aDVeNtUre: Tourism in the Extremes
traVel meDiciNe For
tHe extreme traVeler
additional insurance for sports or adventure coverage is the single most important concept. In addition, health care provid- ers should be aware of the special medical problems that can arise in the growing area of extreme travel.
Although there are no comprehensive demographic data
characterizing this group of travelers, there are some relevant data that can be extrapolated to obtain a profile of extreme trav- elers. Among studies of backpackers to wilderness and interna- tional destinations, the average age of 32 years is younger than that of United States international travelers as a whole, which is 44 years. Illness rates among general international travelers between the ages of 20 and 40 years are almost double that of older international travelers.
General Risks
In reviewing a topic such as extreme travel, the goal is not to
provide an all-encompassing tome giving advice for every pos- sible exotic destination and all manner of extreme recreational activity. Instead, there are common generalizable risks for ex- treme travelers as a group that health care providers should be- come familiar with. Principal among theses risks is longer dura- tion and more remote travel. Common factors in this cohort that have been independently associated with either not seeking or noncompliance of pre-travel advice are: younger age, longer duration of travel, and individual travel. The highest single risk is trauma related to local transportation or the activity itself. Statis- tically, local transportation in a developing country in rural areas is the highest risk for all travelers. Tourists driving themselves have a 6-fold higher likelihood of a motor vehicle collision than a local citizen, with an additional 2.5-fold higher risk if driving E xtreme travel is defined as journeying to remote destina- tions or participating in unusual high-risk activities during tYPical traVel iNsUraNce exclUsioNs
travel, generally far off the beaten path. These destinations may athletic activities, professional events, or contact amateur
be in developing countries or in the wilderness of a developed country. Activities may be unusual in nature (e. g. EcoChal- amateur athletic activities engaged in other than solely for
leisure, recreational, entertainment, or fitness
lenge) or a typical activity in an exotic location (e. g. bird watch- mountaineering where ropes or guides are normally used
ing in remote Guiana).
or above 4500m
aviation (except as a passenger in a commercial aircraft)
Encompassed within this concept of extreme travel are areas Hang gliding, sky diving, parachuting, or bungee jump-
of traditional travel medicine and wilderness medicine. Neither travel nor wilderness medicine alone encompass the realm of snow skiing or snowboarding, except for recreational
potential problems that might be encountered by an extreme downhill or cross-country
traveler. The activities that are typically excluded from travel racing by any animal or motorized vehicle
spelunking (caving), scuba diving, jet skiing
insurance evacuation policies are perhaps the best reference any other sport or athletic activity that is undertaken for
as to what constitutes extreme travel. Recognizing that these thrill seeking and exposes one to abnormal or extraordi-
exclusions exist and that extreme travelers need to purchase nary risk of injury

aDVeNtUre: Tourism in the Extremes
on the opposite side of the road than their home country. One should especially avoid travel at night.
Pre-travel advice should consist of more than the recommend-
ed vaccinations; however, vaccinations are important. Hepatitis A is the most common vaccine-preventable illness, with rates of up to 1 % to 2 %. In many countries with nationalized health geNeral risKs oF extreme/aDVeNtUre
longer travel duration
High risk activities for trauma
more risky food and beverage items
more contact with locals
more austere accommodations (chagas, rats, fleas)
sleeping under a bed net, ideally one pretreated with perme- more brush exposure, thereby tick exposure
health care visi- thrin. Second, pre-travel treatment of clothes with 0.5 % per- methrin, by soaking or spraying, is recommended. Permethrin increased drowning risk
binds to clothing and is effective through up to 10 washings. sexually transmitted diseases
Treatment of clothing or objects, such as tents, protects the in- Psychological disorder unmasked by stress
dividual and also offers nearly 50 % protection to others in the immediate vicinity. With the emergence of West Nile virus, the North American general population has more recognition of the to Cuzco, Peru, 85 % of Europeans versus 67 % of North Ameri- dangers of mosquito-borne illness. Although mosquito avoid- cans had received pre-travel vaccinations. Nearly half of North ance has traditionally been recommended in regions with ma- American travelers (48 %) did not visit a health care provider laria, other mosquito – and tick-borne illnesses are worldwide in before travel. One encouraging prognostic among Europeans distribution. For example, Aedes aegypti, the vector for dengue travelers is the finding that those intending rural travel are three fever, is an urban day-biting mosquito expanding in geographic times more likely to visit a health care provider. The health range since the 1960s. In a prospective cohort study of Appa- preparation among young travelers is often less than optimal. lachian Trail backpackers, nearly 5 % acquired a vector-borne Younger persons have been shown to seek pre-travel advice illness, principally Lyme disease.
at substantially lower rates. A recent Japanese encephalitis in- vestigation reiterated this dilemma when it found that 40 % of American university students spending one month in Thailand One of humankind's traits is the desire to explore. Within did not seek pre-travel advice.
the outdoor recreation and sporting communities, this trans- lates into a never-ending search for more exotic locations and more chal enging endeavors. In many extreme travel Adventure travelers have been previously shown to have cases, this may mean taking traditional recreational activi- higher risk of traveler's diarrhea as compared with those stay- ties, such as ski ng or scuba diving, and transporting the ac- ing at one hotel or as part of an organized tour. The incidence of tivity to nontraditional locations–frequently without support traveler's diarrhea is expected to be over 50 %. Instructions for or medical backup. Here are some useful recommendations self-treatment of traveler's diarrhea should be given (bismuth, for adventure travelers: loperamide, ciprofloxacin). On longer or more rural trips, basic hygiene should be stressed. When soap, clean water, and clean • Doxycycline prophylaxis daily for malaria, leptospirosis, towels are not available, alcohol-based hand sanitizer is an ef- ricket sioses. Alternate combo: mefloquine + doxycycline fective alternative. Among United States backpackers, frequent hand washing is the single most protective factor to prevent di- • Permethrin pretreatment of clothes, mosquito bednet • Evacuation Insurance. Often «adventure activities» are ex- cluded, and «Sports Rider Coverage» must be purchased, typically at an additional 20 % cost.
Mosquito and tick precautions should be advised for nearly • Medical first aid kit all destinations. In a plethora of studies that included American travelers to Africa, soldiers, aid workers, and Boy Scouts, anti- • Use of licensed/certified guides mosquito measures were used by less than 50 % of travelers. • Advance planning. Word of mouth or via travel-related inter- Passive methods to reduce mosquito exposures are likely to be net chat rooms may be helpful to confirm the quality of tour consistently effective. Two primary examples exist. The first is aDVeNtUre: Tourism in the Extremes
• Detailed cardiac evaluation for those with cardiovascular risk factors or age over 50 years with provision of baseline EKG Among the recommendations for medical examination before extended travel is also: • Detailed history and physical examination, especially cardio- • Dental examination• Underlying illness, discussion of chronic medications• Screening for age-specific guidelines• Identifying cryptic psychiatric disease, substance abuse• Identifying abnormal coping mechanisms for stress (self- awareness) and relationships • Knowledge of trip duration, destination, activity, and local medical capacity affect the extent of evaluation.
With international travel expecting to double by 2020 and with the global population growing at near 2 % per year, probably there will be increased demand for more exotic and remote travel. Adventure travel is primarily a North American, Western European, and Australian hegemony; however, this will presum- ably change in the coming decade with increasing diversity of travel originations and destinations.
By David R. Boulware, MD
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