Table 1 Summary and strength of recommendations

Pre-travel counseling

 1. Elderly patients who anticipate overseas travel should meet with a provider familiar with travel medicine to undergo risk assessment and guidance. (Strong recommendation, moderate-quality evidence)

Assessment of Co-morbidities

 2. Cardiovascular Disease: Elderly patients with a history of coronary artery disease (CAD) should be evaluated for acute or recent cardiac diagnoses prior to travel. (Strong recommendation, moderate-quality evidence)

 3. Pulmonary Disease: Elderly patients with underlying chronic pulmonary disease such as COPD and emphysema, or acute pulmonary disease such as pneumonia should discuss travel plans with a clinician about risks of exacerbation and should contact airlines in advance if there is a need for supplemental oxygen during the flight. (Strong recommendation, moderate quality evidence)

 4. Malignancy & Thromboembolic: Elderly patients at increased risk for venous thromboembolism (VTD) should consider the use of well-fitted below-the-knee compression hosiery or subcutaneous enoxaparin before and one day after when undertaking journeys of greater than three hours. (Strong recommendation, moderate-quality evidence)

Vaccines

 5. General Vaccines: Clinicians should be cognizant that as the immune system ages, it undergoes characteristic changes referred to as immunosenescence which leads to a decline in the protective efficacy from vaccinations and a shortened duration of protection. Strong recommendation, high quality evidence)

 6. Non-travel related immunizations: Ensure elderly travelers are up to date on non-travel related immunizations to include pneumococcal pneumonia (pneumovax® and prevnar 13®), tetanus, diphtheria with acellular pertussis (Tdap), live attenuated herpes zoster vaccine. (zostavax®) and seasonal influenza. (Strong recommendation, high-quality evidence)

 7. Yellow Fever: The yellow fever vaccine should only be considered for elderly travelers to endemic regions and recognize those who require proof of immunization for travel. Clinicians should weigh the risks and benefits in the context of the individual traveler prior to vaccination. (Strong recommendation, high quality evidence)

 8. Hepatitis A: Two doses of hepatitis A vaccine should be given to elderly travelers. (Strong recommendation, high quality evidence)

 9. Hepatitis B: The Hepatitis B vaccine should be given to elderly travelers who are at risk for acquiring the disease (e.g. utilizing health care, at risk for blood borne exposure). (Strong recommendation, high quality evidence)

 10. Rabies: Individual risk assessment should be made concerning rabies pre-exposure prophylaxis for the traveler. Such risk assessment should include factors such as outdoor exposure risk, rabies endemicity of the region, and access to medical care in country. (Strong recommendation, high quality evidence)

 11. Typhoid: Purified Vi Polysaccharide Parenteral vaccine or Ty21a Live-Attenuated Oral vaccine should be considered for travelers to endemic regions. (Strong recommendation, moderate quality evidence)

 12. Meningococcal: The conjugated meningococcal vaccine should be considered, and may be a requirement, for elderly travelers to going to regions endemic (e.g. Hajj) with N. meningitides. Endemic regions (e.g. Hajj). (Strong recommendation, very low quality evidence)

 13. Polio: The polio vaccine should be considered and documentation of vaccination may be required for travelers to endemic regions. (Strong recommendation, moderate quality evidence)

 14. Japanese Encephalitis: The Japanese encephalitis vaccine should be given to elderly patients traveling to endemic regions. (Strong recommendation, moderate quality evidence)

Travel Specific Concerns

 15. Travelers’ Diarrhea: Treatment of travelers’ diarrhea in elderly patients should be reserved for severe cases. (Strong recommendation, high quality evidence)

 16. Jet Lag: In adult patients traveling eastbound on journeys greater than five time zones, melatonin taken for 2 days prior to departure and for 3 days after arrival at the bedtime of the target destination can shorten the duration of jet lag, and in the elderly is safer than using hypnotics or benzodiazepines.; Conditional recommendation, low quality of evidence)

 17. Altitude: When traveling to regions at elevation greater than 8200 ft (2500 m), elderly patient should be educated about the effects of altitude illness and prescribed acetazolamide for disease prevention but avoided in patients on high dose aspirin (325 mg daily). (Strong recommendation, moderate quality evidence)

 18. Travel Insurance: Elderly patients should be counseled to review their medical insurance policies to see overseas coverage and consider purchasing travel insurance prior to travel as many domestic insurance policies will not cover international aeromedical evacuation. (Conditional recommendation, low quality evidence)

Malaria

 19. Malaria Prevention: Ensure elderly travelers are well educated about the importance of adhering to personal protective measures and to present early for care if they develop fevers following travel to malaria endemic regions. (Strong recommendation, high quality evidence)