Ms. Spain is Assistant Professor and FNP/DNP Coordinator, and Dr. Edlund is Professor and ANP/DNP Coordinator, Medical University of South Carolina, College of Nursing, Charleston, South Carolina.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Barbara J. Edlund, PhD, RN, ANP, BC, Professor and ANP/DNP Coordinator, Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, PO Box 250160, Charleston, SC 29425; e-mail: firstname.lastname@example.org.
Older adults travel outside the United States at increasing numbers each year. Approximately 3 million U.S. adults older than 65 (9%) traveled abroad in 2004, excluding visits to Canada (U.S. Department of Commerce, 2005). Many older adults, particularly those retired more than 5 years, take advantage of senior discounts for leisure travel and use their freedom from work responsibilities to visit new destinations (Staats & Pierfelice, 2003). Other older Americans may have been born in another country and return to visit family or friends who live there. Visiting family and friends was the main reason given for travel for 46% of all international travelers in 2004 (U.S. Department of Commerce, 2005). In addition, increasing numbers of older adults are engaging in volunteer or humanitarian work, such as the Peace Corps. Regardless of the reason for travel, older adults need to plan for healthy travel. Health care providers should incorporate basic travel assessment and advising in their care encounters with older adults and be familiar with local and online resources for referral as needed for specific travel immunizations.
While many older adults may seek advice from their primary care providers regarding preparations for travel, this information may not be sought during a routine office visit. Leon (2008) noted that despite recent international travel trends, for a variety of reasons, “some studies have shown that many European and American travelers are not seeking out pretravel advice or getting vaccinated appropriately” (p. 158). Therefore, providers should routinely ask their patients if they are planning any international travel and, if so, encourage the patient to seek care at least 4 to 6 weeks before travel (Reed, 2007). Leon (2008) recommends immunization requirements be reviewed at least 6 to 8 weeks before travel so adequate time is allotted for antibody response and for those vaccines given in several dosages.
For those older adults who are planning international travel, providers should stress the benefits of reviewing their current health status, health concerns while traveling, travel destination, and the importance of referral to clinics that can provide appropriate immunizations (see the Sidebar on page 11). In addition to the itinerary and the length of the stay, it is important to know if the traveler is experienced with traveling, has traveled in the particular country or region previously, and is traveling alone or with a group, as well as whether the patient’s health status would be compromised by the trip. Reed (2007) noted that older adults with a complex medical history may require the cooperation of the primary care provider and the travel clinic provider to determine the appropriate immunization schedule and whether travel should be deferred or the itinerary modified due to health concerns.
• Dates of travel and length of time at each destination.• Areas and regions being visited within the destination country.• Reason for travel (e.g., leisure, visiting family/friends, business).• Modes of transportation.• Types of accommodations.• Physical activities planned (e.g., hiking, climbing, scuba diving, sightseeing).• History and experience of past travel.• Support systems for travel (e.g., organized tour guides, family or personal contacts).
Adapted from Centers for Disease Control and Prevention (2009).
Initially, the primary care provider should update the patient’s medical files to identify any concerns about the patient’s current functional health status; whether routine vaccinations are up to date; whether seasonal, environmental, food, and drug allergies are present; and if any additional assessment of current immune system and health conditions is warranted before travel. Specific questions should ascertain if the patient has allergies to any vaccine-associated components, such as eggs, latex, yeast, mercury, and thimerosal. Contraindications for travel to certain altitudes, climates, and terrains may be identified, as well as for taking particular vaccines or prophylactic medications required by travelers to certain regions of the world (Centers for Disease Control and Prevention [CDC], 2009).
Most primary care providers may be able to provide information and vaccinations for travel to common destinations, such as the Caribbean and Mexico, as well as health promotion suggestions regarding water consumption and hand washing. Providers should be able to offer their patients the routine vaccinations suggested for all older adults, regardless of travel. However, providers should be aware of limitations in their knowledge of travel medicine and recognize when referring the patient to a travel clinic or website is prudent (CDC, 2009; Hill et al., 2006).
Immunizations older travelers may need fall into three categories:
- Routine, as specified by the CDC for all adults.
- Recommended for travel to certain countries or regions.
- Required for entry into certain countries or regions.
Special immunizations and prophylactic medications recommended or required for travel are often more easily obtained at designated medical travel clinics (CDC, 2009
Immunizations that are routinely recommended for all older adults by the CDC (2010) should be available from the primary care provider, taking into account specific recommendations based on the presence of individual patient risk factors. These risk factors may reflect health status, medical condition, livelihood, or other factors, as well as any history of previous contraindications to the immunization. Immunizations commonly recommended for adults 60 and older, regardless of risk factors, include (CDC, 2010):
- A one-time dosage of tetanus/diphtheria/pertussis, then a tetanus/diphtheria booster every 10 years.
- One dosage of herpes zoster vaccine. A single dosage vaccine is recommended regardless of personal history of previous herpes zoster infection. Contraindications to this vaccine include individuals with immunocompromising conditions and HIV infection with <200 cell/microliter lymphocyte count.
- One dosage of seasonal influenza vaccine annually.
- One or two dosages of Pneumococcal vaccine. One-time revaccination is recommended after 5 years if first dosage was received before age 65 and if the person was vaccinated with the first dosage more than 5 years ago.
Additional immunizations that may be required for older adults with specific risk factors include (CDC, 2010):
- Measles, mumps, and rubella (MMR). For adults born after 1957 and those planning to travel internationally, one or more dosages of MMR should be received unless they have laboratory evidence of immunity or documentation of physician-diagnosed measles, mumps, and rubella. Medical contraindications for this vaccine are outlined by the CDC (2010).
- Hepatitis A virus (HAV). Any older adult with the following indications and those seeking protection from HAV should be vaccinated according to CDC (2010) guidelines: (a) individuals traveling to or working in countries where HAV is endemic (See the Diseases Related to Travel portion of the CDC website, http://wwwn.cdc.gov/travel/contentdiseases.aspx, for affected areas of the globe.); (b) individuals with chronic liver disease and those who receive clotting factor concentrates; (c) those with occupational exposure to HAV or primates with HAV in a laboratory setting; (d) men who have sex with other men; and (e) injection drug users.
- Hepatitis B virus (HBV). Any older adult seeking protection from HBV infection should be vaccinated. The CDC (2010) highly recommends this vaccine for those who: (a) may travel internationally to countries identified by the CDC as having a prevalence of HBV infection; (b) have chronic renal or kidney diseases; (c) have occupational exposure to blood or other potentially infectious body fluids; (d) have intimate exposure to persons with chronic HBV infection; (e) are seeking treatment for sexually transmitted infections; (f) had more than three sexual partners within the past 6 months; (g) are injection drug users; (h) are men who have sex with men.
- Meningococcal vaccination is important for older adults if they have an absent or nonfunctional spleen and/or travel internationally to regions where this vaccine is required for entry into the country, such as sub-Saharan Africa and Mecca in Saudi Arabia during the Hajj where meningitis is prevalent. If needed, adults older than 56 should receive the meningococcal polysaccharide vaccine.
If the older adult has an immunocompromising condition, live vaccines (e.g., MMR) should be avoided. The CDC provides specific information on all vaccines at http://www.cdc.gov/vaccines/pubs/acip-list.htm. In addition, the CDC lists contraindications for vaccinations as well as recommendations for immunizations for adults based on medical and other conditions at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a6.htm.
The CDC does not recommend routine pretravel screening for tuberculosis using the PPD test unless travelers will be staying for extended periods, are visiting friends and family in regions where tuberculosis is endemic, or are likely to be in close contact with high-risk populations, such as prisoners or homeless individuals. If tuberculosis screening is indicated, the two-step test should be used to assure accurate results (CDC, 2009).
The specific immunizations recommended for international travel, as well as chemoprophylaxis against certain diseases, are listed in Health Information for International Travel, which is published annually by the CDC and is available online at http://wwwnc.cdc.gov/travel/content/yellowbook/home-2010.aspx. Few immunizations are required but several are recommended based on destination, length of stay, activities, and present health risks. Currently, one vaccine, yellow fever, is required and could prevent a traveler from entering certain countries if documentation were absent. This live attenuated vaccine is given subcutaneously in one dosage. The risk for yellow fever is low for most travelers, but a number of countries, specifically sub-Saharan Africa and tropical South America, require the vaccination for all visitors. In these areas, yellow fever is endemic and intermittently epidemic. The risk of contracting yellow fever is influenced by the duration of exposure, season, local rate of virus transmission, and time of travel. Travelers must comply with the vaccine requirement unless issued a medical waiver. Country requirements may change at any time, so checking periodically with the CDC is strongly recommended. High (2009) advised caution regarding administration of the yellow fever vaccine to older adults, noting that older adults are six times more likely than younger adults to experience serious adverse events. Chin-Hong, Guglielmo, and Jacobs (2010) indicated that this vaccine should not be given to immunosuppressed adults or those with a history of anaphylaxis to eggs. If continued risk exists for travelers to these regions, reimmunization is recommended every 10 years.
Several vaccines are recommended for international travel. For those older adults traveling to Asia and surrounding regions, the risk of contracting Japanese encephalitis (JE) is low but varies according to specific destination, season, and duration of travel. Travel to rural areas of Asia increases the risk. A new inactivated JE vaccine is administered in three dosage intervals (i.e., 0, 7, and 30 days) with the last dosage administered 10 days before travel. A booster can be administered 2 to 3 years after the primary series (CDC, 2010). Adults receiving this vaccine should be observed for 30 minutes following administration and advised that angioedema and urticaria may be signs of delayed reactions (Chin-Hong et al., 2010).
A typhoid vaccination is recommended for those traveling to developing countries (i.e., the Caribbean, Central and South America, Africa, Asia, and the Indian subcontinent) and encountering periods of prolonged exposure to contaminated food and water and poor sanitation. Two preparations of the vaccine are available. A live attenuated oral enteric-coated capsule, administered every other day in four dosages, can be administered at least 1 week before travel. In addition, a single-dosage vaccine can be administered parenterally. Local irritation at the site of injection may occur along with fever and headache (Chin-Hong et al., 2010). The live attenuated vaccine should not be administered to immunosuppressed older adults.
The risk of contracting cholera is rare for older adults traveling internationally. In addition, the vaccine is only marginally effective. As a result, the World Health Organization does not require a vaccine for traveling to endemic areas nor does any country require it for admission (Chin-Hong et al., 2010). Local regions may stipulate immunization; however, a medical waiver can be obtained. Similar to cholera, the risk of plague is very low for travelers. No commercial vaccine is available nor is it required for entry into any country. However, travelers exposed to rodents are at increased risk and should consider antibiotic chemoprophylaxis.
As noted above, older adult travelers should receive HAV and HBV vaccinations. While the risk of HBV is low for most international travelers, adults on humanitarian missions who would have contact with blood or body fluids should be immunized. Similarly, travelers who may experience poor sanitation or contaminated food and water should receive the HAV vaccination.
In certain pretravel situations, rabies vaccination might be suggested due to possible occupational exposure in the case of field biologists and veterinarians or those travelers engaged in outdoor activities where they may come into close contact with wild animals. More commonly, treatment in much of the world would be instituted post-exposure for an animal bite (Reed, 2007).
Polio is considered endemic in a number of countries (i.e., Nigeria, Niger, India, Afghanistan, Pakistan) with periodic outbreaks also occurring in Ethiopia, Somalia, Angola, and Bangladesh (CDC, 2010). Those older adults who previously have been fully immunized should receive a one-time booster before traveling. Adults who have not been previously immunized against poliomyelitis should receive the inactivated vaccine in a series of dosages for protection.
Although malaria is one of the most deadly parasites in the world, transmitted from human to human by the bite of an infected mosquito, there is no commercially available vaccine. Most cases of malaria can be prevented by travelers protecting themselves with adequate clothing covering extremities, insect repellents containing N,N-Diethyl-meta-toluamide (DEET), and mosquito netting while sleeping. In addition, prophylactic medications are available to take before, during, and after the trip. The chosen medication should be prescribed after careful evaluation of existing health problems to avoid adverse reactions.
While travel clinics serve as a important resource for up-to-date information on immunizations, they also provide extremely valuable materials on all aspects of travel that may affect health, such as long flights, high altitudes, routine medications, anticipated health concerns, and medical insurance coverage. In addition, these clinics can help older adults with scheduling immunizations in the appropriate sequence. Adults planning international travel should be encouraged to seek the benefits of this resource.
Finally, it is important that patients schedule posttravel appointments for routine follow-up care. Primary care providers should routinely assess their patients for recent travel when evaluating patients for symptoms, such as fever, rash, diarrhea, or respiratory illness, that may suggest diseases or conditions of international travelers (Hill et al., 2006). Providers should refer patients needing more extensive evaluation and treatment to specialists knowledgeable in tropical medicine or infectious diseases (CDC, 2009).
The number of older adults traveling internationally has greatly increased. Older adults should be sure to plan for healthy travel. Primary care providers are in a key position to perform basic travel assessment and provide routine immunizations as a first step in pretravel preparation. Referral to a travel clinic, as a second step, would ensure older adults receive the appropriate immunizations and the information needed to better plan for international travel.
- Centers for Disease Control and Prevention. (2009). CDC health information for international travel 2010. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2010/table-of-contents.aspx
- Centers for Disease Control and Prevention. (2010). Recommended adult immunization schedule—United States, 2010. Morbidity and Mortality Weekly Report, 59(1). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5901a5.htm
- Chin-Hong, P., Guglielmo, B.J. & Jacobs, R. (2010). Common problems in infectious diseases and antimicrobial therapy. In Mcphee, S. & Papadakis, M. (Eds.), Current medical diagnosis and treatment (pp. 1153–1204). New York: McGraw-Hill Lange Medical.
- High, K. (2009). Infection in the elderly. In Halter, K., Ouslander, J., Tinetti, M., Studenski, S., High, K. & Asthana, S. (Eds.), Hazzard’s geriatric medicine and gerontology (6th ed., pp. 1507–1515). New York: McGraw-Hill Medical.
- Hill, D.R., Ericsson, C.D., Pearson, R.D., Keystone, J.S., Freedman, D.O. & Kozarsky, P.E. et al. (2006). The practice of travel medicine: Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases, 43, 1499–1539. doi:10.1086/508782 [CrossRef]
- Leon, V.T. (2008). Health care of the international traveler. In Buttaro, T., Trybulski, J., Bailey, P. & Sandberg-Cook, J. (Eds.), Primary care: A collaborative practice (pp. 158–164). St. Louis: Mosby Elsevier.
- Reed, C. (2007). Travel recommendations for older adults. Clinics in Geriatric Medicine, 23, 687–713. doi:10.1016/j.cger.2007.05.001 [CrossRef]
- Staats, S. & Pierfelice, L. (2003). Travel: A long-range goal of retired women. Journal of Psychology, 137, 483–493.
- U.S. Department of Commerce. (2005). Office of Travel and Tourism Industries survey of international air travelers US to overseas and Mexico by birth and citizenship. 2004 report, 2004 January–December. 2005. Washington, DC: Author.