Travel Medicine

Cover
Dedication
Travel Medicine
Copyright Page
Preface
List of Contributors
Acknowledgments
Section 1: Practice of Travel Medicine
1 Introduction to Travel Medicine
	Reference
2 Epidemiology
	Abstract
	Keywords
	Key points
	Introduction
	Cornerstones of Travel Health Epidemiology
	Mortality
		Accidents
		Infectious Diseases
		Other Illness and Mortality
		Aeromedical Evacuation
	Morbidity
		Travelers’ Diarrhea
		Malaria
		Vaccine-Preventable Infections
			Required Immunizations.
			Routine Immunizations.
			Recommended Immunizations.
		Other Infections
			Sexually Transmitted Diseases.
			Upper Respiratory Tract Infection (URTI).
			Other Arboviral Infections: Dengue, Chikungunya, Zika.
			Legionella.
			Leishmaniasis.
			Schistosomiasis.
			Trypanosomiasis.
		Noninfectious Health Problems
			Environmental.
			Host.
	Conclusion and Prioritization
	References
3 Starting, Organizing, and Marketing a Travel Clinic
	Abstract
	Keywords
	Key points
	Introduction
	The Practice of Travel Medicine
	Starting a Travel Health Program
		Frequently Asked Questions
			Who Is Qualified to Offer Travel Health Services?
			What Can Health Care Professionals Do to Develop Expertise in Travel Health?
			Are There Different Models of Care Delivery?
			What Policies, Procedures, and Resources Should Be in Place?
			Is Special Documentation Required?
			What Support Services Are Needed?
			Should a Clinic Offer Travel Health Services Full Time? What Are the Best Times for Clinic Sessions?
			What Vaccines Should Be Provided? Should the Clinic Offer Yellow Fever Vaccine?
			How Much Time Should Be Set Aside for Appointments?
			How Should a Clinic Determine Charges?
			What Is It Going to Cost to Establish a Travel Health Program?
		Organizing a Clinic: Equipment and Supplies
			Equipment
				Refrigerator and freezer.
				Computer.
			Supplies
				Vaccine supply.
				Vaccination supplies.
				Managing adverse events.
				Infection control and hazardous waste supplies.
				Other patient supplies.
		Documentation
		Information Resources for the Clinician
		Information Resources for the Traveler: Patient Education
		Legal Issues
			Professional Standards.
	Financial Considerations
		Fees and Revenue for a Travel Health Practice
		Fee-for-Service Care
		When a Clinic Participates in Insurance Plans
		Clinic Charges
		Selling Travel-Related Products
	Combining a Travel Clinic With Other Services
		Pretravel Physical Examinations and Posttravel Care
		Services to Travelers During Their Journeys
		Offsite Services
	Running a Travel Health Program
		Staff and Administrative Issues
		Before the Visit, Preparation of Reception Staff
		Key Issues During the Pretravel Consultation
		After the Consultation
		Reporting Vaccine Adverse Events
		Service Evaluation
		After the Trip
	Marketing and Promoting a Travel Health Program
		Word of Mouth
		Referrals
		Direct Marketing Methods: Internet, Print, and Media
		Other Marketing Approaches
		Mailings
		Contract Services
		Brochures
	Management Challenges
		Telephone, Email, and Text Advice
	Professional Development
	Conclusion
	References
4 Pretravel Consultation
	Abstract
	Keywords
	Key points
	Introduction
	Logistics and Mechanics of the Pretravel Consultation
	Components of Pretravel Consultation and Order of Importance
	Fitness to Travel
	Analysis of Expected Health Risks in Travelers
		General Considerations
		General Topics to Be Covered
	Application of Preventive Measures
	Health Problems During and After Travel
	Challenges Regarding Travel Advice
	Acknowledgments
	References
Section 2: The Pretravel Consultation
5 Water Disinfection for International Travelers
	Abstract
	Keywords
	Key points
	Introduction
	Etiology and Risk of Waterborne Infection
	Water Treatment Methods for Short-Term and Long-Term Travelers and Expatriates
		Heat
		Clarification
			Sedimentation.
			Coagulation–Flocculation.
			Granular Activated Carbon.
		Filtration
		Halogens
			The Disinfection Reaction.
			Iodine Resins.
			Improving Halogen Taste.
			Halogen Toxicity.
		Miscellaneous Disinfectants
			Silver.
			Photocatalytic Disinfection.
			Ultraviolet.
			Solar UV Disinfection (SODIS).
			Citrus and Potassium Permanganate.
		Preferred Technique
	Sanitation
	Conclusion
	References
6 Insect Protection
	Abstract
	Keywords
	Key points
	Introduction
	Stimuli That Attract Insects
	Personal Protection
		Habitat Avoidance
		Physical Protection
		Insect Repellents
			Chemical Repellents
				DEET.
					Choosing a DEET Formulation.
					DEET Safety and Toxicity.
				IR3535.
				Picaridin.
			Botanical Repellents.
				Citronella.
				BiteBlocker.
				BioUD (2-undecanone).
				Lemon Eucalyptus.
				Geraniol.
			Efficacy of DEET Versus Botanical Repellents.
			Alternative Repellents.
	Insecticides
		Permethrin
	Reducing Local Mosquito Populations
	Relief From Mosquito Bites
	Summary—A Comprehensive Approach to Personal Protection
	References
7 Pretravel Considerations for Non-vaccine-Preventable Travel Infections
	Abstract
	Keywords
	Key points
	Introduction
	Dengue, Chikungunya, and Zika
		Overview
		The Mosquito Vectors: Aedes aegypti and A. albopictus
		Dengue
		Chikungunya
		Zika
		Prevention of Dengue, Chikungunya, and Zika
		Additional Considerations for the Prevention of Congenital Zika Infection
	Severe Respiratory Infections With Regional Endemicity
		Middle Eastern Respiratory Syndrome
		Avian Influenza
		Preventative Advice for Severe Respiratory Infections
	Other Regionally Important Infections in Travelers
	References
8 Travel Medical Kits
	Abstract
	Keywords
	Key points
	Introduction
	Summary of Factors Determining Medical and First-Aid Kit Construction
	Contents of Medical and First-Aid Kits
	The Basic Medical and First-Aid Kit
	More Comprehensive Kits
	Expedition and Group Kits
	References
Section 3: Immunization
9 Principles of Immunization
	Abstract
	Keywords
	Key points
	Introduction
	Immunology of Vaccination
		Immunization
		Active Immunization
		Passive Immunization
			Immune Memory and Booster Doses.
		Vaccines
			Inactivated Vaccines.
			Live Attenuated Vaccines.
		Vaccine Administration
			Route of Immunization.
				Intramuscular route.
				Subcutaneous route.
				Intradermal route.
				Oral application.
			Simultaneous Administration/Interchangeability of Vaccines.
			Serologic Testing Before and After Immunizations.
	Vaccine Safety and Management of Adverse Reactions
	Special Conditions/Contraindications
	Immunizations in Travelers/Conclusion
	References
10 Routine Adult Vaccines
	Abstract
	Keywords
	Key points
	Introduction
	Tetanus, Diphtheria, Pertussis
		Indications
		Contraindications
		Precautions
		Dosing Schedules
		Measures of Immune Response and Duration of Immunity/Protection
		Adverse Effects
	Measles, Mumps, and Rubella Vaccine
		Indications
		Contraindications
		Precautions
		Dosing Schedule
		Adverse Effects
		Measures of Immune Response and Duration of Immunity/Protection
	Varicella and Herpes Zoster Vaccines
		Indications for Varicella Vaccination
		Contraindications: Varicella Vaccination
		Precautions
		Dosing Schedules
		Measures of Immune Response and Duration of Immunity/Protection
		Adverse Events
		Drug and Vaccine Interactions
		Herpes Zoster Vaccination
		Pneumococcal Vaccine
		Indications
		Contraindications
		Precautions
		Dosing Schedule
		Measures of Immune Response and Duration of Immunity/Protection
		Adverse Events
	Human PapillomaVirus Vaccine
		Indications
		Dosing Schedules
		Contraindications and Precautions
	Influenza
		Indications
		Dosing Schedules
		Contraindications and Precautions
	Conclusion
	References
11 Routine Travel Vaccines
	Abstract
	Keywords
	Key points
	Hepatitis A Vaccine
		Indications
		Contraindications
		Precautions
		Dosing Schedules
		Accepted Accelerated Schedule
		Measures of Immune Response and Duration of Immunity
		Adverse Events
		Drug and Vaccine Interactions
	Immune Globulin for Hepatitis a Prevention
		Indications
		Contraindications
		Precautions
		Dosing Schedules
		Adverse Events
		Drug and Vaccine Interactions
	Hepatitis B Vaccine
		Indications
		Contraindications
		Precautions
		Dosing Schedules
		Accelerated Schedules
		Measures of Immune Response and Duration of Immunity/Protection
		Adverse Events
		Drug and Vaccine Interactions
	Combined Hepatitis A and Hepatitis B Vaccine
		Indication
		Contraindications
		Precautions
		Dosing Schedules
		Accepted and Possible Accelerated Schedules
		Measures of Immune Response and Duration of Immunity/Protection
		Adverse Events
		Drug and Vaccine Interactions
	Typhoid Vaccine
		Indications
		Contraindications
		Precautions
		Dosing Schedules
			Vi Polysaccharide Typhoid Vaccine.
			Ty21a Oral Typhoid Vaccine.
		Measures of Immune Response and Duration of Immunity/Protection
			Vi Polysaccharide Typhoid Vaccine.
			Ty21a Oral Typhoid Vaccine.
		Adverse Events
		Drug and Vaccine Interactions
	Conclusion
	References
12 Recommended/Required Travel Vaccines
	Abstract
	Keywords
	Key points
	Introduction
		Practical Vaccine Considerations
		Adverse Events
		Attenuated Live Vaccines
	Required Vaccines
		Yellow Fever Vaccine
			Recommendations.
			Indications.
			Contraindications and Precautions
				Age.
				Pregnancy.
				Nursing mothers.
				Thymic disorder or dysfunction.
				Altered immune states.
				Hypersensitivity to eggs.
			Dosing Schedules.
			Measures of Immune Response and Duration of Immunity/Protection.
			Adverse Events.
			Drug and Vaccine Interactions.
	Recommended Vaccines
		Cholera Vaccines
			Indications.
			Contraindications and Precautions (Applies for All Vaccines)
			Dosing Schedules.
			Measures of Immune Response and Duration of Immunity/Protection.
			Adverse Events.
			Drug and Vaccine Interactions.
		Japanese Encephalitis Vaccine
		Inactivated Cell-Culture Vaccines
		Chimeric JE Vaccine (JE-CV)
		Live Attenuated SA-14-14-2 JE Vaccine
			Indications.
			Contraindications
			Dosing Schedules.
			Adverse Events.
			Drug and Vaccine Interactions.
		Meningococcal Vaccine
			Indications.
			Contraindications
			Precautions.
			Dosing Schedules.
			Measures of Immune Response/Duration of Immunity/ Protection.
			Adverse Events.
			Drug and Vaccine Interactions.
		Polio Vaccine
			Indications.
			Dosing Schedules.
			Accelerated Schedules for Primary IPV Immunization.
			Contraindications
			Precautions.
			Side Effects.
		Rabies Vaccine
			Indications.
			Contraindications
			Precautions.
			Dosing Schedules
				Preexposure vaccination.
				Boosting.
			Accepted and Possible Accelerated Schedules.
			Postexposure Vaccination.
			Measures of Immune Response and Duration of Immunity/ Protection.
			Adverse Events.
			Drug and Vaccine Interactions.
		Tickborne Encephalitis Vaccine
			Indications.
			Criteria
			Contraindications
			Dosing Schedules.
			Measures of Immune Response and Duration of Immunity/Protection.
			Adverse Events.
			Drug and Vaccine Interactions.
	References
13 Pediatric Travel Vaccinations
	Abstract
	Keywords
	Key points
	Introduction
	Vaccine Considerations in Infants and Children
		Polysaccharide Vaccines
		Conjugate Vaccines
		Intercurrent Illness and Vaccination
	Routine Pediatric Vaccines
		Diphtheria-Tetanus-Acellular Pertussis Vaccine (DTaP)
		Adolescent Pertussis Vaccine (Tdap)
		Measles–Mumps–Rubella Vaccine
		Polio Vaccine
		Pneumococcal Vaccine
		Influenza Vaccine
		Varicella Vaccine
		Hepatitis B Vaccine
		Rotavirus Vaccine
		Human Papilloma Virus Vaccine
			Indications.
		Meningococcal Vaccines
		Accelerating Routine Vaccines
	Pediatric Travel Vaccinations
		Required Vaccinations
			Yellow Fever Vaccine.
		Recommended Vaccinations
			Hepatitis A Vaccine.
			Hepatitis A–Hepatitis B Combination Vaccine.
		Hepatitis A–Typhoid Combination Vaccine
		Meningococcal Vaccines
		Typhoid Vaccine
		Rabies Vaccine
		Japanese B Encephalitis Vaccine
		Tickborne Encephalitis Vaccine
		BCG
	Summary
	References
Section 4: Malaria
14 Malaria
	Abstract
	Keywords
	Key points
	Introduction
	Distribution of Malaria Species
	Who Is at Risk?
	Where Are Travelers at Risk of Acquiring Malaria?
	Drug-Resistant Malaria
		Chloroquine
		Mefloquine
		Doxycycline
		Atovaquone/Proguanil
		Primaquine
	References
15 Malaria Chemoprophylaxis
	Abstract
	Keywords
	Key points
	Approach to Malaria Prevention
		Assessing Individual Risk—Parasite, Place, and Person
		Preventing Mosquito Bites With Personal Protection Measures
		Taking the “THINK MALARIA” Approach if Fever Develops During or After Travel
		Using Malaria Chemoprophylaxis
	Current Chemoprophylactic Drug Regimens
		Chloroquine, Hydroxychloroquine, Chloroquine/Proguanil
			Description, Pharmacology, and Mode of Action.
			Efficacy and Drug Resistance.
			Tolerability.
			Contraindications, Precautions, and Drug Interactions.
			Indications and Administration.
		Mefloquine
			Description, Pharmacology, and Mode of Action.
			Efficacy and Drug Resistance.
			Prophylactic Failures and Resistance.
			Tolerability.
			Moderate/Severe Adverse Events.
			Serious Adverse Events.
			Neuropsychiatric Adverse Events.
			Contraindications, Precautions, and Drug Interactions.
				New contraindications
				New precautions.
				Pregnancy.
			Indications and Administration.
		Doxycycline
			Description.
			Pharmacology and Mode of Action.
			Efficacy and Drug Resistance.
				P. vivax.
				P. ovale, P. malariae, and P. knowlesi.
			Tolerability.
			Contraindications, Precautions, and Drug Interactions.
			Indications and Administration.
		Atovaquone/Proguanil
			Description.
			Pharmacology and Mode of Action.
			Efficacy and Drug Resistance.
			Tolerability.
			Contraindications, Precautions, and Drug Interactions.
			Indications and Administration.
		Primaquine
			Introduction and Description.
		Pharmacology and Mode of Action
			Efficacy and Drug Resistance.
			Tolerability.
			Contraindications and Precautions.
			Indications and Administration.
	Future Directions
		Tafenoquine
			Introduction and Description.
			Efficacy and Drug Resistance.
			Tolerability.
			Contraindications, Precautions, and Drug Interactions.
			Indications and Administration.
	New Pipeline Drugs for Malaria Chemoprophylaxis
	Chemoprophylaxis in Special Populations
		Pregnant and Breastfeeding Travelers
			Breastfeeding.
		Long-Term Travelers
		Business Travelers
		Migrant and VFR Travelers
		Infants/Children
	Differences in Guidelines and Recommendations on Malaria Chemoprophylaxis
		Primaquine.
	References
16 Self-Diagnosis and Self-Treatment of Malaria by the Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Rapid Diagnostic Tests for Malaria
		Rationale
		Principle and Availability of Test Kits
		Performance of RDTs for Laboratory Diagnosis of Malaria
		Performance of RDTs for Self-Use by Travelers
		SBET for Malaria
			Principle and Rationale for Use.
	Recommendations for Choice of Drugs
		SBET Recommendations for Pregnant Women, Children, and Chronically Ill Patients
		Balancing of Recommendations
	Summary and Outlook
	Conclusion
	References
17 Approach to the Patient With Malaria
	Abstract
	Keywords
	Key points
	Introduction
	The Threat
	The Malarias
	Clinical Presentation of Uncomplicated Malaria
	Clinical Presentation of Severe and Complicated Malaria
	Diagnosis of Infection
		Clinical Diagnosis
			Microscopic Diagnosis.
		Rapid Diagnostic Tests
		Nucleic Acid Diagnostic Tests
	Treatment of Uncomplicated Malaria
	Treatment of Severe Malaria
	Treatment of Severe Malaria in Children
	Treatment of Malaria in Pregnancy
	Antirelapse Therapy With Primaquine
	Primaquine and G6PD Deficiency
	Managing Relapse Risk in Patients Unable to Receive Primaquine
	Conclusion
	References
Section 5: Travelers\' Diarrhea
18 Epidemiology of Travelers’ Diarrhea
	Abstract
	Keywords
	Key points
	Introduction
	History
	Clinical Characteristics
	Etiology
	Bacteria
		Diarrhea Producing E. coli
		Campylobacter spp.
		Salmonella spp.
		Shigella spp.
		Vibrio spp.
	Viruses
	Parasites
		Giardia
		Entamoeba spp.
		Cyclospora
		Cystoisospora belli
		Cryptosporidium
		Blastocystis hominis
	Host Factors
		Age/Gender
		Travelers’ Diarrhea in Children
		Country of Origin
		Immunity
		Underlying Medical Conditions
		Specific Host Factors
	Environmental Factors
		Pretravel Advice
		Travel Packages and Meals
		Lodging
		Risk by Geographic Region
	Complications of Travelers’ Diarrhea
	Postinfectious Irritable Bowel Syndrome
		Association With Travelers’ Diarrhea
	Military Epidemiology
	Conclusion
	References
19 Prevention of Travelers’ Diarrhea
	Abstract
	Keywords
	Key points
	Introduction
	The Impact of Prevention
	Prevention Strategies
		Identifying Hosts at Risk
		Education and Behavior Modification
		Probiotics and Other Nonantibiotic Forms of Prophylaxis
		Vaccines
		Antimicrobial Agents
	Prophylaxis Versus Early Treatment
	Conclusion
	References
20 Clinical Presentation and Management of Travelers’ Diarrhea
	Abstract
	Keywords
	Key points
	Classical and Functional Impact–Based Definitions
	Syndromic Presentations and Etiology
		Acute and Chronic Complications
		Differential Diagnosis
	Management of Travelers’ Diarrhea
		Pretravel Counseling
		Fluids
		Mild Diarrhea
		Moderate Diarrhea
		Severe (Watery) Diarrhea and Dysentery
		Other Nonantibiotic Alternatives
		When to Seek Care
		Antibiotic Resistance as Both Cause and Consequence of Travelers’ Diarrhea
	Conclusion
	References
21 Persistent Gastrointestinal Symptoms in the Ill-Returning Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Definitions and Epidemiology
		Persistent Gastrointestinal Symptoms Incidence
	Pathoetiologic Mechanisms
		Persistent Infection or Coinfection
		Parasites
			Giardia lamblia.
			Entamoeba histolytica.
			Dientamoeba fragilis.
			Microsporidia.
			Cyclospora cayetanensis.
			Cryptosporidium parvum.
			Cystospora Belli.
		Bacteria
			Enterobacteriaceae.
			Clostridium difficile.
		Unknown Pathogens
			Tropical Sprue.
			Brainerd Diarrhea.
		Postinfectious Processes
			Postinfectious Malabsorptive States.
			Postinfectious Functional Gastrointestinal Disorders Epidemiology and Pathogenesis.
		Chronic Gastrointestinal Diseases Unmasked by an Enteric Infection
			Idiopathic Inflammatory Bowel Disease.
			Celiac Sprue.
			Colorectal Cancer.
	Clinical Approach
		History and Physical Examination
		Noninvasive Laboratory Workup
			Stool Studies.
			Blood Testing.
			Endoscopic Evaluation.
		Therapy
	Conclusion
	References
Section 6: Travelers With Special Needs
22 The Pregnant and Breastfeeding Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Pretravel Preparation
		Access to Medical Care Abroad
			Travel by Air.
			Water Sports and Travel by Boat.
			Exercise.
			Travel by Automobile.
	Immunizations
	Infectious Diseases in Pregnancy
		Zika Virus and Pregnancy
	Malaria and Pregnancy
		Guidelines for Prevention
			Personal Protective Measures.
			Chemoprophylaxis.
			Treatment.
	Food and Water Precautions
		Travelers’ Diarrhea
		Water Purification
		Treatment
		Other Infectious Disease Risks
	Altitude and Pregnancy
	Pregnancy Planning
	Breastfeeding
		Drugs in Breast Milk
		Malaria Prevention
		Immunizations
		Practicalities
	Medications
	Other Issues
		Medical Kit
		Alternative Medications
	References
23 The Pediatric and Adolescent Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Comfort and Safety
		Should Children Be Subjected to the Discomforts of International Travel? Is It Safe for Children to Travel Internationally?
		Schedules
		Air Travel
			Is It Safe for Infants to Travel in Commercial Airplanes or Go to High Altitudes?
			What Are the Risks of Injury During Air Travel?
			Assuming Reasonable Safety Precautions Are in Order, What Can Be Done to Ensure Comfort for a Child and Family Traveling by Air?
			Should Children Be Sedated During Long Flights?
			Does Jet Lag Occur in Children?
			What About Earaches With Air Travel?
		Motor Vehicles
		Motion Sickness
		Outdoor Activities
			Water.
			Skin Protection.
			Altitude.
			Animal Contact.
		What Precautions Should Be Taken for Children With Chronic Medical Conditions?
		Risk-Taking Behaviors Especially for Adolescents
		Medical Kit for Families
	Immunization
	Insect-Borne Diseases
		Treatment of Bites
		Additional Preventive Strategies for Specific Insect-Borne Diseases
			Malaria.
			Tickborne Diseases.
			Yellow Fever and Japanese Encephalitis; Dengue, Chikungunya, and Zika.
	Diarrhea
		Food and Water Hygiene
		Epidemiology of Diarrhea in Pediatric Travelers
		Treatment
			Which Antibiotic Should Be Used in Children?
		Screening
			What Should Be Done for Children Returning From International Journeys?
		Managing Illness in Arriving Pediatric Travelers
		Psychosocial Adjustment and Integration Into the New Setting
	Conclusion
	References
24 The Older Traveler
	Abstract
	Keywords
	Key points
	Introduction
		Why Are Elderly Travelers at Greater Risk?
	General Advice
		Choosing a Trip
		Fitness to Travel
		Making Travel Arrangements
		Health Insurance
		Medications and Medical Supplies
		Accessing Medical Services Abroad
		Practical Tips During Air Travel
	Medical Conditions Arising During Travel
		Motion Sickness
		In-Flight Medical Emergencies
		Venous Thromboembolic Disease
		Jet Lag
		Hyperthermia and Hypothermia
			Heat Stress.
			Cold Stress.
		Altitude Sickness
		Accidents and Injury
	Travel-Related Infections in the Elderly
		Malaria
		Travelers’ Diarrhea
		Sexually Transmitted Infections
	Vaccine-Preventable Infections
		Routine Immunizations
			Pneumococcal Vaccine.
		Travel Vaccines
			Hepatitis A and B.
			Japanese Encephalitis.
			Cholera Vaccine for Travelers’ Diarrhea.
			Typhoid Fever.
			Varicella.
			Yellow Fever.
	Conclusion
	Additional Resources
	References
25 The Physically Challenged Traveler
	Abstract
	Keywords
	Key points
	Introduction
	General Advice
	Choosing a Trip and Making Travel Arrangements
	Traveling With an Attendant
		The Physically Disabled Traveler
		Air Travel With a Wheelchair or Scooter
		Air Travel With Canes, Crutches, Walkers, and Other Medical Devices
		Cruising With a Wheelchair or Scooter
	The Hearing-Impaired Traveler
	The Speech-Impaired Traveler
	The Visually Impaired Traveler
	Service Animals
	The Developmentally or Cognitively Impaired Traveler
	Conclusion
	References
26 The Traveler With Preexisting Disease
	Abstract
	Keywords
	Key Points
	General Principles
	Before You Go
	The Voyage
	While in the Destination Country
	After the Trip
	Specific Medical Problems
		Cardiac Disease
		Anemia
		Respiratory Disease
		Renal Disease
		Diabetes Mellitus
		Gastrointestinal Disease
		Liver Disease
		Neurologic Disease
			Malaria Prophylaxis in Patients With Neurologic Diseases
		Allergies
	Conclusion
	References
27 The Immunocompromised Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Corticosteroids, Disease-Modifying Antirheumatic Drugs, and Biologic Therapies
	Asplenic Travelers
	Transplant Recipients
	Cancer Chemotherapy
	Special Vaccine-Related Topics
		Pretravel Vaccination of the Immunocompromised Host
		Yellow Fever
		Measles
		Influenza
	Rabies Vaccination and Postexposure Prophylaxis
	Health Care Workers and Medical Missions
		Cholera
		Meningococcal Meningitis
		HIV and Bloodborne Risk
	Suspending Immunosuppression for Vaccination
		Vaccination of Family Members and Household Contacts
	Additional Considerations
		Medication-Related Issues in the Traveling Transplant Recipient
		Gastroenteritis
		Sun Protection
		Environmental Exposures, Animal Bites, Sexual Contact
		Tuberculosis
		Strongyloides
	Medical and Transplant Tourism
	Conclusions
	References
28 The Traveler With HIV
	Abstract
	Keywords
	Key points
	Introduction
	Health Risks to the Traveler
	Pretravel Advice
		Behavioral Precautions
		Vaccination
			Immune Status of the Traveler.
			Nature of Vaccine.
				Inactivated vaccines.
			Risk and Severity of Vaccine Preventable Disease in the HIV-Infected Traveler.
			Risk of HIV Rebound as a Consequence of Vaccination.
		Antiretroviral Prophylaxis to Prevent HIV in Travelers
		Drug Interactions
	Health Care Abroad
	Crossing International Borders
	Conclusion
	References
29 The Business Traveler
	Abstract
	Keywords
	Key points
	Introduction
	Health Risks of International Business Travelers
		Travel-Related Infections
	Environmental Risks
		Air Pollution
		Safety and Security Risks
	Medical Considerations for International Travel
		Pretravel Considerations for Health Risks Before International Travel
		Travel Health Considerations During Travel and at the Destination
		Posttravel Care Considerations
	Special Issues for Business Travelers
		Travel Kits
		Jet Lag
		Zika
		Medical Insurance Coverage for Business Travel
	Conclusion
	References
30 VIP Traveler
	Abstract
	Keywords
	Key points
	Introduction
	The Man, the Mission, and Medicine
	Mission-oriented Medicine and VIP Travel Medicine
	Operationalizing VIP Travel Support
		Medical Threat Assessment and Countermeasures
		Communicate: Translating the Medical Threat Assessment Into a Medical Travel Advisory
		Support Requirements
		The Plan
		Nothing More, Nothing Less
			Right Problem.
			Right Person.
				Right person: expeditionary medical staffing.
				Staffing options: right training.
				Staffing options: right team.
			Right Equipment.
				Common pitfalls.
			Right Place, Right Time.
				Rested and ready to respond.
				Right environment.
	Knowing Where to Get Help: Host Country Solutions
	What Next? Evacuation Planning
	Operational Security: Don’t Become a Liability
		Economics of VIP Travel Medicine Support
	Conclusion
	References
31 Health Aspects of International Adoption
	Abstract
	Keywords
	Introduction
	Preadoption
		The Children
		The Parents
	The Adoption
		The Children
		The Parents
		The Immediate Postadoption Visit
			General Evaluation.
		Screening for Infectious Diseases
			Skin and Intestinal Infections.
			Hepatitis A.
			Hepatitis B.
			Hepatitis C.
			HIV.
			Measles and Other Vaccine Preventable Diseases.
			Vaccinations in New Arrivals.
			Tuberculosis (TB).
			Syphilis.
			Malaria.
			Rarities.
		Conclusion
	References
32 Visiting Friends and Relatives
	Abstract
	Keywords
	Key points
	Introduction
		Who Are Visiting Friends and Relatives Travelers?
		Why Are Visiting Friends and Relatives a Risk Group for Travel-Related Illness?
	Epidemiology of Travel by Visiting Friends and Relatives
		Hepatitis A
		Enteric Fever
		Malaria
		Sexually Transmitted Infections and Bloodborne Viruses
		Tuberculosis in Ethnic Groups
		Other Infections
	Approaches to the Visiting Friends and Relatives Pretravel Consultation
		Improving Access to Pretravel Services
		Routine Immunizations
		Travel-Specific Immunizations
		Malaria Prevention
	General Travel Advice
	Conclusion
	Acknowledgment
	References
Section 7: Travelers With Special Itineraries
33 Expatriates
	Abstract
	Keywords
	Key points
	Expatriates: Preparing and Caring
		Hidden Costs of Expatriation
		Premature Attrition
	Deaths, Accidents, and Injuries
	Predeparture Assessment
		The Purpose of Predeparture Medical Assessments
		Tuberculosis Skin Test
		Predeparture Psychologic Assessment
			Psychologic Interview.
			Psychologic Interview—When There Is No Time or Expertise.
			The Role of Psychometric Testing.
	Predeparture: Preparation
		Health Briefings
		Immunizations
			Hepatitis A and B.
			Japanese Encephalitis.
			Rabies.
		Malaria
			Rapid Diagnostic Testing.
		Diarrheal Diseases
		Sexually Transmitted Diseases
		Infection Control Policies
		Risk Behavior
		Security Issues and Evacuation Policies
		Psychologic Training and Preparation
			Information and General Counsel.
	Culture Shock and the U-Curve Hypothesis
	“Normal” Adjustment Difficulties
		Children
	Factors That Can Facilitate Cultural Adaptation
	Caring for Expatriates in International Settings
		Models of care that are utilized:
		Self-Care
		Telemedicine and the Internet
		Organizational Support
	Caring for Expatriates at the Time of Repatriation
		Returning Home
		Premature Repatriation and Medical Evacuation
	Who Requires a Medical Consultation on Return Home?
	Illness in Returning Expatriates
		Infectious Diseases
		Mental Health
	Factors Influencing Reintegration
		Issues for Families
		Easing Return
	References
34 The Migrant Traveler
	Abstract
	Keywords
	Key points
	Health Evaluation of Migrants
	Health Status of Migrants
		Infectious Diseases
			Tuberculosis.
			Chronic Viral Hepatitis.
			Human Immunodeficiency Virus.
			Intestinal Parasites Including Strongyloides and Schistosomiasis.
			Other Parasitic Infections.
		Immunizations
		Noncommunicable Diseases, Women’s Health, and Mental Health
			Noncommunicable Diseases.
			Women’s Health Issues.
			Mental Health Issues.
	Core Values and Best Practices in the Care of Immigrant Patients
		Optimizing Health During Pretravel and Posttravel Visits
	Conclusion
	References
35 Humanitarian Aid Workers
	Abstract
	Keywords
	Key points
	Introduction
	Mortality in Humanitarian Workers
	Morbidity in Humanitarian Workers
		Morbidity Among Rescue Teams and Volunteers Working in Acute Disaster-Stricken Areas
	Specific Diseases and Medical Conditions
		Malaria
		Tuberculosis
	Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
		Rabies
		Dental Care
		Mental Health
	Humanitarian Aid Workers—The Public Health Aspects
	Health Recommendations for the Relief Worker Traveling to Challenging Work Zones
	References
36 The Deployed Military
	Abstract
	Keywords
	Key points
	Introduction
	Noncombat-Related Injuries and Back Pain
	Combat-Related Injuries
	Psychiatric Disorders
	Malaria and Other Vectorborne Diseases
	Sexual Health
	Dermatologic Diseases
	Gastrointestinal and Respiratory Infections
	Conclusion
	Disclosure
	References
37 Expedition Medicine
	Abstract
	Keywords
	Key points
	Introduction
	Questions to Ask
	Risk Assessment and Preparation
		Personal Preparation
	First-Aid Kits
		Contents
		Design
		Supplies
		Liability
	On the Road
		Field Data
		Psychiatric Problems
		Polar Environments
		Mountaineering
		Desert Environments
		Jungle/Tropical Environments
		Kayaking and Rafting
		Scuba Diving Expeditions
		The Luxury Expedition
	Local Health Care
		Difficult Situations
		Medical Care of Others
		Safety and Security
	Repatriation
	Death Overseas
		Back Home
	Conclusion
	References
38 Ecotourism
	Abstract
	Keywords
	Key points
	Introduction
	Ecotourists
	Physical Risks
		Physical Risks From Other Species.
	Infectious Disease Risks
		Zoonotic Disease Risks.
		Risks to Other Species.
	Recommendations
	References
39 Medical Tourism
	Abstract
	Keywords
	Key points
	Introduction
	Medical Tourism Defined
	General Considerations Related to Medical Treatment Abroad
	Cosmetic Surgery Tourism Recommendations
	Dental Work Abroad
	Transplant Tourism
	Bariatric Tourism
	Reproductive Tourism
	Medications
	Adverse Effects and Complications
	Conclusions
	References
40 Cruise Ship Travel
	Abstract
	Keywords
	Key points
	Introduction
	The Cruise Industry
		The North American Cruise Industry
		The Passengers and Crew
	Cruise Health, Sanitation, and Safety Regulations
		International Regulations
		US Regulations
	Medical Care Aboard Cruise Ships
	Illness on Cruise Ships
		Respiratory Infections
			Influenza.
			Legionnaires Disease.
		Gastrointestinal Illness
			Waterborne Diseases.
			Foodborne Diseases.
			Norovirus.
	Miscellaneous
		Vaccine-Preventable Diseases (VPD)
		Injuries
		Seasickness
	Health Preparation and Prevention Measures for Cruise Travel in Large/Small Vessels
		Pretravel
		During Travel
		After Travel
	Conclusion
	Acknowledgment
	References
41 Mass Gatherings
	Abstract
	Keywords
	Key points
	Introduction
	Communicable Diseases
	Noncommunicable Diseases and Trauma
	Specific Mass Gatherings
		Hajj Pilgrimage
		Olympic Games, FIFA, and Other Sport Events
		Other Community Events
	Canceling Mass Gatherings
	Planning for Mass Gatherings
	Individual Pregathering Advice
	Conclusions
	References
42 High-Altitude Medicine
	Abstract
	Keywords
	Key points
	Introduction
		The High-Altitude Environment
	Acclimatization
		Effects of High Altitude on Exercise
		Sleep at High Altitude
	High-Altitude Syndromes
	High-Altitude Headache
		Epidemiology
		Pathophysiology of High-Altitude Headache
		Clinical Presentation and Diagnosis
		Treatment
		Prevention
	Acute Mountain Sickness and High-Altitude Cerebral Edema
		Epidemiology
		Pathophysiology of Acute Mountain Sickness/ High-Altitude Cerebral Edema
		Clinical Presentation and Diagnosis
		Treatment
		Prevention
		Preacclimatization
	High-Altitude Pulmonary Edema
		Epidemiology
		Pathophysiology
		Clinical Presentation and Diagnosis
		Treatment
		Prevention
	Other Altitude-Related Conditions
	Children at Altitude
		Acute Mountain Sickness
		Treatment
		Prevention
		Pulmonary Hypertension and High-Altitude Pulmonary Edema
		Treatment
		Prevention
		Periodic Breathing
		Travel Advice for Parents
	Effect of Altitude on Common Medical Conditions
		Pulmonary and Cardiac Problems
		Hematologic Disorders
		Neurologic Disorders
		Diabetes
		Ophthalmologic Conditions
		Obstetrics/Gynecology
		Psychiatric Conditions
	References
Section 8: Environmental Aspects of Travel Medicine
43 Diving Medicine
	Abstract
	Keywords
	Key points
	Introduction
	Unique Environment and Physiologic Challenges
	The Ears, Nose, and Throat System and Diving
	Cardiovascular Fitness
	Respiratory Fitness
	Specific Considerations
		Asthma and Diving
		Diabetes and Diving
		Medication and Diving
		Age
		Aerobic Fitness and Watermanship
		Diving-Related Maladies
		Altitude Exposure After Diving
	Further Information and Advice
	Conclusion
	References
44 Extremes of Temperature and Hydration
	Abstract
	Keywords
	Key points
	Introduction
		“Normal” Body Temperature
		Monitoring Body Core Temperature
			Measuring Instruments.
			Measurement Sites.
	Thermoregulation
		Heat Balance
		Dry Heat Exchange
		Evaporative Heat Exchange (Sweating)
		Fever
	Environmental Conditions Assessment
		Heat Stress.
		Cold Stress.
	Acclimatization
		Heat Adaptation
		Cold Adaptation
		Steam Baths and Saunas
	Heat-Related Illnesses
		Heatstroke
			Pathophysiology.
			Early Presentation.
			Diagnosis.
			Clinical Picture.
			Treatment.
			Prognosis.
			Prevention.
		Other Heat-Related Concerns
			Heat Exhaustion.
			Heat Cramps.
			Heat Syncope.
			Heat Edema.
	Cold Injuries
		Hypothermia
			Diagnosis.
			Treatment.
			Complications Associated With Active Re-Warming.
		Frostbite
			Treatment.
		“Trench Foot” (Immersion Foot)
			Treatment.
		Chilblains
			Treatment.
		Preventing Cold Injuries
	Dehydration and Fluid Consumption
		Hypohydration
		Voluntary Dehydration
		Overhydration and Hyponatremia
		Isotonic Fluids (Sport Drinks)
		Rehydration
	Conclusion
	References
45 Jet Lag
	Abstract
	Keywords
	Definition
	Physiology
	Clinical Features
	Treatments
		Resetting the Clock
			Pretravel Sleep Schedule Adjustment.
			Sleep Schedule on Arrival.
			Light Therapy.
			Diet.
			Exercise.
			Melatonin and Melatonin Agonists (MMAs) for Resetting the Clock.
	Getting to Sleep (see Table 45.2)
		Hypnotics
			MMAs.
			Sedatives.
			Dual Orexin Receptor Antagonists (DORAs).
			Antihistamines.
			Antidepressants and Anxiolytics.
	Staying Awake
		Stimulants
			Caffeine.
			Amphetamines.
			Modafinil and Armodafinil.
			Nicotinamide Adenine Dinucleotide (NADH).
	Conclusion
	References
46 Motion Sickness
	Abstract
	Keywords
	Key points
	Introduction
	Triggers of Motion Sickness
		What Is Motion Sickness?
	Who Is Likely to Get Motion Sickness?
		What Is the Mechanism of Motion Sickness?
	The Vestibular System
	Nonmedicinal Prevention and Treatment Options
	Medications for Prevention and Treatment of Motion Sickness
	Treatment of Established Motion Sickness
	Adjunctive, New, and Experimental Agents
	Individualized Recommendations for Prevention or Treatment of Motion Sickness
	Conclusion
	References
47 The Aircraft Cabin Environment
	Abstract
	Keywords
	Key points
	Introduction
	The Pressurized Cabin
		Humidity
		Ozone
		Cosmic Radiation
		Pesticides in the Cabin
	Infectious Diseases and Cabin Air: Droplet and Airborne Spread
		Tuberculosis
		Influenza
		Measles
		Mumps
		Infectious Diseases and Contamination of Aircraft Interior Furnishings
		Ebola Virus, Middle East Respiratory Syndrome, and Other Intermittent Outbreaks of Concern to Air Travel
	Passenger Health
		Preflight Assessment and Medical Clearance
		Assessment Criteria
		Deep Vein Thrombosis and Prevention of Pulmonary Embolism
		Considerations of Physical Disability or Immobility
		Oxygen
		In-Flight Medical Emergencies
		Telemedicine
		Aircraft Emergency Medical Equipment
		Resuscitation Equipment
	Conclusions
	References
Section 9: Health Problems While Traveling
48 Bites, Stings, and Envenoming Injuries
	Abstract
	Keywords
	Key points
	Introduction
	Nonvenomous Injuries
		Arthropod Bites
			Prevention of Arthropod Bites.
			Treatment of Arthropod Bites.
		Animal Attack Injuries
			Prevention of Animal Attack.
			Treatment of Animal Attack Injuries.
			Infection From Animal Attacks.
	Venomous Bites and Stings
		Prevention of Venomous Bites and Stings
		Venomous Arthropods
			Hymenoptera.
			Spiders and Scorpions.
		Venomous Reptiles
	Marine Animal Bites and Stings
		Prevention of Marine Animal Stings and Attacks
		Treatment of Marine Bites, Stings, and Attacks
		Marine Infections
	References
49 Seafood Poisoning
	Abstract
	Keywords
	Key Points
	Introduction
	Ciguatera
	Scombroid (Histamine Fish Poisoning)
	Pufferfish (Fugu) Poisoning
	Paralytic Shellfish Poisoning
	Neurotoxic Shellfish Poisoning
	Diarrheic Shellfish Poisoning
	Amnesic Shellfish Poisoning
	CONCLUSION
	References
50 Injuries and Injury Prevention
	Abstract
	Keywords
	Key points
	Introduction
	Fatal Injury
	Nonfatal Injuries
	A Global Public Health Approach for Travel Medicine
	Road Traffic Safety
		Seatbelts and Child Safety Seats
		Helmets
	Water-Related Injuries
	Alcohol as a Risk Factor
	Conclusion
	References
51 Mental Health Issues of Travelers
	Abstract
	Keywords
	Key points
	Introduction
	Sources of Stress in International Travel
	Epidemiology of Psychiatric Disorders and International Travel
	Clinical Operating Environments Overseas and Their Vicissitudes
	The Pretravel Risk Assessment
	Psychosis: Some Specifics and Relation to International Travel
		Mania
		Substance Use Disorders
			Relationship to International Travel.
	Posttravel Consultations
	References
52 Travelers’ Thrombosis
	Abstract
	Keywords
	Key points
	Introduction
	Venous Thrombosis
	Size of the Risk After Travel
	Factors Influencing the Risk
		Passenger-Related Risk Factors
		Travel-Related Risk Factors
	Mechanism
	Prevention
	Conclusions and Recommendations
	References
53 Health Care Abroad
	Abstract
	Keywords
	Key points
	Introduction*
		Risks of Needing Care Abroad
	Factors Influencing Development of Health Care Abroad
		Continued Globalism of Quality
		Growth of Medical Tourism
	Obtaining Care While Abroad
		Critical Incident Management Principles
			Preparation.
				Risk considerations.
			Health Care Resources.
				Self-care or buddy-care.
				Telemedicine services.
				Local physician offices/clinics.
				For-profit international health care organizations.
				Foreigners’ clinics.
				Hospital care.
			Planning for and Accessing Care.
				Self-care.
				Medical assistance plans.
				Other resources for locating care.
	Evacuation Issues
		Local Evacuation Issues
		Long-Distance Evacuation
	Paying for Care
	Critical Differences in Approaches to Health Care Abroad
		Cultural Differences
		Nursing Care
		No “Right to Care”
	Pharmacy and Medication Issues
	Conclusion
	References
54 Personal Security and Crime Avoidance
	Abstract
	Keywords
	Key points
	Introduction
	Before Departure
	Priorities Upon Arrival
	In the Hotel
	Out and About
	Taxis and Public Transport
	Theft
	Accidents
	Getting Sick
	Learn Local Regulations Early
	Mobile Phones and Electronic Devices
	Active Shooter
	Being a Hostage
	Conclusion
	References
Section 10: Posttravel
55 Posttravel Screening
	Abstract
	Keywords
	Key points
	Introduction
	Who and When to Screen?
		Targeted Populations
			Asymptomatic Short-Term Traveler.
			Asymptomatic Long-Term Traveler or Expatriate.
			Asymptomatic Adventurous Traveler.
			Travelers With Self-Identified Risk Factors and/or Disease Symptoms During Travel.
	General Screening
		Medical Interview
		Physical Examination
		General Paraclinical Tests
			General Laboratory Tests.
			Blood Eosinophil Count.
			Abdominal Ultrasound.
			Resting Electrocardiogram.
	Specific Screening Tests in a Posttravel Evaluation
		Screening for Latent Tuberculosis
		Chest X-ray
		Tuberculin Skin Testing and Interferon-γ Release Assay
		Sexually Transmitted Infections
		Viral Hepatitis
		Dengue
			Zika.
		Foodborne Infections
		Screening for Parasitic Diseases
			Introduction.
			Strongyloidiasis.
			Schistosomiasis.
			(Neuro)cysticercosis.
			Other Intestinal Helminths.
			Invasive Amebiasis.
			Other Intestinal Protozoa.
			Infections With Blood-Dwelling or Tissue-Dwelling Parasites.
			Malaria.
			Leishmaniasis.
			Trypanosomiasis.
	Conclusions
	References
56 Fever in Returned Travelers
	Abstract
	Keywords
	Key points
	Introduction
	Epidemiology of Fever in Travelers
		Prevalence of Fever in Travelers
	Causes of Fever in Travelers
	Approach to the Patient With Fever
		The Travel and Exposure History
		Incubation Period
		Mode of Exposure
		Impact of Pretravel Vaccination
	Clinical Presentations
		Undifferentiated Fever
			Always Look for Malaria.
			Dengue.
			Chikungunya.
			Zika.
			Rickettsial Infections.
			Enteric Fever.
			Leptospirosis.
			Acute Schistosomiasis.
			Amebic Liver Abscess.
		Hemorrhagic Fevers
		Fever and CNS Changes
		Persistent and Relapsing Fevers
	Laboratory Clues
		Routine Laboratory Studies
		Elevated Liver Enzymes
		Fever and Eosinophilia
		Initial Diagnostic Workup
		Management
	Conclusion
	References
57 Skin Diseases
	Abstract
	Keywords
	Key points
	Epidemiological Data
		Dermatoses Diagnosed Abroad.
		Dermatoses Diagnosed Upon Return
	Tropical Dermatoses in the Traveler
		Hookworm-Related Cutaneous Larva Migrans
		Localized Cutaneous Leishmaniasis
		Myiasis
		Tungiasis
		Cutaneous Gnathostomiasis
		Other Tropical Dermatoses of Interest for Travelers
	Cosmopolitan Dermatoses
		Pyodermas
		Dermatophytosis
		Arthropod-Related Dermatoses
		Scabies
		Cercarial Dermatitis
		Sea-Bather’s Eruption
		Marine Life Dermatitis
		Photosensitivity and Photo-Induced Disorders
		Other Cosmopolitan Dermatoses of Interest to Travelers
	Diagnosis of a Skin Lesion in the Traveler
		Pruritus
		Creeping Eruption, Cutaneous Larva Migrans
		Urticaria
		Febrile Rash
		Edema
		Nodular Lymphangitis
	Sexually Transmitted Infections
	Conclusion
	References
58 Eosinophilia
	Abstract
	Keywords
	Key points
	Introduction
	Causes of Eosinophilia
		Overview
		Allergic Disorders/Asthma
		Drug Hypersensitivity
		Infection
			Helminths.
			Ectoparasites.
			Protozoa.
			Fungi.
			Other.
			Other Causes.
	Clinical Syndromes
		Skin/Soft Tissue Involvement
		Pulmonary Manifestations
		Gastrointestinal Symptoms
		Neurologic Disease
		Fever
			Other.
		Asymptomatic Eosinophilia
			Schistosomiasis.
			Filarial Infection.
			Strongyloidiasis.
			Hookworm Infection.
	Evaluation of Patients With Eosinophilia
	Approach to the Patient With Undiagnosed Eosinophilia
	Conclusion
	References
59 Respiratory Infections
	Abstract
	Keywords
	Key points
	Introduction
	Causative Agents and Clinical Presentation
	Epidemiology
	Risk Factors
	Transmission
	Management of Respiratory Tract Infections
	Prevention in Travelers
	Infections of the Respiratory Tract Associated With Epidemics
		Severe Acute Respiratory Syndrome
		Avian Influenza
		Influenza
		Middle East Respiratory Syndrome Coronavirus
		Legionellosis
	Tropical and Geographically Restricted Respiratory Infections
		Melioidosis
		Leptospirosis
		Anthrax
		Plague
		Paragonimiasis
		Coccidioidomycosis and Histoplasmosis
		Tuberculosis
			TB Among Travelers From Low-Endemic to High-Endemic Areas.
	Conclusion
	References
Appendix Sources of Travel Medicine Information
	Key points
		Abstract
		Keywords
	Introduction
	Reference Texts
	Journals
	Travel Medicine Websites
	Point-of-Care Travel Clinic Destination Resources
	Electronic Discussion Forums
	Electronic Notifications and Feeds
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	Y
	Z