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Introduction to travel medicine. Dr Peter A Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Australia, & Visiting Professor, School of Public Health, University of the Witwatersrand. About the author.

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introduction to travel medicine

Introduction to travel medicine

Dr Peter A Leggat

MD, PhD, DrPH, FAFPHM, FACTM, FFTM

Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Australia, &

Visiting Professor, School of Public Health,

University of the Witwatersrand

about the author
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.
objectives
Objectives
  • In this session
    • Define travel medicine
    • Examine some figures for global and local migration
    • Hopefully gain an appreciation of the importance of giving travel health advice
    • Discuss some of components that are needed in order to give correct advice to traveller
what is travel medicine
What is travel medicine?

It is a science and an art

what is travel medicine5
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)
slide6
“the art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenience”

(Steffen, 1994)

challenge of travel medicine
Challenge of travel medicine
  • Sea of global migration of people
    • More people travelling
  • People travelling further a field
  • Rapid movement of travellers
slide8

Travellers from industrialised areas to developing areas 1999 (WTO)

2.4

2.8

6.1

Europe

25.0 million

USA / Canada

35.2 million

4.6

Japan

11.4 mio

3.6

7.8

1.6

19

6.8

2.3

4.8

1.3

2.5

1.9

2.6

1.2

AUS / NZ

3.3 million

n million travelers

0.2-1 million travelers

Total:

~ 80 million travelers

globalization of health and safety
Globalization of health and safety

Commerce and Health

  • Affects
    • Health of local populations
    • Health determinants
    • Safety and security
  • Results in
    • Global impacts
    • Emerging and re-emerging infectious disease

Influenza

SARS

Terrorism

Tsunami

Pathogens travel as fast as transportation: borders are not respected

the importance of travel health measures
The Importance of Travel Health Measures
  • 100,000 travelers to the developing world for 1 month…..
    • 50,000 will become ill
    • 8,000 will see a physician
    • 5,000 will stay in bed
    • 1 will die

Steffen, 1994

the importance of travel health measures12
The Importance of Travel Health Measures
  • Per 100,000 travellers that have travel insurance …..
    • 8000 will make a claim (8%)
    • 2000 will use emergency assistance (2%)
      • 400 ER or clinic referrals (0.4%)
      • 200 Hospital admissions (0.2%)
      • 50 Aeromedical evacuations (0.05%)

Leggat et al. Travel Med Inf Dis 2005;3:9-17.

the importance of travel health measures13
The Importance of Travel Health Measures
  • Mortality
    • Cardiovascular Disease (50 to 70%)
    • Accidents/Trauma (20-25%), esp. MVAs
    • Infectious diseases (2.8-4%)

(Reid and Cossar, BMBull. 1993;257-268; Prociv, MJA. 1995;163:27-30; Baker et al., PHR 1992;107:155-159; MacPherson et al, JTM. 2000; 2000:227-233; Steffen, Trans RSTM&H 1991;85: 156-162 )

travel medicine is a continuum
Travel medicine is a continuum
  • Travellers do get sick or injured abroad or when they come back
  • The commitment to travel health can therefore be regarded as a continuum
slide15

The Continuum of Travel Medicine

Preventive Medicine

Pre-Travel

Visitors

During Travel

Contingency Planning

Post-Travel

Treatment & Rehabilitation

travel health advice needs information

Travel Health Advice needs Information

“Information is power in Travel Medicine”

travel health advice needs training

Travel Health Advice needsTraining

Training gives you a framework for using that information

travel health advice needs experience

Travel Health Advice needsExperience

Experience helps put the information and training in perspective

travel health advice needs to be documented

Travel Health Advice needsto be Documented

Documentation is important for Quality assurance and reinforcing travel health advice

travel health advice needs travellers

Travel Health Advice needsTravellers

Marketing is essential in travel health, whether in general practice or in specialist travel clinics

giving the correct advice to travellers
Giving the correct advice to travellers
  • Giving the correct health advice to travellers needs:
    • Information
    • Training
    • Experience
    • Documentation
    • Travellers
travel health advice needs information23
Travel Health Advice needs Information
  • Guidelines
  • Policies
  • Textbooks, including an World Atlas
  • Journals
  • Professional organisations
  • Staff/colleagues
  • Electronic Databases
  • WWW
international guidelines
International Guidelines
  • WHO
  • International Health Regulations
  • International Travel and Health
    • www.who.int/ith
    • Yellow fever requirements
national guidelines
“National Guidelines”
  • Travel Health Guidelines
  • Malaria Guidelines
  • Immunisation Guidelines
  • Antibiotic Guidelines
  • Journals
  • Seminars
you need access to www sites
You need access to www-sites
  • International Society of Travel Medicine
    • www.istm.org
  • US Centers for Disease Control and Prevention
    • www.cdc.gov/travel
    • US Guidelines
    • Similar government sites for UK and Canada
  • World Health Organization
    • http://www.who.int/ith
    • The former “yellow book” is now published as the “blue book” online
it is very useful to have access to a multicountry travel medical advisory service
It is very useful to have access to a multicountry travel medical advisory service
  • CDC Travel Health, see http://www.cdc.gov/travel/index.htm
  • MASTA, see http://www.masta.org
  • TRAVAX, see http://www.travax.nhs.uk
  • Shorelands, see http://www.tripprep.com
professional organisations
Professional Organisations
  • Local professional groups

and

  • THE ISTM
slide29
ISTM
  • International Society of Travel Medicine
    • International Network
      • International Clinic Directory
      • Useful for marketing/recognition
    • www.istm.org
    • Listserve
      • Outbreak alerts
    • Journal
    • Geosentinel
    • Certificate of Travel Health
    • Great Conferences!!
journals
Journals

Weighing the Evidence

weighing the evidence
Weighing the evidence
  • “Travel medicine prevention should be based on epidemiological data.” Robert Steffen, 1991
  • What are the likely risks of a person travelling to particular destinations?
  • What are the likely benefits of intervention?
giving the correct advice to travellers32
Giving the correct advice to travellers
  • Giving the correct health advice to travellers needs:
    • Information
    • Training
    • Experience
    • Documentation
    • Travellers
pre travel health advice needs training
Pre-Travel Health Advice needs Training
  • Helps give structure and consistency
    • Provides a framework for practice
    • Discusses evidence for practice
  • Policy and Procedures Manual
    • Consistent approach to travel health
part of the commitment is to also have a consistent and structured approach to travel health advice
Part of the commitment is to also have a consistent and structured approach to travel health advice
  • WHO Checklist (www.who.int/ith)
    • Information on local conditions
    • Prevention
    • Accident avoidance
    • Medical and dental check-up
  • NZPHR-Prevention
    • Vaccinations
    • Health Advice
    • Prescription

Source: http://www.who.int/ith

vaccinate ihc
VACCINATE (IHC)
  • Always National schedule
  • Often hepatitis A
  • Sometimes Japanese encephalitis meningococcal disease polio rabies yellow fever Influenza Pneumococcal disease

Other vaccines (adapted* from NZPHR; 1996;3(8):57-59)

advise and discuss
ADVISE AND DISCUSS
  • Insects repellents, nets, permethrin
  • Ingestions care with food and water diet/teeth (including airlines/jetlag/DVT)*
  • Indiscretions STI’s, HIV
  • Injuries accident avoidance, personal safety
  • Immersion schistosomiasis
  • Insurance* health and travel insurance* finding medical assistance o/s* (adapted* from NZPHR; 1996;3(8):57-59)
prescribe script dr s letter bracelet
PRESCRIBE(Script/Dr’s letter/bracelet)
  • Always regular medication medical kit (first aid)*
  • Sometimes antimalarial medication diarrheal self-treatment condoms (NZPHR; 1996;3(8):57-59)
courses
Courses
  • Increasing number of travel medicine academic programs globally (see educational opportunities at www.istm.org)
  • Get relevant endorsements
    • Aviation medical examiner
    • Diving medical certification (SPUMS)
    • Certificate of Travel Health (ISTM)
    • Occupational health training
courses39
Courses
  • Weighing the evidence
  • Contributing to the discipline through research (also through GeoSentinel)
  • Despite training, still need to keep up to date and to keep seeing travellers to help build experience
giving the correct advice to travellers40
Giving the correct advice to travellers
  • Giving the correct health advice to travellers needs:
    • Information
    • Training
    • Experience
    • Documentation
    • Travellers
travel health advice needs experience41
Travel health advice needs experience
  • Let’s just do it!
  • Affiliation with a group with experience can be useful
    • Travel clinic group
    • Travel medical advisory group (eg MASTA, Worldwise, Travax etc)
    • University
  • Those NZ GPs that were interested in travel medicine were significantly more likely to have had tropical medicine/developing country experience (Leggat et al. JTM 1999; 7: 55-58.)
travel is part of experience
Travel is part of experience
  • Professionals working in travel medicine need to travel and have that personal experience to communicate to travellers
  • Helps to put travel health advice in context and helps to build a positive travel experience
giving the correct advice to travellers44
Giving the correct advice to travellers
  • Giving the correct health advice to travellers needs:
    • Information
    • Training
    • Experience
    • Documentation
    • Travellers
travel health advice needs to be documented45
Travel health advice needs to be documented
  • Standardised forms/questionnaires
  • Informed consent
  • International Health Certificate/Vaccination record
  • Doctor’s letter/copy of prescription/medialert bracelet
  • Written advice/videos/Books/Health advisory documents
correct advice is even better if the advice is actually followed by the traveller
Correct advice is even better if the advice is actually followed by the traveller
  • Documentation
  • Follow-up
  • Use staff resources
  • Reinforce health advice
giving the correct advice to travellers47
Giving the correct advice to travellers
  • Giving the correct health advice to travellers needs:
    • Information
    • Training
    • Experience
    • Documentation
    • Travellers
travel health advice needs travellers48
Travel Health Advice needs Travellers
  • Inform own patients concerning the need for seeking travel health advice, and seeking this advice early
  • Market travel health advice
    • Direct, if possible
    • Join group/affiliate
    • Links/promotion with traveller groups, travel agents, travel insurance, consulates etc
    • Join travellers health networks, such as ISTM, IAMAT etc
take home points
Take home points
  • More people are traveling to more destinations, becoming exposed to the health and safety of that destination and also having the potential to impact on the health and safety of that destination, especially through emerging infectious disease
  • Travelers’ health is a continuum and includes the pre-travel health, contingency planning while abroad and caring the traveler after travel
  • Travel health advice needs information (including a capacity to undertake a risk assessment), training, experience, documentation and travelers
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