The Importance of a Pre-travel Clinic Visit at BMC

Melanie Cole (Host): The travel clinic at Boston Medical Center provides travelers health services including routine and travel vaccines, malaria prevention, travelers' diarrhea prevention, and management. My guest today is Dr. Natasha Hochberg. She's an infectious disease specialist and the co-director of the Boston Medical Center Travel Clinic. Welcome to the show, Dr. Hochberg. Who needs pre-travel advice?

Dr. Natasha Hochberg (Guest): Thank you for the invitation to join you. So, I would suggest that individuals that are traveling overseas, primarily those with underlying medical conditions, people that are at extremes of age, either they're very young or they're very old, should discuss their travel plans. So, you know, it's hard to sometimes say who exactly needs travel advice, so my best suggestion is to talk to your primary care doctor about it and say "I'm planning a trip, do you think that I need to go see a travel clinic, or is there any advice that you need to provide me ahead of time?" So, I would suggest that people do this routinely. If you're thinking about traveling, talk to your primary care doctor about it and see if you need referral, and especially if you have any medical problems, you really probably should be referred to a travel clinic for expert advice.

Melanie: How soon before a trip should they come to the traveler’s clinic and seek advice?

Dr. Hochberg: That's a great question. Oftentimes, we see people only a few days before they go, and that's fine. Better late than never. But, we do ideally see people about four to six weeks before they travel and the reason is this: there's certain vaccines that you need to have multiple doses of before you go in order for the vaccines to be effective. So, for example, with a rabies vaccine, you need to get three shots before you go and that takes about a month, just because they need to be separated in time. It takes about a month, so we want to make sure we see people at least a month before you go. This also gives us time to check to see your antibody levels, to see if you're previously protected from certain infections or not, to decide whether or not you really need to get certain vaccines. So, ideally, 4-6 weeks before you travel, you should be seen in a travel clinic.

Melanie: What information would you like listeners to bring with them when they come to the travel clinic?

Dr. Hochberg: So, information that can be very helpful for us is the following: one is an itinerary of where you're going. I understand that plans change and people don't know all of the specifics but having a general sense of where you are going within a country can be very helpful because risks are different within a country. There might be malaria in certain parts of the country and not in others. So, the more information that you have about your itinerary, the better. The other things I would suggest bringing are a copy of your vaccine records. Sometimes this takes a little bit of digging to call a pediatrician or to call a primary care doctor but this information could be very helpful because it can mean that we can understand about what shots you've received and what shots you might need. The last thing I would say is just to check with your insurance company before you go to the travel clinic to doublecheck what vaccines might be covered and whether the visit is covered. Your itinerary, your vaccine record, and information from your insurance company are all useful things to bring with you.

Melanie: And, what do you think, Dr. Hochberg, are some of the problems, the most common problems, that travelers encounter?

Dr. Hochberg: Yes, so there are a number of different things that we think about and I'll let you know sort of when we see people at the visit, we address a range of different things. So, we address and provide some counseling information, but we also provide vaccines, we provide--and this is a combination both of travel-specific vaccines as well as sometimes, people are just not up-to-date on their routine vaccinations with things like tetanus and so we can double-check about that and make sure people are up-to-date with routine vaccinations. We also will provide medicine to prevent you from getting malaria if you're going to a country that has malaria; medicine to treat traveler's diarrhea; and other medications, depending on one's exposure. So, your question is sort of what things do you have to worry about during a trip and what kinds of problems do people have? Recent studies have shown that, you know, quite commonly, people will have diarrhea during a trip and, obviously, this depends on exactly where you're going, but travelers' diarrhea is quite common. So, that is something that we definitely spend time talking about. Other things that are common are respiratory infections, either the flu or other respiratory infections and sometimes skin problems. So, what we can do during the visit is really try to talk about ways to prevent these things because it's common to get diarrhea but there's a number of things you can do during your trip to really reduce that risk. So, some of the time I spend with people at the travel clinic is to discuss measures to prevent food and water-borne transmissions. So, we recommend that people drink bottled water or boiled water, that they avoid any ice cubes, and this is particularly to going to sort of low- and middle-income countries, and that the mantra really about food for fruits and vegetables is boil it, peel it, or forget it. So, we tend to tell people not to eat their nice, leafy lettuce when you're on vacation in some of these countries, but to stick to sort of boiled or peeled vegetables. Other advice that we tend to give is really around insects and preventing transmission of insect-related illnesses. So, this includes things like malaria, but also Zika virus, that's been much in the news, and then we go through a variety of other sort of counseling measures that are quite important for people to think about that their primary care doctor might not have time to discuss. So, this includes transmission of things from you're swimming. Unfortunately, there are parasitic infections you can get from swimming and bacterial infections. We talk about car accidents and the real need to wear your seatbelts. I know it sounds like I'm being your mom, but it's really important in terms of wearing seat belts and because car accidents are actually the major cause of mortality of people dying when they travel. We talk about a number of other travel-related illnesses actually transmitted infections and things like that. So, I think in answer to your question, what things do we have to worry about? Well, there's a whole range of infectious diseases and non-infectious problems that one can encounter during your travel that we can try to help people avoid.

Melanie: Do you think that people, and do you recommend or advise, that people look up, if they're going with children, that they look for walk-in clinics or doctors in the area that they're going, just so they can have those if they need them?

Dr. Hochberg: I think it's always a good idea, particularly if you’re traveling with young children, or if you have underlying medical problems--if you take blood thinners or if you have cancer, or you have underlying medical problems--I always think it's a good idea to know where you could get care if you need to. So, the CDC, the Centers for Disease Control, has some of that information; the International Society of Travel Medicine has a list of reputable clinics in various countries and you can always check with your primary care provider if they have contacts in a certain area or with a travel medicine provider, but I do think that makes sense. The other thing that makes sense is to bring all of your prescriptions with you on board the plane and not to check any of those medicines in case your bags get lost which, unfortunately, happens. You don't want your medications to get lost. You always want to bring a copy of the actual prescription so that in case somebody looks at the bottles, they see that these are medicines that have been provided by a doctor. So, I do think that's important to look up where you can get care. The other thing that's really important to look up before you go is are there any alerts or ongoing outbreaks that one needs to know about in this destination? And so, again, the Centers for Disease Control has updated information about this. You can also go to the embassy information for the country that you're going to but I do recommend this for travelers before they go.

Melanie: Dr. Hochberg, some people like to be traveling medicine cabinets. Do you recommend, and to parents, again, that might be traveling with children, that they bring a prophylactic antibiotic or prescription for one, or that they bring cold and flu medication with them in case in the country that they are going to it isn't so easily accessible?

Dr. Hochberg: So, this really depends on sort of where exactly you're going and who the child is. Definitely for countries where there is a risk of malaria, we do recommend bringing malaria medicine. Most of the time, we will recommend bringing a prescription or medication to presumptively treat traveler's diarrhea, if you have severe diarrhea associated with it. As for other medications, it depends a little bit on the risk and what you're going to be doing there. You know, obviously if you're going to be doing an adventure race somewhere where you could be exposed to water, then there's other antibiotics we might give you. The Centers for Disease Control, again, has a very nice list of what to consider packing in your medicine kit before you go, and things that are useful to bring with you. Again, these are topics that one can go over with the travel medicine provider.

Melanie: And, do you want to see people post-trip and what would you like them to be aware of or to look for after their trip?

Dr. Hochberg: This is a really important point. So, the travel care really does not end before your visit. It's very important for patients and for doctors to know about the potential for travel-related illness. So, if you have a fever after coming back from an international trip, particularly one where you're going to a lower- or middle-income country, it's very important that your primary care doctor hear from you right away and that you probably get an urgent referral either to a travel and tropical medicine provider or that you go to the emergency room for evaluation. The thing to note, too, is that malaria doesn't always come on right away after travel, so even if it this is fever or illness that's come on months after travel, you need to let your doctor know that this might be that you traveled overseas, so that they can consider whether it might be travel-related. So, other things that one might consider contacting your doctor for are not only fever, but any diarrheal illness, particularly one that's lasting, particularly more than a few days. You probably want to let your doctor know that you just came back and you have this diarrheal illness. There's oftentimes sort of skin conditions that can be caused by international travel. So, definitely fever, and probably also diarrhea, particularly diarrhea that lasts, skin problems, and other concerning symptoms, I would recommend talking to your doctor and talking to them urgently and letting them know about the travel.

Melanie: So, wrap it up for us, Dr. Hochberg, if you would, with your best advice for travelers about traveling safely and visiting the travel clinic at Boston Medical Center.

Dr. Hochberg: So, the things that I would say are number one, remember to talk about your travel with your primary care doctor. Two, seek a referral at a travel clinic, particularly if you have any underlying medical problems or you're going to a low- or middle-income country where there are travel-related illnesses. And three, try to get there within enough time that the travel medicine provider really has the time to give you the vaccines that you need. And then, the last is if you have any conditions, any symptoms that develop after your travel, really be sure to contact your doctor and let them know that you were traveling and you're sick.

Melanie: Thank you so much for being with us today. It's really important information for listeners to hear and you're listening to Boston MedTalks and for more information on the travel clinic at Boston Medical Center, you can go to www.bmc.org/travelclinic. That's www.bmc.org/travelclinic. This is Melanie Cole. Thanks so much for listening.