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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
Travel Health for the Globetrotting Student

Gary W. Brunette, MD, MS

Travelers’ Health Team

Centers for Disease Control and Prevention

outline
Outline
  • Travel Patterns
  • Infectious Disease Risks
  • Other Risks to the Traveler
  • Traveler Assessment
  • Itinerary Review
  • Sources of Information
  • Travel Vaccines
  • Travel Medications
  • Counseling
u s residents traveling abroad
U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico

travelers health risks
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; 156:84-91

deaths related to international travel
Deaths Related to International Travel

N = 2463

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

injury deaths and international travel
Injury Deaths and International Travel

N = 601

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

infectious disease risks to the traveler
Malaria

Diarrhea

Leishmaniasis

Rabies

Dengue

Meningococcal Meningitis

Schistosomiasis

Tuberculosis

Leptospirosis

Polio

Yellow Fever

Measles

JEV

Infectious Disease Risks to the Traveler

ETC.

malaria
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
rabies
Rabies
  • 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
polio
Polio
  • Viral infection
  • Acute onset flaccid paralysis
  • Transmitted via fecal-oral route or pharyngeal spread
  • High transmission areas are India, Pakistan, Afghanistan, Nigeria, Niger.
yellow fever
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
other health risks to the traveler
Other Health Risks to the Traveler
  • Accidental injury
  • Animal bites, stings and envenomations
  • Crime and assault
  • Environmental hazards
  • Deep vein thrombosis (DVT)
  • Jet lag
deep vein thrombosis dvt
Deep Vein Thrombosis (DVT)
  • 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
measures to prevent dvts
Measures to Prevent DVTs
  • Regular activity
    • exercises: moving ankle and knee joints
    • standing and short walks
  • Loose fitting clothing
jet lag
Jet Lag
  • 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
measures to prevent jet lag
Measures to Prevent Jet Lag
  • 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
the pre travel medical visit
The Pre-Travel Medical Visit
  • Important to see a medical provider
    • travel medicine specialist
  • 4 – 6 weeks before departure
  • Risk Assessment
  • Risk Management
    • Immunizations
    • Medications
    • Counseling
the patient medical issues
The Patient: Medical Issues
  • Age-specific issues
  • Underlying illness, immunosuppression
  • Systems review
  • Medical history
  • Medication use
  • Vaccination history
  • Allergies
  • Contraindications to vaccines and medications
travel itinerary
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
travel health resources
Travel Health Resources
  • 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
destination pages
Destination Pages
  • Country-specific pages
immunizations for adult travelers
Routine immunizations

Required immunizations for travel

Recommended immunizations for travel

Immunizations for Adult Travelers
routine immunizations
Routine Immunizations
  • Diphtheria*
  • Tetanus*
  • Pertussis*
  • Measles +
  • Mumps+
  • Rubella +
  • Varicella
  • Pneumococcus
  • Influenza

* Td or Tdap

+ MMR

required immunizations for travel
Required Immunizations for Travel
  • Yellow Fever
  • Meningococcal
recommended immunizations for travel
Recommended Immunizations for Travel
  • Hepatitis A
  • Hepatitis B
  • Typhoid
  • Japanese encephalitis
  • Polio
  • Rabies
travel medications prophylaxis self treatment
Travel Medications:Prophylaxis & Self Treatment
  • Malaria
    • chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine
  • Diarrhea
    • quinolone, azithromycin
  • Altitude
    • acetazolamide
  • Motion sickness
    • scopolamine, dimenhydrinate (Dramamine)
patient counseling
Patient Counseling
  • Sufficient time for patient education
  • Tailored to suit traveler
  • Fitness for travel
    • Understanding impact on existing conditions
    • Advisability of destinations
travel preparation
Travel Preparation
  • Travel health insurance
    • Medical care
    • Hospitalization
    • Evacuation
  • Obtaining medical care abroad
  • Awareness of travel notices
environmental precautions
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
food and water precautions
Food and Water Precautions
  • Bottled water
  • Selection of foods
    • well-cooked and hot
  • Avoidance of
    • salads, raw vegetables
    • unpasteurized dairy products
    • street vendors
    • ice
vector precautions
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
bloodborne and std precautions
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
animal precautions
Animal Precautions
  • Animal avoidance
  • Rabies
    • Specific animal threats
    • Medical evaluation of bites/scratches
    • Post exposure immunization and immunoglobulin
  • Envenomations
    • Snakes, scorpions, spiders
    • Maritime animals
injury and crime
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
travel emergency kit
Travel Emergency 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
post travel care
Post-Travel Care
  • Post-travel checkup
    • Long term travelers
    • Adventure travelers
    • Expatriates in developing world
  • Post-travel care
    • Fever, chills, sweats
    • Persistent diarrhea
    • Weight loss
student travel medicine
Student Travel Medicine
  • Models
    • In-house medical departments
    • Local public health clinics
    • Local clinics
  • Minimum services:
    • Travel immunizations
    • Travel medications
    • Travel health counseling
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