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PostTravel Health Consultation

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46 Hospital admissions (0.2%) 10 Aeromedical evacuations (0.05 ... Most travelers' diarrhea is brief, self-limiting and non-inflammatory (about 4 days in duration) ... – PowerPoint PPT presentation

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Title: 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.
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