The Pre-Travel Consultation
The pre-travel consultation is a risk-based assessment process that provides a guide to prioritizing and customizing pre-travel health care to the traveler’s itinerary, risks, and needs. The goal of the pre-travel consultation is the effective and efficient preparation of travelers with the appropriate counseling, vaccinations, and medications to help reduce their risk of illness and injury during travel.

To conduct a risk-based assessment, health-care providers involved in preparing travelers must—

• Have a working knowledge of destination-specific disease and health risks and standard recommendations to promote health and prevent illness among travelers. The information and recommendations presented in this publication, the Body of Knowledge in Travel Medicine (as published by the International Society of Travel Medicine [ISTM]), and other authoritative sources (see Appendix B) form the basis for this knowledge.
• Understand the standard for and expectations of conducting a pre-travel consultation and gain expertise in the process. The well-organized and well-executed pre-travel consultation supports consistent, appropriate, and efficient pre-travel health preparation with the following three essential elements:
  1. Risk Assessment
  2. Risk Communication
  3. Risk Management
  
  Risk AssessmentThe risk assessment provides the foundation for the recommendations given during the consultation. A risk assessment involves gathering pertinent information about the itinerary (“where and when”) and traveler (“who, why, what, and how”) to highlight the traveler’s risks and alert the provider to any contraindications and precautions to vaccinations or medications that may be indicated. A questionnaire designed to collect and organize the itinerary and traveler data is an essential tool to help support the risk assessment process and facilitate consistent practice.

The most important information to gather includes the following:

• Itinerary data
  • Countries and regions to be visited; urban versus rural
  • Dates and length of travel
  • Purpose of travel (e.g., business, vacation, visiting friends and relatives)
  • Mode(s) of transportation
  • Planned and possible activities
  • Types of accommodations
• Traveler demographic and health/medical history
  • Age, sex
  • Vaccination history, including prior adverse events
  • Medical and psychiatric history (past and current)
  • Medications
  • Allergies
  • Pregnancy and breastfeeding status (current status and plans)
  
  A basic example of using the itinerary and traveler data includes determining if there will be a risk of yellow fever disease or a requirement for yellow fever vaccination based on the itinerary, and if there is a contraindication (e.g., egg allergy) or a precaution (e.g., >60 years of age) to the traveler’s receiving the vaccine. Malaria risk is another important consideration. Will the traveler be going to a region endemic for malaria, and what are the appropriate measures to help prevent malaria based on the details of the itinerary and traveler’s medical history?
  
  During the risk assessment, the provider must remain alert to other factors about “who” will be traveling. Such factors include the traveler’s previous travel experience, perception of risk, cultural background, peer group(s), and possible barriers to care, such as economic issues, attitudes regarding vaccine safety, and fear of vaccines. These factors may greatly affect the traveler’s ability and willingness to accept and adhere to the recommendations, and therefore affect the pre-travel consultation.
  Anticipating the unique needs of high-risk travelers and preparing them for healthy travel will help prevent illness and injury. The following travelers may be considered high risk:
  
  
• Travelers visiting friends and relatives (VFRs). These individuals have typically migrated from a less-developed area to a developed area and are now returning to the region of their birth. This is especially important when these individuals are traveling with new family members or children. The traveler returning to his or her country of origin may not understand the dynamics of risk and waning immunity (see the VFR section in Chapter 8).
• The elderly
• Families with young children
• Persons traveling to adopt children abroad
• Persons with weakened immune systems
• Women who are pregnant or breastfeeding

The next phase of the consultation process is focused on risk communication and includes the presentation of reliable, evidence-based information in a context appropriate for the individual traveler. Time should be allocated for discussion of the risks with the traveler to promote informed decision making about risk avoidance and prevention measures, such as vaccinations and malaria chemoprophylaxis. Risk communication depends heavily upon the risk assessment for the individual traveler, as well as that traveler’s perception of risk. For example, three travelers may be going to the same country: one for a week-long, urban-based, business visit; the next on an adventure-seeking, backpack trip to rural areas over several months; and the third is a pregnant VFR traveler. The recommendations and preparation for each of these travelers will vary, even though the destination country is the same.

It is important to give both verbal and written information to the traveler to help guide and focus the discussion and reinforce important issues based on his or her risk assessment. Examples include information pamphlets, malaria risk maps, and vaccine information statements (VISs). Through careful risk assessment and thoughtful risk communication, a risk management plan (i.e., vaccinations, medications, and targeted risk-avoidance education) takes shape.

The essential elements of risk management include the following:

• Selection, administration, and documentation of vaccinations
  • Required, recommended, and routine vaccinations should all be considered (see below)
  • Providers should consider indications, contraindications, precautions, and timing of dosages
• Prescribing and advising about preventive medications
  • Where appropriate according to risk, antimalarial chemoprophylaxis and medications for travelers’ diarrhea, motion sickness, and altitude sickness
• Education related to malaria prevention and adherence to chemoprophylaxis (if indicated by the risk assessment)
• Information on risk and prevention of other insect-borne diseases
• Instruction on methods to reduce foodborne and waterborne illness and the self-management of travelers’ diarrhea
• Instruction about animal avoidance and rabies
• Information to help reduce the negative effect of
  • Other itinerary risks (e.g., altitude, pollution)
  • Activity-specific risks (e.g., diving, rafting, rural road travel)
  • Personal behavior risks (e.g., sexually transmitted diseases)
• General guidance on
  • Symptoms (e.g., fever, gastrointestinal or dermatologic symptoms) that may require medical attention during or after travel
  • Preparing a travel health kit (see the Travel Health Kits section later in this chapter)
  • Accessing medical care abroad and obtaining medical/evacuation insurance

When considering vaccinations, common terms used include “required,” “recommended,” and “routine.” Required vaccines are those needed when a destination country requires documentation of vaccine administration or some sort of medical waiver. Recommended vaccines are those vaccines that are considered based on the actual disease risk the traveler may encounter during travel. Routine vaccines refer to those vaccines that are recommended in the United States, regardless of travel. These routine vaccines are an important part of pre-travel care because many of the diseases they protect against are more common in countries outside the United States.

Careful documentation of all vaccinations, medications, and specific recommendations given to the traveler helps to complete the care plan record. Providers who are registered to give yellow fever vaccine should be familiar with properly completing the International Certificate of Vaccination or Prophylaxis (ICVP) to ensure that this documentation will be accepted at the borders of destination countries. Using an electronic record or standardized form facilitates documentation and helps ensure consistency of practice.

Providers should plan to spend an average of 30–45 minutes conducting a complete pre-travel consultation, based on the risk assessment, given the potential complexities in preparing the traveler. Providers with limited knowledge and expertise in travel medicine and the pre-travel consultation should consider referring travelers with complex itineraries or special needs to a travel medicine clinic or travel medicine specialist through CDC’s Travelers’ Health website.