The Traveler with Special Needs
The Traveler with Special Needs
Reviewed by David R. Hill, MD, DTM&H
Sources: FC3.1: Adventure travel and pregnancy. R.L. Smith, Dept of Obstetrics and Gynecology, Northwest Hospital, Seattle, WA; FC3.2: Health problems in children traveling to developing countries to visit friends and relatives, and usefulness of pre-travel advice. Chen CE, Klass PE, Barnett ED, Geltman P. International Clinic and Department of Pediatrics, Boston Medical Center, Boston, MA; FC3.3A: Survey of U.K. health professional attitudes to severe travel phobic anxiety and therapeutic interventions. McIntosh I, Swanson V, Karatzzias K. Anxiety Centre, Psychology Department., Stirling University, UK.; FC3.4: Travel health advice for U.K. medical students on overseas elective study periods. Moss PJ, Beeching NJ, Division of Tropical Medicine, Liverpool School of Tropical Medicine, U.K.; FD3.5: A survey of the travel health experiences of international business travelers. Rogers HL, University of Calgary, Nursing Faculty, Calgary, Canada.
A free communication session with five papers examined some of the issues related to travelers with special needs. The first paper was presented by Dr. R. L. Smith from Seattle, covering adventure travel during pregnancy, and focusing on travel to sites without ready access to medical care. Although much information is known concerning safety of vaccination and anti-malarial medication during pregnancy, Dr. Smith emphasized other, less well-known points. Women should have an ultrasound to assure that the pregnancy is intrauterine, thereby avoiding any chance of hemorrhage during travel from an ectopic pregnancy. Travel to altitudes higher than 4000 meters should be avoided because of hypoxia to the fetus. Additionally, acetazolamide is contraindicated in pregnancy, as well as is iodine for the disinfection of water. While travel can often be undertaken safely, careful pre-travel decisions will need to be made as to the type of trip, the use of vaccines and preventive medications, and the access to medical care in the event of problems. This topic is reviewed more completely an the article by Samuel and Barry.1
Dr. Chen and colleagues from the Boston Medical Center examined the health of children during travel. In our experience at the International Traveler’s Medical Service at the University of Connecticut Health Center, children aged 15 years and younger make up 8% of travelers and those aged 5 years and younger, 4%. Although this is a relatively small percent, children have a high likelihood of becoming ill during travel and, not infrequently, require medical care. In the study presented, the authors surveyed the health of 40 children younger than 22-years-old from 25 families, who were traveling to 12 different countries, usually to visit friends and relatives. These children were likely to be first or second generation immigrants. One of the initial problems was in conveying pre-travel advice, since 56% of the interactions required an interpreter. During travel, 35% of the children developed diarrhea and 15% required medical care. Information which had been provided during the pre-travel visit for malaria prophylaxis, as an example, was frequently disagreed with by relatives living in the country visited. Unexpected areas of difficulty during travel were long plane flights and the level of heat and humidity which was encountered. Chen et al recommended that travel clinics which see many families visiting friends and relatives in their native country develop educational material in several languages so that the information can be clearly conveyed during the pretravel visit. Hopefully this would enhance compliance once overseas. They also recommended that some time be spent preparing the children for long plane flights and for dealing with heat and humidity.
A special needs group which may never go on the trip is those who experience anxiety or even have a phobia about travel. Of all phobias, fear of flying is second only to concerns about foods and water. A fear of flying itself, or of being in an enclosed space, at high elevation, may each contribute to this phobia. Dr. McIntosh of Sterling University, Scotland, presented data on the attitudes and interventions by health care providers about travel-related stress. The authors surveyed physicians and nurses and found that 30-50% would prescribe medication for this problem—usually an anxiolytic or a betablocker. However, most felt that medication would only treat the phobic symptoms rather than deal with the cause. Thus, a majority would be willing to refer patients for behavioral therapy or counseling. The authors’ opinion was that behavioral modification using desensitization techniques is the most effective way to deal with the underlying problem.
Interest in health care issues of the developing world is fostered by overseas electives by medical students. In many institutions, particularly those in the United Kingdom, this is a common part of the educational experience. However, the medical preparation of students may be inadequate. Drs. Moss and Beeching from the Liverpool School of Tropical Medicine conducted a survey of 26 U.K. medical schools about their medical preparation of students for overseas electives.2 Although 20 of the 26 schools provided health information on travel, only seven of the schools gave on-site immunizations, and 10 of them checked to see that students had received the immunizations. HIV prevention education was given, however, it was usually taught as part of the general medical curriculum. Only two of the schools gave students HIV post-exposure prophylaxis (PEP) to carry with them. In an accompanying article3 (reviewed in Travel Medicine Advisor Update4), it was established that students from a London medical school, do experience percutaneous or mucosal exposure to bloodborne pathogens during these electives (4/148, 3%). And, only 58% of students traveling to a country with high prevalence of HIV knew this. Of those who visited such a country, 34% carried a starter dose of retrovirals (in this case AZT monotherapy).
Moss and Beeching propose that there be more consistency between schools on advice to students, and that standardized, written advice be provided. Schools should check to assure that students have received the recommended immunizations, and there should be a mechanism to survey the student’s health during their elective once they have returned. Moss and Beeching also encourage HIV education and prevention but do not make specific recommendations about PEP. An accompanying editorial from Australia goes further and makes the recommendation that all students going on overseas electives to highrisk areas be provided with PEP.5 The recommendation to carry PEP is certain to generate debate, but it bears careful consideration by any travel medicine specialist who advises those with the potential for HIV exposure during an overseas elective or service trip.
The final paper was presented by H. L. Rogers of Calgary on 242 international business travelers who were overseas for 12 weeks or less. Although the health experience of this group is not necessarily different than that of other travelers, there are issues unique to this group—specifically the effect of stress and separation from family on work performance and enjoyment. More than 90% experienced travel-related worries and at least a third experienced stress or negative feelings. Nearly three-quarters described their travel as having a negative effect upon their family and 15% felt that this adversely affected their work. Thus, there should be emphasis on the psychologic well-being of the business traveler, so that their enjoyment of the trip is enhanced, their work performance does not suffer, and their family is minimally affected.
References
1. Samuel BU, Barry M. The pregnant traveler. Infect Dis Clin North Am 1998;12:325-354.
2. Moss PJ, Beeching NJ. Provision of health advice for UK medical students planning to travel overseas for their elective study period: Questionnaire survey. BMJ 1999;318:161-162.
3. Gamester CF, et al. Medical students' risk of infection with bloodborne viruses at home and abroad: Questionnaire survey. BMJ 1999;318:158-160.
4. Fischer PR. HIV precautions for traveling medical personnel. Trav Med Advisor Update 1999;9:10-12.
5. Wilkinson D, Symon B. Medical students, their electives, and HIV (editorial). BMJ 1999;318:139-140.
Persons traveling overseas for medical electives or service projects should be aware:
a. HIV may be prevalent in the countries of travel
b. the modes of transmission of HIV infection
c. HIV prevention measures
d. the use of post-needle-stick or mucosal exposure prophylaxis with antiretroviral therapy
e. All of the above
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