Introduction to travel medicine

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Introduction to travel medicine

• Dr Peter A Leggat
• MD PhD DrPH FAFPHM FACTM FFTM
• Associate Professor School of Public Health and
  Tropical Medicine James Cook University
  Australia
• Visiting Professor School of Public Health
• University of the Witwatersrand

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About the author

• Dr Peter Leggat has co-ordinated the Australian
  postgraduate course in travel medicine since
  1993. He has also been on the faculty of the
  South African travel medicine course conducted
  since 2000 and the Worldwise New Zealand Travel
  Health update programs since 1998. Dr Leggat has
  assisted in the development of travel medicine
  programs in several countries and also the
  Certificate of Knowledge examination for the
  International Society of Travel Medicine.

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Objectives

• In this session
• Define travel medicine
• Examine some figures for global and local
  migration
• Hopefully gain an appreciation of the importance
  of giving travel health advice
• Discuss some of components that are needed in
  order to give correct advice to traveller

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What is travel medicine

• It is a science and an art

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What is travel medicine

• It is that part of health professional practice
  that
• seeks to prevent illnesses and injuries occurring
  to travellers going abroad
• manages problems arising in travellers coming
  back or coming from abroad
• is concerned about the impact of tourism on
  health and also advocates for improved health and
  safety services for tourists
• is increasing concerned about refugee and migrant
  health (Primer of Travel Medicine 3rd Ed)

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• the art of travel medicine is selecting the
  necessary prevention strategy without unnecessary
  adverse events cost or inconvenience
  
• 
  (Steffen 1994)

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Challenge of travel medicine

• Sea of global migration of people
• More people travelling
• People travelling further a field
• Rapid movement of travellers

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Travellers from industrialised areas to
developing areas 1999 (WTO)
2.4
2.8
Europe 25.0 million
6.1
USA / Canada 35.2 million
4.6
Japan 11.4 mio
3.6
7.8
1.6
19
6.8
2.3
1.3
4.8
2.5
1.9
2.6
1.2
AUS / NZ 3.3 million
n million travelers
0.2-1 million travelers
Total
80 million travelers
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Globalization of health and safety

• Affects
• Health of local populations
• Health determinants
• Safety and security
• Results in
• Global impacts
• Emerging and re-emerging infectious disease

Commerce and Health
Influenza
SARS
Terrorism
Tsunami
Pathogens travel as fast as transportation
borders are not respected
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Travellers are exposed to a variety of hazards
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The Importance of Travel Health Measures

• 100000 travelers to the developing world for 1
  month..
• 50000 will become ill
• 8000 will see a physician
• 5000 will stay in bed
• 1 will die

Steffen 1994
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The Importance of Travel Health Measures

• Per 100000 travellers that have travel insurance
  ..
• 8000 will make a claim (8)
• 2000 will use emergency assistance (2)
• 400 ER or clinic referrals (0.4)
• 200 Hospital admissions (0.2)
• 50 Aeromedical evacuations (0.05)

Leggat et al. Travel Med Inf Dis 200539-17.
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The Importance of Travel Health Measures

• Mortality
• Cardiovascular Disease (50 to 70)
• Accidents/Trauma (20-25) esp. MVAs
• Infectious diseases (2.8-4)
• (Reid and Cossar BMBull. 1993257-268 Prociv
  MJA. 199516327-30 Baker et al. PHR
  1992107155-159 MacPherson et al JTM. 2000
  2000227-233 Steffen Trans RSTMH 199185
  156-162 )

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Travel medicine is a continuum

• Travellers do get sick or injured abroad or when
  they come back
• The commitment to travel health can therefore be
  regarded as a continuum

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The Continuum of Travel Medicine
Preventive Medicine
Pre-Travel
Visitors
During Travel
Contingency Planning
Post-Travel
Treatment Rehabilitation
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What do we need to do in order to be giving the
correct advice to travellers
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Travel Health Advice needs Information

• Information is power in Travel Medicine

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Travel Health Advice needsTraining

• Training gives you a framework for using that
  information

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Travel Health Advice needsExperience

• Experience helps put the information and training
  in perspective

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Travel Health Advice needsto be Documented

• Documentation is important for Quality assurance
  and reinforcing travel health advice

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Travel Health Advice needsTravellers

• Marketing is essential in travel health whether
  in general practice or in specialist travel
  clinics

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Giving the correct advice to travellers

• Giving the correct health advice to travellers
  needs
• Information
• Training
• Experience
• Documentation
• Travellers

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Travel Health Advice needs Information

• Guidelines
• Policies
• Textbooks including an World Atlas
• Journals
• Professional organisations
• Staff/colleagues
• Electronic Databases
• WWW

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International Guidelines

• WHO
• International Health Regulations
• International Travel and Health
• www.who.int/ith
• Yellow fever requirements

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National Guidelines

• Travel Health Guidelines
• Malaria Guidelines
• Immunisation Guidelines
• Antibiotic Guidelines
• Journals
• Seminars

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You need access to www-sites

• International Society of Travel Medicine
• www.istm.org
• US Centers for Disease Control and Prevention
• www.cdc.gov/travel
• US Guidelines
• Similar government sites for UK and Canada
• World Health Organization
• http//www.who.int/ith
• The former yellow book is now published as the
  blue book online

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It is very useful to have access to a
multicountry travel medical advisory service

• CDC Travel Health see http//www.cdc.gov/travel/i
  ndex.htm
• MASTA see http//www.masta.org
• TRAVAX see http//www.travax.nhs.uk
• Shorelands see http//www.tripprep.com

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Professional Organisations

• Local professional groups
• and
• THE ISTM

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ISTM

• International Society of Travel Medicine
• International Network
• International Clinic Directory
• Useful for marketing/recognition
• www.istm.org
• Listserve
• Outbreak alerts
• Journal
• Geosentinel
• Certificate of Travel Health
• Great Conferences!!

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Journals
Weighing the Evidence
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Weighing the evidence

• Travel medicine prevention should be based on
  epidemiological data. Robert Steffen
  1991
• What are the likely risks of a person travelling
  to particular destinations
• What are the likely benefits of
  intervention

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Giving the correct advice to travellers

• Giving the correct health advice to travellers
  needs
• Information
• Training
• Experience
• Documentation
• Travellers

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Pre-Travel Health Advice needs Training

• Helps give structure and consistency
• Provides a framework for practice
• Discusses evidence for practice
• Policy and Procedures Manual
• Consistent approach to travel health

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Part of the commitment is to also have a
consistent and structured approach to travel
health advice

• WHO Checklist (www.who.int/ith)
• Information on local conditions
• Prevention
• Accident avoidance
• Medical and dental check-up
• NZPHR-Prevention
• Vaccinations
• Health Advice
• Prescription

Source http//www.who.int/ith
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VACCINATE (IHC)

• Always National schedule
• Often hepatitis A
• Sometimes Japanese encephalitis
  meningococcal disease polio
  rabies yellow
  fever Influenza
  Pneumococcal disease
• Other vaccines (adapted from NZPHR
  19963(8)57-59)

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ADVISE AND DISCUSS

• Insects repellents nets permethrin
• Ingestions care with food and water diet/teeth
  (including airlines/jetlag/DVT)
• Indiscretions STIs HIV
• Injuries accident avoidance personal safety
• Immersion schistosomiasis
• Insurance health and travel insurance finding
  medical assistance o/s (adapted from NZPHR
  19963(8)57-59)

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PRESCRIBE (Script/Drs
letter/bracelet)

• Always regular medication medical kit
  (first aid)
• Sometimes antimalarial medication diarrheal
  self-treatment condoms (NZPHR
  19963(8)57-59)

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Courses

• Increasing number of travel medicine academic
  programs globally (see
  educational opportunities at www.istm.org)
• Get relevant endorsements
• Aviation medical examiner
• Diving medical certification (SPUMS)
• Certificate of Travel Health (ISTM)
• Occupational health training

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Courses

• Weighing the evidence
• Contributing to the discipline through research
  (also through GeoSentinel)
• Despite training still need to keep up to date
  and to keep seeing travellers to help build
  experience

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Giving the correct advice to travellers

• Giving the correct health advice to travellers
  needs
• Information
• Training
• Experience
• Documentation
• Travellers

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Travel health advice needs experience

• Lets just do it!
• Affiliation with a group with experience can be
  useful
• Travel clinic group
• Travel medical advisory group (eg MASTA
  Worldwise Travax etc)
• University
• Those NZ GPs that were interested in travel
  medicine were significantly more likely to have
  had tropical medicine/developing country
  experience (Leggat et al. JTM 1999 7 55-58.)

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Travel is part of experience
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Travel is part of experience

• Professionals working in travel medicine need to
  travel and have that personal experience to
  communicate to travellers
• Helps to put travel health advice in context and
  helps to build a positive travel experience

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Giving the correct advice to travellers

• Giving the correct health advice to travellers
  needs
• Information
• Training
• Experience
• Documentation
• Travellers

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Travel health advice needs to be documented

• Standardised forms/questionnaires
• Informed consent
• International Health Certificate/Vaccination
  record
• Doctors letter/copy of prescription/medialert
  bracelet
• Written advice/videos/Books/Health advisory
  documents

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Correct advice is even better if the advice is
actually followed by the traveller

• Documentation
• Follow-up
• Use staff resources
• Reinforce health advice

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Giving the correct advice to travellers

• Giving the correct health advice to travellers
  needs
• Information
• Training
• Experience
• Documentation
• Travellers

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Travel Health Advice needs Travellers

• Inform own patients concerning the need for
  seeking travel health advice and seeking this
  advice early
• Market travel health advice
• Direct if possible
• Join group/affiliate
• Links/promotion with traveller groups travel
  agents travel insurance consulates etc
• Join travellers health networks such as ISTM
  IAMAT etc

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Take home points

• More people are traveling to more destinations
  becoming exposed to the health and safety of that
  destination and also having the potential to
  impact on the health and safety of that
  destination especially through emerging
  infectious disease
• Travelers health is a continuum and includes the
  pre-travel health contingency planning while
  abroad and caring the traveler after travel
• Travel health advice needs information (including
  a capacity to undertake a risk assessment)
  training experience documentation and travelers