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Travel Health for the Globetrotting Student Gary W. Brunette, MD, MS Travelers’ Health Team Centers for Disease Control and Prevention Outline Travel Patterns Infectious Disease Risks Other Risks to the Traveler Traveler Assessment Itinerary Review Sources of Information

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Travel health for the globetrotting student l.jpg
Travel Health for the Globetrotting Student

Gary W. Brunette, MD, MS

Travelers’ Health Team

Centers for Disease Control and Prevention


Outline l.jpg
Outline

  • Travel Patterns

  • Infectious Disease Risks

  • Other Risks to the Traveler

  • Traveler Assessment

  • Itinerary Review

  • Sources of Information

  • Travel Vaccines

  • Travel Medications

  • Counseling


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U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico




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Travelers’ Health Risks receiving credit for study abroad)

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; 156:84-91


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Deaths Related to International Travel receiving credit for study abroad)

N = 2463

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


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Injury Deaths and International Travel receiving credit for study abroad)

N = 601

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


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Malaria receiving credit for study abroad)

Diarrhea

Leishmaniasis

Rabies

Dengue

Meningococcal Meningitis

Schistosomiasis

Tuberculosis

Leptospirosis

Polio

Yellow Fever

Measles

JEV

Infectious Disease Risks to the Traveler

ETC.


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Malaria receiving credit for study abroad)

  • 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


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Malaria Risk Areas receiving credit for study abroad)


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Rabies receiving credit for study abroad)

  • Acute viral encephalomyelitis

  • Invariably fatal

  • Humans contract rabies by being bitten or occasionally by being scratched by an infected animal.

  • 40,000 deaths per year


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Distribution of Rabies receiving credit for study abroad)


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Polio receiving credit for study abroad)

  • Viral infection

  • Acute onset flaccid paralysis

  • Transmitted via fecal-oral route or pharyngeal spread

  • High transmission areas are India, Pakistan, Afghanistan, Nigeria, Niger.


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Polio Risk Areas receiving credit for study abroad)


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Yellow Fever receiving credit for study abroad)

  • 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


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Distribution of Yellow Fever receiving credit for study abroad)


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Other Health Risks to the Traveler receiving credit for study abroad)

  • Accidental injury

  • Animal bites, stings and envenomations

  • Crime and assault

  • Environmental hazards

  • Deep vein thrombosis (DVT)

  • Jet lag


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Deep Vein Thrombosis (DVT) receiving credit for study abroad)

  • Thrombus (blood clot) within a deep vein, commonly in the thigh or calf

    • tenderness/redness plus pain & swelling in affected area

    • potential risk of pulmonary embolism

  • WRIGHT Project (2007):

    • x2 risk associated with flights >4 hrs

    • result of immobility and restrictions in blood flow


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Measures to Prevent DVTs receiving credit for study abroad)

  • Regular activity

    • exercises: moving ankle and knee joints

    • standing and short walks

  • Loose fitting clothing


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Jet Lag receiving credit for study abroad)

  • Physiological condition due to alterations to the circadian rhythm.

  • Recovery rate of "one day per time zone"

  • Symptoms can vary widely:

    • Disturbed sleep (insomnia, early waking, excessive sleepiness)

    • Irritability, mild depression

    • Difficulty concentrating

    • Headaches

    • Muscle soreness

    • Stomach problems, constipation or diarrhea


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Measures to Prevent Jet Lag receiving credit for study abroad)

  • Arrive early, give your body time to adjust

  • Adequate sleep and rest before trip

  • Drink plenty of fluids and eat lightly

  • Avoid alcohol and caffeine

  • Adjust to destination cycles early:

    • sleep if it's night time at destination

    • stay awake if it's day time at destination

  • At destination, try not to sleep until night time


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The Pre-Travel Medical Visit receiving credit for study abroad)

  • Important to see a medical provider

    • travel medicine specialist

  • 4 – 6 weeks before departure

  • Risk Assessment

  • Risk Management

    • Immunizations

    • Medications

    • Counseling


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The Patient: Medical Issues receiving credit for study abroad)

  • Age-specific issues

  • Underlying illness, immunosuppression

  • Systems review

  • Medical history

  • Medication use

  • Vaccination history

  • Allergies

  • Contraindications to vaccines and medications


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Travel Itinerary receiving credit for study abroad)

  • 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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Travel Health Resources receiving credit for study abroad)

  • CDC Travelers’ Health Website

    • www.cdc.gov/travel

  • Health Information for International Travel

    • CDC “Yellow Book”

  • World Health Organization

    • www.who.int/int

  • International Travel and Health

    • WHO “Green Book”

  • State Department

    • travel.state.gov

  • International Society of Travel Medicine

    • www.istm.org


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Travelers’ Health Website receiving credit for study abroad)www.cdc.gov/travel


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Travel Notices & Announcements receiving credit for study abroad)


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Destination Pages receiving credit for study abroad)

  • Country-specific pages


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Routine immunizations receiving credit for study abroad)

Required immunizations for travel

Recommended immunizations for travel

Immunizations for Adult Travelers


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Routine Immunizations receiving credit for study abroad)

  • Diphtheria*

  • Tetanus*

  • Pertussis*

  • Measles +

  • Mumps+

  • Rubella +

  • Varicella

  • Pneumococcus

  • Influenza

* Td or Tdap

+ MMR


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Required Immunizations for Travel receiving credit for study abroad)

  • Yellow Fever

  • Meningococcal


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Recommended Immunizations for Travel receiving credit for study abroad)

  • Hepatitis A

  • Hepatitis B

  • Typhoid

  • Japanese encephalitis

  • Polio

  • Rabies


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Travel Medications: receiving credit for study abroad)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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Patient Counseling receiving credit for study abroad)

  • Sufficient time for patient education

  • Tailored to suit traveler

  • Fitness for travel

    • Understanding impact on existing conditions

    • Advisability of destinations


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Travel Preparation receiving credit for study abroad)

  • Travel health insurance

    • Medical care

    • Hospitalization

    • Evacuation

  • Obtaining medical care abroad

  • Awareness of travel notices


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Environmental Precautions receiving credit for study abroad)

  • 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 receiving credit for study abroad)

  • 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 receiving credit for study abroad)

  • 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 receiving credit for study abroad)

  • 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 receiving credit for study abroad)

  • Animal avoidance

  • Rabies

    • Specific animal threats

    • Medical evaluation of bites/scratches

    • Post exposure immunization and immunoglobulin

  • Envenomations

    • Snakes, scorpions, spiders

    • Maritime animals


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Injury and Crime receiving credit for study abroad)

  • 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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Travel Emergency Kit receiving credit for study abroad)

  • 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


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Post-Travel Care receiving credit for study abroad)

  • Post-travel checkup

    • Long term travelers

    • Adventure travelers

    • Expatriates in developing world

  • Post-travel care

    • Fever, chills, sweats

    • Persistent diarrhea

    • Weight loss


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Student Travel Medicine receiving credit for study abroad)

  • Models

    • In-house medical departments

    • Local public health clinics

    • Local clinics

  • Minimum services:

    • Travel immunizations

    • Travel medications

    • Travel health counseling


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Questions? receiving credit for study abroad)


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