Pre-travel advice: an overview.

The message of the pre-travel provider is necessarily paradoxic. First the provider lists a score of causes of illness and premature demise, and then states, "But it sounds like a great trip and I think you'll have fun." Pre-travel providers need to walk a fine line: they must encourage patients to be cautious but not paranoid, optimistic but realistic. This discussion is complicated further by the fact that risk reduction is not the only consideration; if it were, practitioners would advise patients to remain in the developed world and foray from their homes only to visit health clubs and the fruit-and-vegetable section of grocery stores. A tacit assumption in travel medicine is that some degree of acceptance of heightened risk is tolerated for the benefit of improved quality of life offered by travel abroad. The amount of risk that is reasonable to accept for a given benefit in quality of life yielded by travel cannot be quantified, however. Providers must render judgments on what is "reasonable" and what is not, and this complex decision is based on equal parts medical knowledge and intuition. At one extreme, mountaineers in Nepal have been found to have a 2.4% mortality rate per expedition [83,84]. The travel provider might make the reasonable decision to counsel these travelers to avoid that activity. These travelers most likely will ignore that advice, at which point the provider must endeavor to reduce risk to the extent possible. Other situations in which the provider should advise a change in itinerary or activities include counseling parents who plan to take an infant to high altitude or a pregnant woman who plans to scuba dive. If travelers remain cloistered in their hotel rooms, eating all meals from room service and watching CNN, then it could be suggested that they are overly risk-adverse and might consider foraying out of the hotel, despite the potential associated increased risks to health. Conversely, if travelers find themselves on motorcycles after a few drinks with a new love interest, they are perhaps not sufficiently risk-adverse; however, the "point of optimal risk acceptance" between these two extremes is a matter of conjecture. Risks associated with travel can never be eliminated; however, appropriate advice and immunizations can tilt the odds in travelers' favor.