Prioritizing Care for the Resource-Limited Traveler
Travelers seen in pretravel clinic consultations often have financial constraints and must pay out of pocket for pretravel care, as many health insurance plans provide no or limited coverage for travel immunizations and prophylactic medications. The variety of insurance plans, number of travelers without adequate insurance coverage, and number of student and budget travelers challenges even the most savvy travel medicine clinicians. As an example, the estimated cost of a US pretravel consultation for a backpacker planning a 4-week trip to West Africa may be as high as $1,400 for the initial consultation and vaccinations, excluding malaria prophylaxis.
Travelers with limited budgets may be at higher risk for travel-associated infections, as they often visit remote areas, stay in more modest accommodations, and eat in restaurants with lower hygiene standards. The total cost of a becoming ill with a vaccine- or prophylaxis-preventable disease (e.g., hospitalization, treatment, lost wages) may, in many cases, outweigh the initial cost of vaccination and prophylaxis, making a pretravel consultation particularly important. The cost and benefit of obtaining travel health insurance and evacuation insurance before travel must also be considered (see Chapter 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). The goal of this section is to guide travel health recommendations for travelers with financial constraints.
Only 2 vaccines are required categorically for some travelers: meningococcal vaccine for pilgrims traveling to Mecca during the Hajj and yellow fever vaccine for travelers to certain countries in Africa and South America (see Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country in this chapter). Prioritize these vaccines, since the traveler may be denied entry to the country without proof of vaccination. Note that those staying in a yellow fever–endemic country only briefly (such as during an airport layover) may still need evidence of vaccination to enter other countries on their itinerary.
In a few specific circumstances, travelers to polio-affected countries may be asked to show proof of polio vaccination before departure if their duration of stay is >4 weeks (see Chapter 4, Poliomyelitis). Travelers and clinicians are advised to check the latest recommendations for their destinations.
All travelers should be up-to-date with routine vaccines before international travel, regardless of destination. The benefits of these vaccines extend beyond the travel period, and in many cases lifelong immunity is achieved. Since these vaccines are mass-produced as part of the scheduled national childhood and adult vaccination programs, associated costs are generally low, and many insurance companies reimburse the patient for the cost of administration. Travelers can also obtain these vaccines in a health department or primary care setting, where costs may be lower than those at a travel clinic. Prioritize the routine vaccines that protect against diseases for which the traveler is most likely to be at general risk, for example influenza, measles, and hepatitis A.
Some travelers may be immune to the disease for which immunization is being considered. Pretravel antibody testing may be covered by insurance when vaccines are not. The decision to test rather than vaccinate will also depend on time to departure.
Consider time until departure, risk of disease at the destination, effectiveness and safety of vaccine, and likelihood of repeat travel. For example, although currently not a routine vaccine for US adults, hepatitis A vaccine can provide lifelong immunity and should be considered for travel to all destinations. On the other hand, hepatitis B (also not a routine vaccine for US adults) is not as significantly associated with travel, and vaccination may be a lower priority. Typhoid vaccine for both adults and children has limited effectiveness, and protection lasts only 2–5 years depending on formulation, thus making it more valuable just for higher-risk destinations or those where typhoid is more likely to be acquired (such as the Indian subcontinent).
Review the itinerary in detail to determine need for Japanese encephalitis vaccine. Some travelers may be able to obtain single-dose vaccine at a much lower cost outside the United States, bearing in mind issues surrounding quality of vaccines in many countries (see Chapter 6, Perspectives : Avoiding Poorly Regulated Medicines and Medical Products during Travel). Those who decline vaccine should have a clear understanding of when and how to use insect repellents and other measures to prevent mosquito bites.
When considering rabies vaccine for resource-limited travelers, consider the risk of animal exposure, access to local health care, and availability of rabies immune globulin and rabies vaccine at the traveler’s destination. Travelers who decline preexposure immunization should have a plan of action if an exposure occurs. In many areas, rabies vaccine or immune globulin are difficult or impossible to obtain, and travelers may need to be evacuated to receive postexposure prophylaxis.
Every pretravel consultation should include detailed advice about preventing mosquito bites (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). The risk of acquiring malaria varies widely depending on destination, accommodations, and activities during travel. Costs associated with the different regimens vary widely. Providers should stay up-to-date on the usual cost of antimalarial medications in their region and at the pharmacies used by their travelers so that the most cost effective drug can be recommended to the traveler for their itinerary. Travelers who raise the question of purchasing antimalarial drugs at their destination should be advised about the risk of inappropriate, substandard, and counterfeit medications and discouraged from this practice (see Chapter 6, Perspectives : Avoiding Poorly Regulated Medicines and Medical Products during Travel).
Travelers’ diarrhea (TD) is among the most common travel-related illnesses. Antibiotics to treat moderate to severe diarrhea should be considered; prophylaxis may be indicated only in select cases of patients at high risk for TD-related complications (see Travelers’ Diarrhea later in this chapter). As with antimalarial drugs purchased at the destination, advise travelers about the risk of purchasing counterfeit antibiotics overseas.
Budget travelers and those who cannot afford travel vaccines will continue to challenge travel medicine practitioners. When immunization or prophylactic medications cannot be given because of financial constraints, educate travelers about alternative ways to reduce risk. For example, advise travelers to avoid animal bites, use insect precautions, follow safe sex practices, wash their hands or use alcohol-based hand sanitizer frequently, and observe food and water precautions to the best of their ability.
Travelers can be reassured that the actions they take to avoid these preventable hazards may, in the long run, protect against travel-associated risks that are more prevalent than certain vaccine-preventable diseases.
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Zoon Wangu, Elizabeth D. Barnett