Health Leader, The Road Less Traveled

STORY BY

Karen Krakower

Fifty million travelers from industrialized areas will crisscross the globe to developing countries this year.

That doesn't count Aunt Sylvia and Uncle Sol's second honeymoon at Niagara or the timeshare in Cancun. Nor does that represent your son's tour through every youth hostel in Europe. Those are counted among the 715 million worldwide arrivals, as of 2002.

"The travel trends are so global now and with technology that keeps us connected, our patients are able to stay longer in remote areas and wander the hinterlands that they normally would never visit," says travel medicine specialist Charles Ericsson, professor of internal medicine and head of the Clinical Infectious Disease department at the University of Texas Medical School at Houston.

"A good travel clinic is set up to handle the subtleties and nuances of a traveler's particular health needs and itinerary," says Ericsson, also outgoing editor of The Journal of Travel Medicine.

But not all travelers are created equal, not even on the same footpath.

For instance, just because a person is visiting Thailand does not mean they will require the encephalitis vaccine. However, if they mention that their Bangkok leg might be more interesting if they could get in a little trekking, "then you have to ask the right questions and have some personal knowledge of the area" that is not covered on the CDC website, Ericsson says.

Common Travel Concerns

Aside from recent emerging viruses such as
SARS and Norwalk , travelers need advice
about more common complications.

"Take DVT [deep vein thrombosis] for
instance-for persons on long flights who have
a history of this condition, we will prescribe
injectibles of Lovenox. There's no need to
monitor it, unlike other anti-clottingdrugs,"
Ericsson explains.

"And what most people don't know is that
aspirin is of no use in DVT, only arterial
conditions."

Ericsson still recommends isotonic exercises
for anyone on long flights and support hose
for those with circulation issues.

Jet lag "treatment" has changed a bit. "We
used to prescribe melatonin for long trips until
we found the variance in potency was too
great. We still recommend light therapy in a
timed fashion for long flights and jet lag. And
we have no problem prescribing a short
course of Ambien for sleep," Ericsson says.

Acute altitude sickness is also an issue and if
there is a history of mountain sickness,
Ericsson sends them with certain diuretics, like
Diamox [acetazolamide], or uses
dexamethasone if they are sensitive to sulfur
drugs.

"But you also need to know how to take them,"
Ericsson says.

Public education is necessary for the smallest
of details, like sunscreen. And apparently,
most of us have no clear idea how to use it.
Ericsson advises that "the average bikini-clad
woman needs one full ounce per application,
beginning 30minutes before she hits the
beach, and then needs to reapply regularly.
Yet, most people come home with a half-full
eight-ounce bottle."

Take the tourist in Acapulco staying at the Princess versus the tourist who is also going to rent a jeep and camp for a few nights in the jungle. The family doctor is going to look at a map and see that it's color-coded in red to indicate a malarial risk.

"While there is malaria and dengue fever in the surrounding jungle, there's also the tourist who is never going to leave their hotel patio. Malaria won't be that tourist's problem, but diarrhea may be. Very different recommendations for visitors to the very same city," Ericsson says.

"First, do no harm."

Sometimes, the job of a travel medicine clinic is to spare the traveler certain medications and vaccines that simply are not necessary.

Ericsson has seen people that have been prescribed anti-malarial drugs during their stays in Guadalajara , a city that sits a mile above sea level, where no malaria-carrying mosquito can survive.

Non-travel medicine infectious disease experts agree that travel clinics are a must. Dr. Luis Ostrosky-Zeichner, assistant professor of infectious disease at the UT Medical School at Houston refers his traveling patients to a travel clinic "because they have the most updated information of the current conditions in that country. You really must have a depth of experience and the latest information to make pre-travel recommendations and also to diagnose and treat post-travel illness."

Traveler's Diarrhea

Though it probably won't kill anyone, Traveler's Diarrhea (TD) can certainly kill a good vacation. No one is immune completely, even in light of recent discoveries of a genetic predisposition for this travel malady.

Doctors used to try to educate their patients about food-borne illness and provide them with medication that they could take after they threw caution to the wind and ate the mango on the street.

"But the paradigm is shifting-we know that education doesn't work and we need to admit that our patients will get sick. We need to revisit aggressive prophylaxis and prevention," Ericsson says. And rifaximin, a new non-absorbable antibiotic, soon to be available in the U.S. , may start the trend.

Originally an Italian drug, available only in Europe , rifaximin shows great promise in the prevention and treatment of TD. This comes at a good time, since it was recently released to the travel medicine community that Campylobacter, a nasty but common pathogen, is resistant to certain traditional antibiotics, like fluoroquinolones, Ericsson says.

It also is effective against certain liver infections and works well as a presurgical prophylaxis for some surgeries.

The fact that it is non-absorbable puts rifaximin in bright, favorable light for TD: since only nannogram levels cross the bloodstream, overuse and risk of resistance development is low. This also makes it safe for children and pregnant travelers. However, by its very nature, it will not be useful for other diseases, like pneumonia, that need the absorbability factor.

"It matches well with the profile for travelers," Ericsson says.

As with many travel-borne diseases, length of stay is a big factor in predicting TD. "We now know that illness can be charted. With students taking a four-week Spanish course in Guadalajara , the highest rate of illness occurs during the first week of stay," Ericsson says, "but the risk continues for the entire four weeks."

One-Stop Shopping

Ostrosky-Zeichner also views the travel clinic as the most convenient way to manage pre-travel help. "It's 'one-stop shopping' for the patient. Primary care physicians don't stock anti-malarials routinely, not to mention some of the more specialized vaccines necessary."

Travel clinics are set up to offer complicated and intricate advice and preventive medications and supplies.

Film student Andy Krakower, a UT-Austin senior was invited to Uganda for a month as the documentarian for a film on the world AIDS crisis. "The travel clinic was invaluable, not only for required meds and vaccines, but also advice on the concentration of DEET I'd need, the brand of water purifier, even the differing social customs between the north and southern regions. The information was thorough and comforting," Krakower says.

Ailments and Agendas

But not every traveler will be teetering on the edge of jungle fever. "In fact, the average traveler has disposable income right at the age when one or two chronic or underlying conditions occur. One of the specialties of travel clinics is to customize the protection of that patient to fit their current health profile," Ericsson says.

Ostrosky-Zeichner says the additional benefit of a travel clinic is that they usually have contacts in other countries should a serious health problem arise.

Not all towns, or even cities have a designated travel clinic. "That's why education is very important for the family practitioner or internist. But the current yardstick to follow when thinking about setting up a travel clinic is: unless you are seeing 400 traveler-patients a year, you are not keeping your skills up."

UPDATED: 12-01-2003