Introduction to Travel Medicine

1
Introduction toTravel Medicine
2
Travel and Tourism

• Large and growing industry
• More than 500 millions persons annually cross
  international borders on commercial airplanes
  (early 90s)
• Pleasure, business, study etc
• Short term travelers, repeated visit, reside or
  prolonged periods
• Risk of morbidity and mortality

3
International Travel
4
Travel and Tourism

• Transportations
• Accommodation
• Food and beverages
• Handicrafts, gifts
• Others related industry

5
What might happened to travelers

• Infections
• Accidents
• Disasters

6
Travelers Health Risks

• Of 100,000 travelers to a developing country for
  1 month
• 50,000 will develop some health problem
• 8,000 will see a physician
• 5,000 will be confined to bed
• 1,100 will be incapacitated in their work
• 300 will be admitted to hospital
• 50 will be air evacuated
• 1 will die
• Steffen R et al. J Infect Dis 1987 15684-91

7
Infectious Disease Risks to the Traveler

• Schistosomiasis
• Tuberculosis
• Leptospirosis
• Polio
• Yellow Fever
• Measles
• JEV

• Malaria
• Diarrhea
• Leishmaniasis
• Rabies
• Dengue
• Meningococcal Meningitis

ETC.
8
Injury Deaths and International Travel
N 601
Hargarten S et al, Ann Emerg Med, 1991. 20622-626
9
Essential questions to assess predisposing risks
and host risk factors

• What is your destination(s) state countries,
  city/resort/off-the-tourist-trail, itinerary
• What is the purpose of your visit
  tourism/business or other professional visit
  (specify)/visit (to relatives/expatriates), other
  reasons (military, airline crew, adoption, etc.)

10
Essential questions to assess predisposing risks
and host risk factors

• What standard of hygiene do you expect throughout
  your visit high (e.g., five-star hotels)/low
  (e.g., low budget travel)
• Are you planning any special activities e.g.
  high altitude trekking, diving, hunting, camping,
  etc.
• What is your planned date of departure?
• How long do you intend to stay abroad?

11
Potential travelers should also answer at least
the following set of questions on their health
status and medical history

• Do you currently use any medication? If yes,
  which ones?
• Are you currently unwell?
• Do you feel feverish? If yes, do you know what
  your temperature is?
• Do you suffer from any chronic illness If yes,
  which ones?
• Are you allergic to eggs or medication? If yes,
  describe.

12
Travel Notices Announcements
13
The Patient Medical Issues

• Age-specific issues
• Underlying illness, immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and medications

14
Potential travelers should also answer at least
the following set of questions on their health
status and medical history

• Are you pregnant or breast-feeding? Provide
  details
• Have you ever had seizures? Provide details
• Have you ever had psychiatric or psychological
  problems? Provide details
• Have you ever had jaundice or hepatitis? Provide
  details
• Are you or anybody in your household infected by
  HIV? Do you have any other immunodeficiency
  illness? Provide details

15
The Patient Other Issues

• Reproductive
• Pregnant
• Breastfeeding
• Preconception
• Risk-taking behaviors

16
Immunizations to Consider for Adult Travelers

• Routine
• Diphtheria
• Tetanus
• Pertussis
• Measles
• Mumps
• Rubella
• Varicella
• Pneumococcus
• Influenza

• Travel related
• Hepatitis A
• Hepatitis B
• Typhoid
• Rabies
• Meningococcal disease
• Polio
• Japanese encephalitis
• Yellow Fever

Td or Tdap MMR
17
Vaccine for Adult Travelers

• Routine
• Updated as needed diphtheria-tetanus,
  measles-mumps-rubella
• Routine for defined groups influenza, hepatitis
  B, pneumococcal, varicella
• Required by some countries
• Yellow fever
• Meningococcal

18
Vaccine for Adult Travelers

• Recommended for travelers to developing countries
• Standard for travelers to developing countries
  hepatitis A, typhoid, poliovirus
• Special for travelers to developing countries
  cholera, hepatitis B, meningococcal, Japanese B
  encephalitis, plague, rabies

19
(No Transcript)
20
Travel MedicationsProphylaxis Self Treatment

• Malaria
• chloroquine, atovaquone/proguanil (Malarone),
  doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
• quinolone
• Altitude
• acetazolamide
• Motion sickness
• scopolamine, dimenhydrinate (Dramamine)

21
Sources and Acquisition of Infection during Travel

• Food and drinks
• Soil and water
• Animals and arthropods
• Other human
• Air travel
• Infections acquired en route
• Infections acquired in temperate and
  industrialized area

22
Sources and Acquisition of Infection during Travel

• Food and drinks
• Travelers diarrhea
• Hepatitis A
• Typhoid fever
• Cholera
• Soil and Water
• Enteric infections
• Soil associated fungus (Histoplasma capsulatum)
• Leptospirosis

23
Sources and Acquisition of Infection during Travel

• Animals and arthropods
• Rabies
• Hantavirus
• Dengue
• Malaria
• Other Human
• STD
• Airborne infections

24
Sources and Acquisition of Infection during Travel

• Air Travel
• Venous thrombosis and pulmonary emboli
• Influenza, Tuberculosis
• Infections acquired en route
• Influenza, rubella
• Infections acquired in temperate and
  industrialized area
• Colorado Tick fever
• HFRS
• Murray Valley encephalitis

25
Environmental Precautions

• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
• dehydration, heat stroke
• hypothermia, frostbite
• Altitude
• Water recreation
• Drowning, boating diving accidents
• Risk of schistosomiasis or leptospirosis
• Biological and chemical contamination

26
Vector Precautions

• Covering exposed skin
• Insect repellent containing DEET 25 50
• Treatment of outer clothing with permethrin
• Use of permethrin-impregnated bed net
• Use of insect screens over open windows
• Air conditioned rooms
• Use of aerosol insecticide indoors
• Use of pyrethroid coils outdoors
• Inspection for ticks

27
Food and Water Precautions

• Bottled water
• Selection of foods
• well-cooked and hot
• Avoidance of
• salads, raw vegetables
• unpasteurized dairy products
• street vendors
• ice

28
Bloodborne and STD Precautions

• Prevalence of
• STDs
• Hepatitis B
• Hepatitis C
• HIV
• Unprotected sexual activity
• Commercial sex workers
• Tattooing and body piercing
• Auto accidents
• Blood products
• Dental and surgical procedures

29
Animal Precautions

• Animal avoidance
• Rabies
• Specific animal threats
• Medical evaluation of bites/scratches
• Post exposure immunization and immunoglobulin
• Envenomations
• Snakes, scorpions, spiders
• Maritime animals

30
Deaths Related to International Travel
N 2463
Hargarten S et al, Ann Emerg Med, 1991. 20622-626
31
Key concepts Travel-related illness and Death

• Injury are an important cause of travel related
  death
• Most infections acquired during travel to
  tropical and developing countries are cause by
  pathogens that are widely distributed
• Risk of infection from exposure to many widely
  distributed pathogens )e.g. hepatitis A, typhoid
  fever, salmonellosis) is substantially higher
  during travel to developing countries than during
  life at home

32
Key concepts Travel-related illness and Death

• Unusual infections can be found in temperate and
  industrialized countries, including United States
• Recreational activities ( swimming, hiking)
  facilitate exposure to many pathogens
• Activities that pose no risk at home may be
  hazardous in other environment (e.g. eating raw
  foods, swimming in fresh water, going barefooted,
  sustaining mosquito bites, petting stray animals)

33
Key concepts Travel-related illness and Death

• Expensive hotels and posh restaurants are no
  guarantee of safe food and beverages
• Disease during and immediately after travel may
  be unrelated to exposures during travel (acute
  appendicitis, pyelonephritis)
• Infections can be acquired en route and on brief
  layover
• Travel-associated diseases include non infectious
  diseases (pulmonary emboli related to prolonged
  seating, drug reactions0

34
Have a Nice Vacation