TRAVEL MEDICINE...

Dr. Gatoet Ismanoe, SpPD-KPTI, FINASIM

Division of Tropical and Infectious Diseases Department of Internal Medicine Saiful Anwar Teaching Hospital Brawijaya School of Medicine

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)

What is Travel medicine ?

16th century: Smallpox and Measles devastating Native American populations

The Grand-Saint-Antoine & The 1720 Great Plague of Marseille

Speed & Growth in International Travel

+ 6% per year 80 million persons from industrialized nations travel to the developing world each year >200 million persons now reside outside their country of birth

With 1 billion people crossing international borders each year, there is no where in the world from which we are remote and no one from whom we are disconnected

Travellers from industrialised areas to developing areas 1999 (WTO)

2.8
USA / Canada 35.2 million

2.4

3.6

Europe 25.0 million

4.6 1.6

6.1
Japan 11.4 mio

2.3

19

7.8

6.8
2.5 1.9

1.3

4.8 2.6
AUS / NZ 3.3 million

1.2

n million travelers 0.2-1 million travelers

Total:~ 80 million travelers

Travel & Health

Causes of Mortality in Travelers

Deaths Related to International Travel

Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

10

Infectious Disease Risks to the Traveler

Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis

Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV

ETC.
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Injury Deaths and International Travel

Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other

N = 601

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

12

Other Risks to the Traveler

Accidental injury Environmental hazards Crime and assault Psychiatric problems Animal bites, stings and envenomations Dermatologic disorders Altitude . ETC.

13

The Continuum of Travel Medicine

Pre-Travel
Preventive Medicine

Visitors

Contingency

During Travel

Planning

Treatment & Rehabilitation

Post-Travel

Travel Itinerary

Full itinerary
Dates, duration, stopovers Seasonal considerations

Styles of travel
Rural vs. urban Budget vs. luxury

Accommodation
Hotel vs. camping

Activities
Business vs. tourism Adventure, safari Missionary/Humanitarian/NGO
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The Patient: Medical Issues

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

17

The Patient: Other Issues

Reproductive
Pregnant Breastfeeding Preconception

Risk-taking behaviors

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PRE-TRAVEL HEALTH ADVICE

Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel Prescribe appropriate chemoprophylactic and self-treatment medications

VACCINATE

Always National schedule (incl Hep B) Often hepatitis A (non-immune) Sometimes Japanese encephalitis meningococcal disease (Mecca) polio rabies typhoid yellow fever (WHO) Older age gp Influenza (Others) Pneumococcal disease
(adapted* from NZPHR; 1996;3(8):57-59)

IMMUNISE AGAINST
Mandatory

vaccinations (WHO) National schedule vaccinationsupdate routine immunizations Vaccinations for most or all travelers Vaccinations for travelers at special risk+

Mandatory vaccines

Travelers to/from Yellow fever endemic areas Travelers going to Mecca for the Hajj

Vaccinations for most travelers

Diseases associated with poor hygiene & sanitation

ETEC? Hepatitis A Typhoid

PRESCRIBE
(Script/Drs letter/medialert bracelet)

regular medication medical kit (first aid)* Sometimes antimalarial medication diarrheal self-treatment condoms/PEP Other hygiene pdts

(NZPHR; 1996;3(8):57-59)

Always

Immunizations for Adult Travelers

1.

Routine immunizations Required immunizations for travel Recommended immunizations for travel

2.

3.

Routine Immunizations

Diphtheria Tetanus Pertussis Measles Mumps Rubella Varicella Pneumococcus * Td or Tdap Influenza + MMR Human papillomavirus (HPV)

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

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Travel Medications: Prophylaxis & Self Treatment

Malaria
chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine

Diarrhea
quinolone, azithromycin

Altitude
acetazolamide

Motion sickness
scopolamine, dimenhydrinate (Dramamine)
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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
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Food and Water Precautions

Bottled water Selection of foods

well-cooked and hot

Avoidance of
salads, raw vegetables unpasteurized dairy products street vendors ice
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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
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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
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Animal Precautions
Animal avoidance Rabies

Specific animal threats Medical evaluation of bites/scratches Post exposure immunization and immunoglobulin

Envenomations
Snakes, scorpions, spiders Maritime animals

33

Injury and Crime

Vehicles
Risk of road and pedestrian accidents Night travel Seat belts and car seats

Use of drugs and alcohol Understanding local crime risks

Scam awareness Situational awareness Location avoidance
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Malaria
Mosquito-borne disease Parasite: Plasmodium May lead to severe complications or death ~500 million cases/year worldwide Risk in over 100 countries Prophylactic medication before, during, and after travel

Malaria Risk Areas

Yellow Fever

Mosquito-borne viral infection

Aedes aegypti

Varying severity:
influenza-like syndrome to severe hepatitis and hemorrhagic fever

200,000 YF infections cause 30,000 deaths per year

Distribution of Yellow Fever

Japanese Encephalitis
Flavivirus transmitted via bite of Culex mosquito 50,000 cases and 15,000 deaths yearly Supportive care only Up to 50% of survivors have significant neurologic sequelae

Distribution of Japanese Encephalitis

Dengue Fever
Mosquito-borne flavivirus endemic in most tropical areas of the world No vaccine and no medication for dengue Illness usually mild; it can be severe and cause dengue hemorrhagic (bleeding) fever (DHF)

Distribution of Dengue

Chikungunya Fever
Mosquito-borne disease - primary vector is aedes aegypti Mainly occurs in areas of Africa and Asia Symptoms can include sudden fever, chills, headache, nausea, vomiting, joint pain with or without swelling, lower back pain, and a rash. No specific drug treatment People usually recover on their own; fatalities are rare

Hepatitis A

Viral infection transmitted via fecal-oral route

Contaminated food and water Person to person

Asymptomatic, or ranges in severity from a mild illness to severely disabling disease lasting months Treatment is supportive

Distribution of Hepatitis A

Hepatitis B

Viral infection transmitted via bloodborne route

Sexual contact Transfusions, surgical or dental procedures Shared injection needles

Ranges in severity from no symptoms to fulminant hepatitis Treatment is supportive Risk determined by behavior and prevalence of chronic infections at destination

Distribution of Hepatitis B

Typhoid
Acute, life-threatening febrile illness caused by Salmonella enterica serotype Typhi Transmission via fecal-oral route, usually contaminated food or water Chronic asymptomatic carrier Worldwide: 22 million cases and 200,000 related deaths each year

Distribution of Typhoid

Source: sanofi pasteur MSD

Travelers Diarrhea
> 50% of travelers away from home even for only 2 weeks develop TD ~ 40% will have to alter itineraries ~ 20% will be confined to bed

Polio
Viral infection Acute onset flaccid paralysis Transmitted via fecal-oral route or pharyngeal spread High transmission areas are India, Pakistan, Afghanistan, Nigeria

Polio Risk Areas

WHO/POLIO database, as of Sept. 2007

Meningococcal Meningitis
Bacterial

infection transmitted via the respiratory route Outbreaks in Africa during dry season (December to June) Associated with crowded conditions

Distribution of Meningococcal Disease (Meningitis Belt)

Rabies
Acute

viral encephalomyelitis Invariably fatal Humans contract rabies by being bitten or occasionally by being scratched by an infected animal 55,000 deaths per year

Distribution of Rabies

Schistosomiasi s

Parasite found in some areas of tropical S. America, Africa, and the Far East Second only to malaria in terms of morbidity over 200 million infected Transmitted while swimming in fresh water lakes, streams, rivers Most will have no symptoms; if exposed, requires testing on return, and then treatment if infected Missionaries and VFRs more likely to be infected*
*Nicolls D & GeoSentinal, ISTM 2005

Geographic Distribution of Schistosomiasis

Environmental Precautions
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

Safety Precautions
Wear a helmet Wear seatbelts Drink responsibly Stay alert in crowds Follow local laws and customs Understand local crime risks

Travel Health Kit

Copy of medical records and extra pair of glasses Prescription medications Over-the counter medicines and supplies Analgesics Decongestant, cold medicine, cough suppressant Antibiotic/antifungal/hydrocortisone creams Pepto-Bismol tablets, antacid Band-Aids, gauze bandages, tape, Ace wraps Insect repellant, sunscreen, lip balm Tweezers, scissors, thermometer

THANK YOU......