PostTravel Health Consultation

1
Post-Travel Health Consultation

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

2
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.

3
Objectives of the session

• Review statistics
• Briefly review the sorts of problems travelers
  have abroad
• Examine why it may be important to see travelers
  if they are unwell on return and what policies
  may be applicable in practice
• Document some important aspects of the
  post-travel history and examination

4
Some References

• Steffen et al. Manual of Travel Medicine and
  Health. Decker, 2003 Sec 4.
• Leggat et al. Primer of Travel Medicine. ACTM
  Publications, 2002 Ch. 19.

5
The Continuum of Travel Medicine
Preventive Medicine
Pre-Travel
Visitors
During Travel
Contingency Planning
Treatment Rehabilitation
Post-Travel
6
The Good News

• Most travelers report no major problems whilst
  travelling and most are asymptomatic on return

7
Travelers are exposed to a variety of hazards
8
Swiss Travelers

• 15-50 of travelers to developing countries
  report some illness or injury
• 8 in the study of 10,000 Swiss travelers
  consulted a medical officer
• 1 required hospitalization and 3 had time off
  work

9
Insured Australian travelers

• Approx 20,000 policies issued each year (incl.
  Exec. Gold)
• About 1600 claims (8)
• 400 claims for emergency assistance (2)
• 80 ER or clinic referrals (0.4)
• 46 Hospital admissions (0.2)
• 10 Aeromedical evacuations (0.05)

Leggat et al (2005) Emergency assistance
provided abroad to insured travellers from
Australia. Travel Med Inf Dis 3 9-17
10
Common things occur commonly

• Gastrointestinal-diarrhoeal diseases effecting
  20-40 or more of short term travelers
• Respiratory tract infection
• Cutaneous infections
• Trauma and injuries (accidents- commonest cause
  of preventable death)
• Sexually transmitted infections
• Dental problems
• Others (remember malaria)

11
Post-Travel Consultation

• Many travel related problems are self-limiting
• Why might it be important to see travelers who
  have an illness post-travel?

12
The traveler may have a life threatening
infections

• Malaria due to P. Falciparum
• Viral hepatitis
• Typhoid
• Amoebiasis/Amoebic liver abscess
• Legionnaires disease
• Melioidosis
• Rabies
• Others

13
Travelers may have infections that pose a risk to
public health

• Dengue (2-5 days)
• Lassa, Ebola and others (3-21 days)
• Japanese Encephalitis (3-7 days)
• Yellow fever (3-6 days)
• Typhoid (1-2 days)
• Malaria (Pv-10 days to year-relapses Pf 10-28
  days)
• SARS (2-10 days)
• Others

14
It is important to develop policies in travel
medicine

• Policy and procedures, including
• Policy of follow-up of travelers
• Policy on notifiable diseases
• Policy on reporting adverse reactions
• Policy on eradication treatment

15
Policy on follow-up of travelers

• Do you see travellers
• Symptomatic on return?
• Symptomatic whilst aboard?
• Asymptomatic abroad and asymptomatic now?
• To complete immunization courses?

16
It is important that the clinic have a written
policy

• It is essential that travellers who become ill on
  return seek medical attention as soon as possible
• The traveller should be advised to inform the
  clinic that they have been or are currently
  traveling
• It is also important to ask if patients
  Have you been traveling recently?

17
Policy on reporting notifiable diseases and
adverse reaction

• Is it a notifiable disease? Early liaison
  concerning suspected cases and formal
  notification to public health units
• Keep a list of notifiable diseases and reporting
  forms
• Document and report any possible serious adverse
  reactions to immunisations and chemoprophylaxic
  and other medications experienced by traveller
  whilst abroad
• Is the traveler part of a clinical trial?

18
Travel medicine has assumed a major role in
monitoring global trends in infectious disease,
especially emerging infectious diseases
19
Travel medicine networks

• GeoSentinel (ISTM/CDC)
• May provide early warning of outbreak amongst
  travelers returning to disparate locations
• TropNet Europ
• WHO
• Local networks
• Other networks

20
Eradication Policy

• Do you prescribe empiric eradication treatment?
• If so, what groups of travelers?

21
Eradication Treatment

• Malaria - primaquine (check G6PD deficiency),
  (tafenoquine)
• Deworming agent for soil transmitted roundworms
  (consider strongyloides)
• Deworming agent for flatworms- praziquantel
• Deworming agent for filariasis - albendazole
• Antiprotozoal agent - giardiasis
• Others (?)

22
Groups where eradication treatment may be
considered

• Medium to long term travelers or overseas workers
• Those travellers at high risk of infection
• Those where diagnosis suggestive but
  investigations inconclusive
• Where required by authorities-refugees
• Even when on preventive measures!

23
Occasionally preventive measures do fail

• Immunizations and chemoprophylactic agents and
  personal protective measures are not 100
  protective
• Variable compliance with preventive advice
• Incorrect/insufficient advice/health intelligence

24
Post-travel Consultation

• History
• Examination
• Investigations

25
Screening History

• Are they symptomatic now or have been?
• Risk assessment - leading to specific history of
  possible exposures, e.g. schistosomiasis,
  zoonotic disease, sexual history, recently been
  diving, have they been bitten?
• Is there correspondence in relation to treatment
  abroad?
• Travel history can be important in terms of
  working out possible incubation period and
  differential diagnosis

26
Screening History

• Prophylaxis and compliance - was the prophylaxis
  appropriate?
• Could it be a pre-existing condition?
• Could it be related to an occupational/recreationa
  l exposure?

27
Screening Examination

• Post-travel physical examination for most short
  term travelers is usually unremarkable for
  disease, but may be useful for assessment of
  injuries
• Signs of tropical disease can be subtle and can
  be missed unless specifically looked for, e.g.
  rashes, eschar, jaundice
• Abnormalities unrelated to travel

28
Look for the spot diagnosis

• Hookworms and cutaneous larva migrans tracking
  lesions on the foot (or other body areas in
  contact with sand/soil)

29
Look for the spotdiagnosis

• Leishmaniasis non-healing skin ulcers/lesions,
  especially on exposed areas and been to endemic
  areas
• Eschars-may be associated with rickettsial
  infectious such as scrub typhus
• Skin infection bacterial and fungal
  (ask for occupational and recreational
  history)
• Others

30
Screening Examination

• When sending specimens to lab, document current
  medications, history, what you think
• Liaise with lab if unsure what tests available
• Stool microscopy M/C/S, O/C/P-most diarrhoeal
  disease bacterialgtgtparasiticgtviral
• Urine tests-dipstick urinalysis, terminal urine
  for ova of S. haematobium
• Full Blood Count and differential- eosinophilia,
  anaemia, thrombocytopenia

31
Screening Examination

• Rapid tests, e.g. Immunochromographic tests
  (ICT)-often used for initial screening for
  malaria, Bancroftian filariasis, (dengue), etc
• Serological investigations, e.g. schistosomiasis,
  filariasis
• Blood films for malaria
• HIV/STI serology
• TB screening-useful if you can compare with
  pre-travel

32
Does the traveler have diarrhea?

• Most travelers diarrhea is brief, self-limiting
  and non-inflammatory (about 4 days in duration)
• About 20 of travelers have fever and/or bloody
  diarrhea
• Enterotoxigenic Escherichia Coli is probably the
  most frequent pathogen in about 40-75 of cases

33
Travelers diarrhea

• Inflammatory diarrhea may be caused by
  Campylobacter, Shigella or Salmonella infection
• Fever, cramping abdominal pain, pus and/or blood
  in the stool
• Quinolone antibiotics often employed (some
  resistance)
• Remember amoebic dysentery and giardiasis

34
Travelers diarrhea

• Persistent diarrhea may be giardiasis, which may
  need treatment with tinidazole or metronidazole
• Chronic diarrhea may need further investigation
  and referral

35
Does the traveler have fever?

• Possible serious infectious disease causes in
  travelers returning from tropical regions
• Malaria-great mimicker
• Hepatitis A
• Enteric fever (incl typhoid)
• Dengue fever
• Others

36
Has the traveler been injured abroad?

• Need to document extent of injuries
• Are they covered by any insurance or
  superannuation policy?
• Arrange for any further treatment and follow-up
• Liaise with airlines if further travel required
• Arrange for assessment for rehabilitation as
  necessary

37
Post-Travel Consultation

• It is important to elicit a history of travel.
• Many short term travelers will present with
  illness when they get back, following the
  incubation period.
• Investigation and management of some post-travel
  illnesses will be urgent because they are life
  threatening and/or a threat to public health.