Keeping older patients healthy and safe as they travel

,; ,; ,

Applied Evidence

Keeping older patients healthy and safe as they travel

J Fam Pract. 2013 January;62(1):16-23

PDF Download

References

1. Reed CM. Travel recommendations for older adults. Clin Geriatr Med. 2007;23:687-713, ix.

2. Centers for Disease Control and Prevention. Health Information for International Travel 2012. New York, NY:Oxford University Press; 2012. Available at http://wwwnc.cdc.gov/travel/page/yellowboth-2012-home.htm. Accessed December 18, 2012.

3. Cooper MC. The elderly travellers. Travel Med Infect Dis. 2006;4:218-222.

4. Guse CE, Cortes LM, Hargarten SW, et al. Fatal injuries of US citizens abroad. J Travel Med. 2007;14:279-287

5. Tonellato DJ, Guse CE, Hargarten SW. Injury deaths of US citizens abroad: new data source, old travel problem. J Travel Med. 2009;16:304-310.

6. Fenner P. Fitness to travel - assessment in the elderly and medically impaired. Aust Fam Physician. 2007;36:312-315.

7. Smith D, Toff W, Joy M, et al. Fitness to fly for passengers with cardiovascular disease. Heart. 2010;96(suppl 2):Sii1-S16.

8. Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med. 2009;151:180-190.

9. Gavish I, Brenner B. Air travel and the risk of thromboembolism. Intern Emerg Med. 2011;6:113-116.

10. Ansari MT, Cheung BM, Qing Huang J, et al. Traveler’s thrombosis: a systematic review. J Travel Med. 2005;12:142-154.

11. Schwarz T, Siegert G, Oettler W, et al. Venous thrombosis after long-haul flights. Arch Intern Med. 2003;163:2759-2764.

12. Cesarone MR, Belcaro G, Errichi BM, et al. The LONFLIT4—Concorde Deep Venous Thrombosis and Edema Study: prevention with travel stockings. Angiology. 2003;54:143-154.

13. Cesarone MR, Belcaro G, Nicolaides AN, et al. Venous thrombosis from air travel: the LONFLIT3 study—prevention with aspirin vs low-molecular-weight heparin (LMWH) in high-risk subjects: a randomized trial. Angiology. 2002;53:1-6.

14. Sack RL. Clinical practice. Jet lag. N Engl J Med. 2010: 440-447.

15. Davies I, O’Neill PA, McLean KA, et al. Age-associated alterations in thirst and arginine vasopressin in response to a water or sodium load. Age Ageing. 1995;24:151-159.

16. Rikkert MG, Melis RJ, Claassen JA. Heat waves and dehydration in the elderly. BMJ. 2009;339:b2663.-

17. Levine BD, Zuckerman JH, deFilippi CR. Effect of high-altitude exposure in the elderly: the Tenth Mountain Division study. Circulation. 1997;96:1224-1232.

18. Agostoni P, Cattadori G, Guazzi M, et al. Effects of simulated altitude-induced hypoxia on exercise capacity in patients with chronic heart failure. Am J Med. 2000;109:450-455.

19. Higgins JP, Tuttle T, Higgins JA. Altitude and the heart: is going high safe for your cardiac patient? Am Heart J. 2010;159:25-32.

20. Gautret P, Schlagenhauf P, Gaudart J, et al. Multicenter EuroTravNet/GeoSentinel study of travel-related infectious diseases in Europe. Emerg Infect Dis. 2009;15:1783-1790.

21. Adachi JA, Jiang ZD, Mathewson JJ, et al. Enteroaggregative Escherichia coli as a major etiologic agent in traveler’s diarrhea in 3 regions of the world. Clin Infect Dis. 2001;32:1706-1709.

22. Black RE. Epidemiology of travelers’ diarrhea and relative importance of various pathogens. Rev Infect Dis. 1990;12 (suppl 1):S73-S79.

23. Rendi-Wagner P, Kollaritsch H. Drug prophylaxis for travelers’ diarrhea. Clin Infect Dis. 2002;34:628-633.

24. Butzler JP. Campylobacter, from obscurity to celebrity. Clin Microbiol Infect. 2004;10:868-876.

25. Hoge CW, Gambel JM, Srijan A, et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341-345.

26. Adachi JA, Ericsson CD, Jiang ZD, et al. Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis. 2003;37:1165-1171.

27. Tribble DR, Sanders JW, Pang LW, et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis. 2007;44:338-346.

28. Shanks GD, Smoak BL, Aleman GM, et al. Single dose of azithromycin or three-day course of ciprofloxacin as therapy for epidemic dysentery in Kenya. Acute Dysentery Study Group. Clin Infect Dis. 1999;29:942-943.

29. Heatley RV, Sobala GM. Acid suppression and the gastric flora. Baillieres Clin Gastroenterol. 1993;7:167-181.

30. Hill DR, Ford L, Lalloo DG. Oral cholera vaccines: use in clinical practice. Lancet Infect Dis. 2006;6:361-373.

31. Vaughn JA, Miller RA. Update on immunizations in adults. Am Fam Physician. 2011;84:1015-1020.

32. Gergen PJ, McQuillan GM, Kiely M, et al. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med. 1995;332:761-766.

33. World Health Organization. Typhoid vaccines: WHO position paper. Wkly Epidemiol Rec. 2008;83:49-59.

34. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002;347:13-18.

35. Soto J, Medina F, Dember N, et al. Efficacy of permethrin-impregnated uniforms in the prevention of malaria and leishmaniasis in Colombian soldiers. Clin Infect Dis. 1995;21:599-602.

36. Freedman DO. Clinical practice. Malaria prevention in short-term travelers. N Engl J Med. 2008;359:603-612.

Decreased upper GI acidity due to acid-blocking medications such as proton-pump inhibitors can increase the risk for many infections, including salmonella and cholera. Patients taking such medications should be made aware of the risk, and the risks vs benefits of temporarily stopping them should be discussed. Vaccination against cholera should not routinely be recommended.^29,30

Vaccines and pills protect against preventable diseases

An impending trip abroad also presents an opportunity to review the patient’s immunization status, catch up on recommended vaccines, and determine whether any additional vaccinations are needed.

Herpes zoster (HZ). Patients older than 60 years should receive a single dose of the HZ vaccine, whether or not they have a history of this condition. Because this is a live virus-containing vaccine, however, it should not be given to anyone who is immunocompromised.³¹

MMR booster. Adults born before 1957 can be considered immune from both measles and mumps, but not rubella. There is no data on immunization to rubella, but guidelines do not recommend MMR vaccination in the elderly.¹

Pneumococcal polyvalent-23 (PPV-23). One dose of the PPV-23 vaccine is indicated for all adults at age 65. This is especially important for travelers, as the prevalence of pneumococcal disease is likely higher in crowded, urban environments within less developed countries.³¹

FAST TRACK

All adults who are traveling to areas where poliomyelitis cases are still reported should receive another dose of inactivated polio vaccine.

Tetanus. Although tetanus is mainly a disease of the elderly, only 45% of men ages 70 years or older and 21% of women in this age group were found to have protective antibodies.^1,32 In 2011, the Advisory Committee on Immunization Practices (ACIP) recommended one dose of tetanus and diphtheria toxoid (Td) every 10 years, with a single dose of tetanus toxoid, diphtheria toxoid, and acellular pertussis (Tdap) vaccine given in place of Td for adults older than 65.³³ Despite ACIP’s recommendation, the vaccine’s use in adults 65 years and older is an off-label indication, as Tdap is only approved for use in those 11 to 64 years of age.³³

Additional vaccines are recommended for travelers, with some indicated for all travelers and others that are destination-specific (TABLE).

TABLE
Which travel-related vaccines does your patient need?

Disease	Type of vaccine	Primary course	Booster/ follow-up	Route	For which destinations?
Vaccines for all travelers
Hepatitis A*	Killed virus	2 doses (6-18 mo apart)^†	None	IM	All
Hepatitis B*	Recombinant viral antigen	3 doses (0, 1, 6 mo)	None	IM	All
Influenza	Inactivated viral	Single dose	Annually	IM	All
Typhoid	Capsular polysaccharide Live attenuated bacteria	Single dose 4 doses (0, 2, 4, 6 mo)	2-3 y 5 y	IM Oral	All
Vaccines for travelers to select destinations
Japanese encephalitis	Inactivated viral	2 doses (28 d apart)	Unknown	IM	Rural Asia^‡
Meningococcus	Quadrivalent conjugated polysaccharide	Single dose	>10 y	IM	Sub-Saharan Africa; Saudi Arabia
Polio	Inactivated viral	Single dose if patient had childhood series	None	SC; IM	Anyplace where polio still occurs
Rabies	Inactivated cell culture viral	3 doses (0, 7, 21-28 d)	None unless exposure occurs	IM
Yellow fever	Live attenuated virus	Single dose	10 y	SC	Sub-Saharan Africa; tropical South America
IM, intramuscular; SC, subcutaneous. A combined hepatitis A/B vaccine is approved for use in older adults. ^†Second dose may be delayed up to 8 years without diminished efficacy. ^‡Required only for prolonged stays in rural areas of Asia. Adapted from*: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier; 2010.

Meds and safety measures can minimize malaria risk
The risk of acquiring malaria differs significantly among travelers, based on destination, duration and type of travel, and season. Choice of antimalarial agents (eg, atovaquone/proguanil, chloroquine, doxycycline, mefloquine, and primaquine) should be made on an individual basis after considering these factors, as well as the resistance patterns of the countries on the patient’s itinerary, his or her medical history, and the adverse effects profile of potential agents. Because many older adults take multiple medications, the possibility of drug-drug interactions must be considered.¹ You’ll find destination-specific recommendations on malaria prevention on the Centers for Disease Control and Prevention’s Travelers’ Health Web site, listed in “Travel and health: Resources for patients and physicians”. For guidance on the best drug to prescribe, you can also consult a travel medicine specialist.²

Travel and health: Resources for patients and physicians

Access-able Travel Source Web site provides information for older adult travelers with special needs who need help traveling with oxygen or getting around despite decreased mobility (www.access-able.com/tips/).

American Diabetes Association publishes detailed information about traveling with diabetes (http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/public-accommodations/air-travel-and-diabetes/).

Bureau of Consular Affairs publishes information regarding VISA and security requirements at various destinations and travel warnings (http://travel.state.gov/about/about_304.html).

Centers for Disease Control and Prevention publishes “The Yellow Book”—a reference for clinicians who advise international travelers about health risks. There is also a range of other travel-related information on its Travelers’ Health Web site (www.cdc.gov/travel/).

International Travel Medicine Society provides a global travel clinic directory (http://www.istm.org/Webforms/Searchclinics/Default.aspx?SearchType=advanced).

Transportation Security Administration Web site provides information on what can be brought on-board a plane. See “Can I bring my … through the checkpoint?” (http://apps.tsa.dhs.gov/mytsa/cib_home.aspx).

Travel Health Online offers a list of medical providers around the world (www.tripprep.com/scripts).

World Health Organization’s Travel and Health Web site provides free access to selected chapters of its book, “International Travel and Health 2012,” as well as interactive maps, information about infectious diseases and food safety, and more (www.who.int/ith/en/).