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[00:00:06] Tony: Hello, and welcome back to another episode of Microbe Matters, presented by ID Pittstop, where we discuss, dissect, and demystify topics in infectious diseases with our experts here at UPMC and the University of Pittsburgh. I’m your host, Tony Morrison, media specialist here at Pitt ID, and I’m just as curious as you may be about navigating through a world full of microscopic organisms. Please join us as we examine both the dangerous and beneficial microbial microcosms that surround us, promote public health, and showcase research and treatment of modern infectious diseases.

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It’s that time of year again- the dog days of summer are in full swing and the tropical getaway you’ve been planning to take with your family is finally here. After settling in for a few days, you sit on the beach with a fruity drink and take in the sun, the ocean air, and the sound of the tides crashing before you. All your worries are carried away in the Caribbean breeze. The ultimate relaxing holiday in utter paradise.

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But as you kick back and meditate on the rhythm of the island music, you suddenly notice a different kind of rhythm in your body. Your stomach feels like it’s dancing a salsa of its own, twisting and turning. An ache creeps into your bones that make you instantly shiver, and you begin to feel clammier than the oysters you had for lunch.

After spending the rest of the afternoon in the rest room, you decide to go to the clinic on the resort’s campus. It turns out that your tour of the tropics exposed you to typhoid fever, which is caused by bacteria in the drinking water, food, or facilities in places with less-than-ideal sanitation.

Your vacation can transform very quickly into a summer bummer in an instant, but don’t worry. There is a vaccine for typhoid fever, as well as other steps that you can take to reduce your risk of illness while travelling abroad. 

With me today to talk about vaccines concerning travel health is Dr. Carolyn Fernandez. She is the Director of the Travel Health Services and Director of Outpatient ID Services at UPMC, as well as Clinical Associate Professor of Medicine at the University of Pittsburgh. Carolyn, thanks for sitting down with me to discuss vaccines and travel health.

[00:02:46] Carolyn: I’m really happy to be here, Tony.

[00:02:48] Tony: I’ve been looking forward to recording with you for a while now, ever since we first met back in the winter. And I know that you’re a little bit nervous to come onto the show with me, but I think it’s going to be a great episode. So why don’t we dive right in?

[00:03:04] Carolyn: Let’s do it.

[00:03:05] Tony: So, Carolyn, can you tell me just a little bit about the travel health clinic?

[00:03:09] Carolyn: Yeah, sure. So the travel health clinic is sort of run by a specialist who has training in travel and tropical medicine. And the purpose of the clinic is sort of to help people get ready before they travel.

We have a clinic that runs twice a month, sometimes three times a month in the peak season of travel, and most visits are telemedicine through which a traveler can get counseling before they go on a trip.

[00:03:36] Tony: As someone who has experienced traveler’s illness in the form of what is colloquially known as Montezuma’s Revenge, I wish that I had considered the microbial risks before voyaging south of the border. In your opinion, who should receive travel health care, or at least consider it?

[00:03:53] Carolyn: Actually, Tony, pretty much anyone. But let’s take a step back. Right. So if you look at the statistics published by the UN World Tourism Organization, they found that in 2022 alone, more than 960,000,000 international travelers went to countries, and most of that was for leisure travel. And they actually project by 2030, that number is going to be almost 1.8 billion with a B. And so what that means is that’s going to certainly be a fraction of travel that’s going up to travelers with developing and emerging status in the world. And I think what that does is it poses new health risks in unfamiliar environments on travelers. So this is another good reason why people should consider seeking travel health counseling before they go abroad.

[00:04:44] Tony: Some people may possess a certain predisposition to illness for whatever reason, and so I’m wondering what travel care looks like for them.

Carolyn, can you tell us what it means to be a medically complicated traveler and why it’s important for them to consult travel healthcare?

[00:05:00] Carolyn: There are certain categories of travelers that certainly have a heightened risk of getting sick while they’re traveling or certainly upon their return. The people I would put into those categories would be the older adult, because maybe they’re more likely to have adverse outcomes when they get sick.

Travelers who have a compromised immune system, whether they have cancer and are receiving chemotherapy, if they’re taking certain medications such as steroids or other drugs to, say, prevent rejection after a transplant. Certainly persons living with HIV have weakened immune systems along with moms who are pregnant or breastfeeding. Other adults who have certain chronic illnesses such as affecting their kidneys, lungs, liver, or heart could also be put in a medically complicated category. Also, if you want to consider you have disabilities or maybe psychiatric conditions, this would be another reason to seek travel health counseling.

[00:05:59] Tony: Let’s say that I’m gearing up to go backpacking around a continent with many emerging nations, and I’ve made an appointment at the travel health clinic. What is the pretravel consultation process like, and what do I need to provide to my provider?

[00:06:14] Carolyn: That’s a great question. I think there are three main aspects to the pretravel consultation, and let’s go through them one by one. So the first one is to perform sort of an individual risk assessment. And what I mean by that is you want to look at that particular traveler and look at what’s their medical history do they have allergies, what medications are they taking? But besides that medical piece of it, the second part would be, well, what are the specifics of the trip that they’re going on? So what is their itinerary? What countries are they going to? What is the order of travel? Are they intending to be in an urban versus rural environment? And also, I think it matters in terms of how long you’re going on the trip for, what season it might be in the country you’re traveling to. As risks vary, some things to consider is certain things that you might do while you’re traveling. Are you going to go kayaking or caving? Are you going to visit a temple? Maybe there’s a risk of coming into contact with wild animals or maybe high altitude climbing and things like that. The second part of this is once you’ve assessed the risk of the traveler and the destination is then to provide counseling and education, which is, I think, a big chunk of the pretravel visit. And what that does is we talk about specific illnesses, which we’ll get into later on in the podcast, and how to prevent them. And then the last part of this is actually prescribing certain immunizations that would be a traveler can take to prevent getting sick for vaccine preventable illnesses, and then also certain medications that the traveler can take either for prophylaxis or for self treatment of certain conditions.

[00:07:52] Tony: Okay, I’ve completed my consultation, and I’m feeling ready. But what are the next steps? What vaccines are administered prior to a traveler’s departure? Is there a panel of vaccines recommended for all travelers, or does it vary depending on where you travel to?

[00:08:08] Carolyn: And I think the answer to both pieces of your question is yes and maybe no. So the first part is there’s certainly a panel that you want all travelers to take, and I would put routine vaccines in that category. So things like making sure your tetanus shot is up to date. You’ve received your routine childhood immunizations for things like measles, mumps, and rubella. There was an outbreak of measles in multiple countries some years ago, and that became really important. Certainly polio myelitis is another vaccine preventable illness that most people in many parts of the world receive immunization in childhood, but you want to make sure you’ve received that and are up to date. So that’s a panel that everybody should have. The second category is travel specific vaccines, and I think that goes back to the question of destination specific counseling. So certainly we wouldn’t recommend everybody get a yellow fever vaccine, and that is vaccines like hepatitis A, typhoid fever, Japanese encephalitis, tick borne encephalitis, and some of the others.

[00:09:12] Tony: Yeah, I remember seeing all of the outbreaks around the world for measles and polio, and I just remember thinking to myself, “do people still get that?”

[00:09:21] Carolyn: Yeah, exactly. We think we’ve sort of won the fight for some of these. And then because vaccine and immunization levels wane in certain places, these illnesses get a resurgence back up. And so you always want to be on the lookout to what’s happening in the world before you go on your trip.

[00:09:37] Tony: Yeah. So it’s best to keep all of your defenses up. While on the topic of geography-specific vaccines, is proof of vaccination for certain illness required by law to enter or return from specific countries? Which ones and why?

[00:09:52] Carolyn: Yeah, I would say that there’s only one condition at the moment. That is certainly countries can have a requirement to enter, and that’s for the yellow fever.

So according to the Who International Health Regulations or IHR, countries can have requirements where they can deny entry to a traveler who doesn’t show proof of vaccination. And the reason mostly is because they want to prevent the introduction of yellow fever into a country that doesn’t have it, because you may have acquired it while you were traveling.

That varies according to different parts of the world. And sometimes, even if you’re transiting in a country, even if you’re not staying there and you then go to a second country, they might still require that vaccination proof if you are there for certain hours.

[00:10:40] Tony: Yeah, it’s kind of like whenever you go to the UK with your pet, and then they have to be quarantined for some weeks because it’s a rabies free nation.

[00:10:49] Carolyn: That’s right. And if you don’t have proof of vaccination on what’s called the yellow card in colloquial terms, but the actual name is the International Certificate of Vaccination or Prophylaxis, then you either have to have a medical waiver. If you have a medical reason not to get vaccinated. Or they can quarantine you for six days upon entry or vaccinate you at the site of entry.

[00:11:12] Tony: Right, so it’s best to sort of jab up on those before heading out.

[00:11:16] Carolyn: True.

[00:11:17] Tony: Carolyn, although there are more vaccines for travelers than ever before, it would be unrealistic to assume that there’s a vaccine for everything. So tell me, what are the other types of ways that you can counsel travelers to stay safe? Are vaccines enough?

[00:11:35] Carolyn: You know, I wish we had a vaccine for everything, but there are certain things that we really don’t have vaccines for. And I would put diseases like dengue fever, zika virus, and chicken gunya in that category. Malaria is also in that category. But there are certain common sense tips and tricks that travelers can follow to lower their risks of getting these illnesses. And so we certainly counsel travelers about things like safer food and water choices when you’re traveling to lower your risks of getting travelers diarrhea. The age adage is boil it, cook it, peel it, or forget it.

We also counsel travelers on ways to prevent getting bitten by insects and mosquitoes, which lowers your risks of some of the mosquito borne infections I mentioned earlier, but even other things like leash mania or sleeping sickness in certain parts of the country and world.

We also counsel travelers, depending on the activities that they’re going to do, about certain waterborne illnesses like schistosomiasis or even leptospirosis that we don’t have vaccines for. And then things like airborne or droplet infections like the bird flu are ways we can counsel people by maybe avoiding certain high risk areas.

[00:12:52] Tony: Are there any illnesses for which there are no vaccines for? What are some pathogens to be cautious of while traveling?

[00:12:59] Carolyn: So, malaria I alluded to before we don’t have a current viable vaccine for people.

There are certainly some that are in the testing phase, but it certainly can cause a lot of morbidity and certainly mortality in people who have grown up in countries where there is no malaria. And so besides following insect and mosquito bite prevention measures in some countries where the risk of malaria is high enough, we certainly counsel travelers to take a medication for what we call chemoprophylaxis to lower their risk greatly of acquiring malaria. So that would be one thing. And risk can vary within a country depending on if you’re at a high altitude or a lower part where mosquitoes are abundant. Some other things that are not quite infection but we also counsel about is altitude illness and certainly talking about how gradual you should ascend staying hydrated and other measures such as using medications to prevent and or treat altitude illness are key here. One more thing that I think we don’t often think about, but the number one cause of death in travelers is actually accidents on the road. So we do counsel people about road safety, especially when you go to a country where they’re driving on the opposite side of the road that you’re used to. And then the last thing that I think we counsel travelers about is something that they may not have considered is to make sure that they have travel medical insurance because maybe their health insurance that they have in the country may not cover them. And especially to have what’s called an evacuation clause that if they got really sick and they couldn’t get the care that they wanted, then they could maybe be brought back to another country or back to their base country to get care.

[00:14:38] Tony: Okay, so I’m back from my backpacking adventure. I’m all vaxxed up and prepared, per the counsel of my provider and safely back home here in Pittsburgh.

Do you think that it’s necessary to follow up with your provider for a post travel appointment?

[00:14:54] Carolyn: I don’t think so. If you are feeling healthy and you especially sought pre travel counseling, you don’t need to go and see a traveler provider upon your return.

I think the cases where you would want to seek care, though, is if you are not well and if you suddenly start having a fever or have diarrhea that’s not getting better or any other symptom, maybe a rash that doesn’t seem like it is related to something that’s noninfectious.

[00:15:21] Tony: It may not be necessarily required to follow up with my travel health provider after returning from my trip, but what if perhaps I begin to feel ill shortly thereafter? Are there any general guidelines for monitoring one’s health upon returning from their travels?

[00:15:37] Carolyn: So I think you want to make sure that when you seek care, if you don’t feel well, that you mention to the provider that’s seeing you that you did travel and the countries that you went to and the things that you did. You also want to be able to tell them what vaccines you may have taken or medications, because that will then impact their differential diagnosis. Even travelers who have taken malaria chemoprophylaxis can sometimes have a very low risk of actually getting malaria, which can present in a unique way several months after travel. So it’s always key to mention that you traveled abroad and what you did when you were there.

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[00:16:13] Tony: I know it can seem like a scary world with so many pathogens plaguing regions abroad, but it’s important for travelers or those with a desire to travel to do their homework and draw up a precautionary game plan before stamping passports.

Thank you so much again, Carolyn, for all of your insight and describing some of the travel health services that are available at UPMC.

[00:16:35] Carolyn: Happy to be here, Tony. Thanks so much.

[00:16:37] Tony: And that’s it for this week’s episode. Please join me next time as I sit down with Drs. Karen Byers and Sahil Angelo to contemplate vaccine hesitancy what it is, where it comes from, and the role it plays in today’s public health sphere. Until next time, I’m Tony Morrison, and this is Microbe Matters.

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