Travel Health and Vaccinations: An ounce of prevention is worth a pound of cure
My first trip to Southeast Asia has been eye-opening and I even haven’t left home yet! Previous international travel required little in the way of health precautions, but Cambodia and Vietnam are a whole ’nother kettle of fish. Over the past month we’ve had gotchas, close calls, and myths busted. This article offers advice gleaned from our lessons learned; keep reading to get organized, save time and money, and stay healthy out there.
Please note that the tips below are from a sometime traveler with no medical training whatsoever; consult a medical professional to assess your travel health needs.
Start planning 8 weeks out
The Centers for Disease Control and Prevention (CDC) recommends seeing a doctor 4–6 weeks before travel. In reality, you need to prepare for the visit and appointments can be hard to come by. When I called my doctor for an appointment in October, the soonest available was late February, just one month before take-off. That seemed fine at the time, but I later learned that some vaccines require time to complete, such as Japanese Encephalitis which is given in two doses, 28 days apart. Similarly, the inactivated Typhoid vaccine (a shot) needs two weeks to work, and the live Typhoid vaccine (oral) is taken four times over a one week period and then requires one week to work. On top of that, my doc didn’t administer certain vaccines, so I had to scramble for an appointment at a travel health clinic.
Give yourself some breathing room and start researching travel health guidelines at least 8 weeks out; more if your doctor is difficult to schedule. No need to scour the internet - just go to the CDC website page for Travel Destinations, enter your destination, choose what type of traveler you are, and select “Go”. The resulting destination page will be a wealth of information about vaccines, food safety, bug bite prevention, and more.
Read the CDC information carefully, taking notes as needed (more on that below). Our travel nurse also recommended the Fit for Travel website; if traveling to a country with Malaria risk, their Malaria maps are particularly helpful.
List recommended vaccines and medicines
Make a list of all recommended vaccines and medicines, even if uncertain what applies; it’ll be handy when talking to the doctor, checking insurance, or calling travel health clinics. The list can vary wildly depending upon destination and type of traveler. If I were headed to Ireland, the CDC recommends:
- All travelers: Routine vaccinations including measles-mumps-rubella (MMR), polio, diphtheria-tetanus-pertussis (DTP), varicella (chicken pox), and an annual flu shot.
- Some travelers: Hepatitis A, Hepatitis B, and Rabies.
For my travel to Cambodia and Vietnam, the CDC recommends:
- All travelers: Routine vaccinations (as above)
- Most travelers: Hepatitis A and Typhoid
- Some travelers: Hepatitis B, Japanese Encephalitis, Malaria, Rabies, and Yellow Fever
Yikes.
Make a few calls to save big money
Between mandatory consultation fees, vaccinations, and medicines, Chris and I spent over $750; some of those costs could have been avoided:
- Call your insurance company: Go over every vaccine and medicine on your list to see what’s covered and how (e.g., only if administered at an in-network provider). Of the shots we needed, only Hepatitis A, DTP (diphtheria-tetanus-pertussis), and the flu shot were covered. Also check to see which area travel clinics are in your plan; you may need to visit a clinic if your doctor doesn’t administer necessary vaccines.
- Check GoodRx: GoodRx helps find the lowest cost pharmacy for a particular prescription, and provides a coupon to give to the pharmacist. With a GoodRx coupon, we save about 30% on Malaria pills.
- Check Costco prices: At the travel clinic, the live Typhoid vaccine cost $115 per person, but at Costco, the price was about $66 per person. Big difference! Not a member? Not a problem. You don’t have to be a Costco member to use the pharmacy.
- Check travel clinic prices: Know before you go. On top of vaccine and medication costs (which can vary), most clinics charge a consultation fee, and do not bill insurance.
Develop a travel itinerary
It’s not enough to show up at your medical appointment and say “I’m traveling to Cambodia.” Recommendations depend on many factors and you might be asked: How long is your trip? Will you be hiking or backpacking? Will you spend time in rural areas? Exactly what cities will you visit? In what month? Will you do activities at night? In the early morning? Will you stay with a family or in a hotel? And so on.
Before our medical consult, I thought I’d play it safe and get vaccinated for everything, but then we learned that the Japanese Encephalitis vaccine costs $350 per dose and requires two doses. That comes to $700 per person and $1,400 for the two of us. Ok, time to rethink. Japanese Encephalitis is nasty stuff, so definitely worth the money if at risk, but to get it as a super-safe precautionary measure…mmm, no. We had to make some hard and fast itinerary choices in that consult, and then stick with them - can’t get medical advice and vaccines/medications based on one set of circumstances, and then change things up.
Spend time thinking about your itinerary and activities - it matters. Malaria is another good example. Based on our consult, the nurse indicated that we’d be in very low-risk areas for the bulk of the trip, and would only be at higher risk for a 3-day period. She prescribed exactly 12 Atovaquone-Proguanil pills: two for the two days prior to the higher risk area, three during, and seven for the period after. It was a very targeted plan, both to save money and to not over-medicate.
Consult a medical professional
It pays to talk to a medical professional who specializes in travel health to assess risk and develop an individualized travel health plan. Check with your doctor to see if they do travel consults; mine referred me to a travel clinic. Schedule appointments for at least six weeks before travel.
During our consult, the nurse asked about our medical history and travel itinerary, assessed risk, determined necessary vaccines and medicines, administered vaccines, and wrote prescriptions. She also relayed advice for bite prevention, food safety, and how to protect against traveler’s diarrhea (more on those below).
Cautionary note: Before the end of your appointment, re-cap your plan to make sure all bases are covered. Ugh…this story is painful to tell: So we needed the Typhoid vaccine and chose the live version (oral) since it’s good for five years, where the inactivated vaccine (a shot) is only good for two years. The nurse gave us two boxes of Vivotif along with careful instructions about how and when to take it. We then left it in the cupboard for 10 days, at which time I discovered it needed to be refrigerated. It was ruined. In retrospect, duh, it’s a live vaccine, but Chris and I are sure she never mentioned refrigeration, she’s sure she did (and I clearly never examined the box), so what’re you gonna do. Unfortunately, we got the first boxes at the clinic at $115 each, so it was a $230 mistake. We bought the second batch at Costco for $66/box - and wish we’d known about the Costco option in the first place! Live and learn.
Have a solid bite prevention plan
After reading about Japanese Encephalitis (JE) I was a bit fixated and kept circling back to it in our travel consult. The nurse insisted our risk for JE was very low, and argued that we’d potentially be at greater risk for dengue, zika, or chikungunya, none of which have a vaccine, and all of which are spread by mosquitoes. To minimize risk from all mosquito-borne illnesses, it’s best to practice good bite prevention. We plan to:
- Regularly apply a product with at least 25–30% DEET. Our nurse recommended Ultrathon with 34.34% DEET and 12-hour time release protection. The percent DEET indicates how long a product will remain effective, though formulations over 50% don’t increase the length of protection. Other mosquito-repellent options include picardin, lemon eucalyptus, or IR3535, but we chose DEET for its long-lasting defense. Apply sunscreen first and then DEET, don’t apply DEET under clothing, and avoid overly-thick application (more isn’t better). Learn more about DEET from this EPA website.
- Treat clothes and gear with Permethrin. DEET makes it harder for bugs to find us, but it doesn’t kill them. Permethrin, on the other hand, is an insecticide that provides knockdown protection against mosquitoes, flies, ticks, and a host of other nasty buggers. Treated clothing stays effective through multiple washings, though it’s best to hand wash and line dry. We used Martin’s Permethrin this go-around, but I’ve used Sawyer products in the past.
- Sleep under a mosquito net, or better yet, in a well-sealed, air conditioned room.
- Wear long sleeved tops and pants if in mosquito-riddled areas (often where there’s standing water), or if out near dawn, dusk, or at night when some nasty night-flying mosquitoes (anopheles and culex) are about.
Protect against TD (?)
The dreaded TD - traveler’s diarrhea. For our Cancun trip, we regularly took Pepto Bismol as a preventative measure, but our travel nurse advised against it for the Cambodia/Vietnam trip. The active ingredient in Pepto Bismol is bismuth subsalicylate. Studies show that taking two tablets four times per day (eight tablets daily) “…reduces the incidence of TD by approximately 50%.” But it’s also a lot of pills to take, can cause constipation, and shouldn’t be taken for more than three weeks (perhaps since the bismuth may reach toxic levels).
Instead, our nurse recommended taking a probiotic with at least 5–15 billion CFU (colony forming units) per capsule, arguing that one capsule is as effective as eight tablets of Pepto Bismol. Convinced, we started taking a probiotic with 30 strains and 30 billion CFU per caplet two weeks before travel.
When I researched it further, I found that studies are inconclusive concerning probiotics and prevention of TD. We ultimately decided to continue with the probiotics throughout the trip, but also take Pepto along if things go south.
Choose hot food, bottled water, and clean hands
Many maladies can be traced back to unsafe food preparation and handling. Unclean hands (even your own) are a major risk, so wash regularly and use a hand sanitizer that’s at least 60% alcohol. Our nurse’s main cautions:
- Eat hot, cooked food: Stay away from undercooked or raw food, food that’s been sitting around (like at a buffet), or food served at room temperature. Don’t eat/drink unpasteurized products.
- No peel, no deal: Don’t eat raw fruits or vegetables unless they have a peel and you’ve peeled them yourself with clean hands.
- Drink bottled water: No tap water, and no ice. Steaming hot coffee and hot tea are ok. If drinking a sealed, canned beverage, clean the lip first.
To see a more complete list, check out this article from the CDC.
If you survey ten people, you’ll likely get ten different attitudes towards risk-taking and risk-avoidance. Do your research, talk to a medical professional, and make choices that are right for you. I’m pretty risk-averse and extremely attractive to mosquitoes (no joke - they love me!) so I’ll try to follow every recommendation to a T.
One final note on Permethrin:
