The purpose of the trip, accommodations, and likely activities are essential considerations when providing individualized advice. Tourist and business travelers typically take short-term trips to visit major cities and stay in better accommodations, while long-term travelers (e.g., missionaries, aid workers, business expatriates, students, etc.) are more likely to eat, sleep, and travel in conditions closer to that of locals and stay for durations that make health problems more likely. Immigrants visiting friends and relatives in their countries of origin (VFRs) can be unique. While this group shares some risk factors with the long-term travelers, they might not have the financial resources to afford travel vaccinations, and many do not recognize the importance of malaria prophylaxis when visiting their countries of origin.

The usual activities of the business, tourist, and adventure travelers are very different, and each traveler should be counseled about the infections, injuries, and exposures that are most likely. For example, popular freshwater activities in Africa, such as whitewater rafting in the Nile River in Uganda or swimming in East African Rift Valley Lakes can result in schistosomiasis infection. Rural itineraries and direct animal contact can be risk factors for various vaccine-preventable (e.g., rabies, Japanese encephalitis) and nonvaccine preventable (e.g., avian influenza, African tick-bite fever) infections.

Travelers should be aware that blood- and bodily fluid-borne infections such as HIV, hepatitis B, and hepatitis C are more prevalent in much of the world, and routine advice of avoiding unprotected sexual contact and percutaneous exposures (e.g., tattooing, piercings) is prudent. All travelers are potentially at some risk of bloodborne infections when seeking medical care, especially in areas where unsafe injection practices occur or when administration of unscreened blood products occurs. Those working in healthcare settings (i.e., medical missionaries, healthcare trainees, etc.) should be advised to investigate the availability of reliable HIV postexposure prophylaxis medications should an occupational percutaneous bodily fluid exposure occur.

Immunizations

When providing pre-travel advice, it is important to review both routine immunizations as well as those that are particularly recommended or required for the particular itinerary. Travelers should be up to date on routine vaccinations (see Chapter 115, Immunizations). On the other hand, for US residents, indications for yellow fever, typhoid, and Japanese encephalitis vaccination are almost exclusively limited to international travel. Some vaccinations, such as polio or meningococcal vaccination, are routinely administered to children and adolescents in the United States, while adult boosters are recommended for travel to specific areas. Two rarely indicated vaccines are bacille Calmette–Guérin (BCG) and cholera, of which the latter is not available in the United States. Table 116.2 lists the immunizations of special importance for travel and their schedules.

Immunizations should generally be recommended according to risk of disease and not according to the country visited. The risk of specific infections can vary significantly in different areas within a country; furthermore, infection risk can vary with different activities, accommodations, and eating habits. Trip duration is also important to consider due to the increased risk of infection exposure over time, and some vaccinations such as Japanese encephalitis, hepatitis B, or rabies vaccination, are of higher priority in long-term travelers.

Most vaccines can be administered simultaneously at separate sites, and this is often necessary when multiple are indicated. However, immunologic response to live-virus vaccines (i.e., MMR, varicella, yellow fever, or intranasal live attenuated influenza vaccines) might be attenuated when administered within 30 days of another live-virus vaccine. Therefore, live-virus vaccines should be administered on the same day or spaced apart at least 30 days.

Tetanus, diphtheria, and pertussis

All travelers should be up to date with tetanus, diphtheria, and pertussis vaccination as per routine. Diphtheria continues to be endemic in many countries outside the United States and Western Europe. Pertussis is increasingly recognized worldwide, including in the United States. Adult travelers who have not previously received the combined tetanus/diphtheria/acellular pertussis vaccine (Tdap) should receive one dose of Tdap regardless of the interval since the

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