends and even his local community. It is the the travel medicine specialist who provides an in-depth and accurate assessment of the risk of getting an illness depending on the traveler’s characteristics and his itinerary.
Travel Risk Assessment
Travelers must ascertain their specific itinerary several weeks prior to departure. This is necessary procedure in the travel risk assessment. The trip details should include the geographic itinerary, duration and season of travel, urban versus rural travel, anticipated living conditions, reason for travel and medical care resources available during travel. To effectively communicate and manage risk, an enquiry into the traveler’s past medical and immunization history, special conditions, knowledge of any known disease risk or precautions advised and prior travel experience is also done.
Aside from updating routine vaccinations, travel vaccines may also be advised. Vaccines against yellow fever, typhoid, Japanese encephalitis, cholera, hepatitis A and rabies are travel vaccines. Proof of routine and travel vaccination is required. The yellow fever vaccination, for example, is recorded on a regular yellow certificate form (photo credit: seamanrepublic.com). The specialist has intensive knowledge of multiple vaccine administration and contraindications, as well as medication interactions.
For travelers leaving on short notice, vaccinations may be updated on the first instance according to destination. Health counseling may be done during the appointment or by other secure means of communication. The traveler may be asked to put together a basic health travel kit that should include standard first aid items plus destination-appropriate prophylactic drugs.
Specialized travel health insurance may be required and may even be part of the pre-travel preparation, especially for those planning extended travel. Quality health care providers and facilities at destination should be identified in medical cases requiring assistance.
Aside from country-specific incidence of yellow fever and malaria, travel medicine specialists also watch out for more than 50 tropical diseases. Health risks during cruise and air travel are considered. The specialist must also possess thorough knowledge of travel-related obstetrics, psychiatry, occupational health, military and migration medicine and environmental hazards.
Most post-travel illnesses can be managed on an outpatient basis, but patients presenting with systemic febrile illnesses may need to be hospitalized. A comprehensive knowledge of incubation periods is particularly helpful. As with the usual history taking, components of a complete travel history include the chief complaint, the trip details, recreational activities, common and other exposures (e.g. sexual history), use of travel precautions, past medical history, medications, pre-travel and routine vaccinations received. Additional information regarding family history, personal and social history and recent travel history within the last 6 months is part of the history-taking, too.
Information regarding COVID-19 is continuously evolving. One point to consider on top of the regular entries for risk assessment is if the traveler has any of the established predisposing factors such as diabetes mellitus, hypertension, cardiac and renal disease, obesity and respiratory disorders that interfere with immune function. Elderly travelers with high-risk conditions may have to defer travel until an effective vaccine is available.
Six COVID-19 vaccine candidates have already entered Phase 3 of clinical trials. These six vaccines are the Inactivated Vaccine by Wuhan Institute of Biological Products and Sinopharm; CoronaVac (inactivated) by Sinovac; mRna-1273 by Moderna; AZD1222 by the University of Oxford and Astra Zeneca; BNT162 (mRna-based) by Pfizer and BioNTech, and Ad5-nCoV by CanSino Biologics. These vaccines will now be given to thousands of people to measure efficacy and to test further for safety.
The level of potential exposure to COVID-19 during travel must be estimated from the point of origin to the destination according to evident efforts for disinfection, volume of traffic limitation and physical distancing promotion. Essential travelers are advised to practice frequent hand washing and the use of face masks, and to reduce face-to-face and indoor interactions with people.
Additional travel kit mainstays are an abundant supply of hand sanitizers and wipes, face masks, thermometer and possibly even pulse oximeters. There is no evidence that supports the use of “immunity certificates” as of yet, hence the World Health Organization does not recommend it.
The travel medicine specialist can guide essential travelers regarding transmission situations, quarantine policies and requirements, healthcare preparedness and over-all precautions of the city or country of destination. Now more than ever, travelers must avail tailored pre-travel health advice from physicians with sufficient travel medicine expertise to minimize risk of infection.