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HEALTH EVALUATION CASE SCENARIOS

HEALTH EVALUATION CASE SCENARIOS. PRESENTED BY M. ASSUNTA MARCOLONGO IAMAT JUNE 2008. CONSIDERATIONS. AFTER REVIEW OF VACCINATION REQUIREMENTS AND ADMINISTRATION OF NEEDED BOOSTERS AND TRAVEL VACCINES, WE MUST DISCUSS WITH THE TRAVELLER POTENTIAL DISEASES RISKS BASED ON

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HEALTH EVALUATION CASE SCENARIOS

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  1. HEALTH EVALUATIONCASE SCENARIOS PRESENTED BY M. ASSUNTA MARCOLONGO IAMAT JUNE 2008

  2. CONSIDERATIONS • AFTER REVIEW OF VACCINATION REQUIREMENTS AND ADMINISTRATION OF NEEDED BOOSTERS AND TRAVEL VACCINES, WE MUST DISCUSS WITH THE TRAVELLER POTENTIAL DISEASES RISKS BASED ON • HEALTH AND SANITARY CONDITIONS AT THE DESTINATION • TRAVEL TO URBAN OR RURAL AREAS • STYLE OF TRAVEL AND ACCOMMODATION: BUSINESS/BACKPACK • PURPOSE OF TRAVEL: BUSINESS, FAMILY/FRIENDS, ADVENTURE, ATTENDING SCHOOL, WORKING ASSIGNMENT • DURATION OF VISIT • CLIMATE AND ENVIRONMENT

  3. CONSIDERATIONS THE FOLLOWING DISEASE RISKS SHOULD BE CONSIDERED • DENGUE FEVER • CHIKUNGUNYA • LEPTOSPIROSIS • MALARIA • CHAGAS’ DISEASE • SCHISTOSOMIASIS • HIV AND SEXUALLY TRANSMITTED DISEASES • DIARRHEA, FOOD AND WATERBORNE DISEASES (HEPATITIS E, GIARDIASIS, ETC) • TUBERCULOSIS

  4. DENGUE FEVER • A FLAVIVIRUS INFECTION TRANSMITTED BY DAY TIME BITING Aedes aegypti AND Aedes albopictus MOSQUITOES MOSTLY IN URBAN AREAS OF SUBTROPICAL AND TROPICAL COUNTRIES • FOUR SEROTYPES (DEN 1, DEN 2, DEN 3, DEN 4) EACH GIVING SPECIFIC LIFELONG PROTECTION (NO CROSS PROTECTIVE IMMUNITY) • ALL SEROTYPES CAN CAUSE SEVERE AND FATAL DISEASE • THERE ARE GENETIC VARIATIONS WITHIN SEROTYPES, SOME ARE MORE VIRULENT • 100 MILLION CASES PER YEAR • 20 -100 IN TRAVELLERS TO THE U.S.

  5. DENGUE FEVER DATA FROM GEOSENTINEL: FEVER IN RETURNED TRAVELLERS ETIOLOGY CARIB. C.AM S.AM SSA SA SEA MALARIA <1 13 13 62 14 13 DENGUE 23 12 14 <1 14 32 RICKETTSIA 0 0 0 6 1 2 SALMONELLA 2 3 2 <1 14 3

  6. DENGUE FEVER CLASSICAL CLINICAL PICTURE • INCUBATION 4-7 DAYS (RANGE 3-14) • SUDDEN ONSET • FEVER LAST 5-7 DAYS ALSO KNOWN AS “BREAKBONE” FEVER • RASH MAY APPEAR 2-5 DAYS AFTER FEVER ONSET • BRADYCARDIA • HEPATOMEGALY • LYMPHADENOPATHY • HEMORRHAGIC MANIFESTATIONS IN 5-30 % OF CASES: - HEMATEMESIS AND MELAENA - PETECHIAE

  7. DENGUE FEVER DENGUE HEMORRHAGIC FEVER INCREASE IN OCCURRENCE 1956 – 1980 (25 YEARS) 715’238 (21’345 DEATH) 1986 - 1990 ( 5 YEARS) 1’263’321 (15’940 DEATH) ESTIMATED 500’000 HOSPITALIZATIONS/YEAR CONTRIBUTING FACTORS: • URBANIZATION • POPULATION GROWTH • INADEQUATE HOUSING AND POVERTY • INEFFECTIVE MOSQUITO CONTROLS AND INCREASE IN BREEDING SITES • GLOBAL WARMING • INCREASED TRAVEL ‘00

  8. DENGUE FEVER DENGUE HEMORRHAGIC FEVER • DEVELOPS RAPIDLY OVER A FEW HOURS • OFTEN NO FEVER • SPONTANEOUS BLEEDING, POSITIVE TOURNEQUET TEST • HEMOCONCENTRATION, ASCITIS, PLEURAL EFFUSION • INCREASED CAPILLARY PERMEABILITY LEADS TO PLASMA LEAKAGE LEADS TO SHOCK • RESOLVES WITH RAPID TREATMENT WITHIN 1-2 DAYS TREATMENT: - FLUID AND ELECTROLYTE BALANCE - ACETOMINOPHEN - AVOID ASA (ASPIRIN) - STEROIDS ARE NOT HELPFUL ‘00

  9. DENGUE FEVER Source: CDC, 2005-06

  10. DENGUE FEVER Source: CDC, 2005-06

  11. CHIKUNGUNYA • ALPHAVIRUS FIRST MENTIONED IN TANGANYIKA (TANZANIA) IN 1952 • TRANSMITTED BY THE SAME MOSQUITOES AS DENGUE FEVER: Aedes aegypti AND Aedes albopictus • OCCURRENCE: AFRICA, INDIAN SUBCONTINENT, INDIAN OCEAN ISLANDS, SOUTH EAST ASIA • REPORTS IN TRAVELLERS: 22 PATIENTS FROM INDIAN OCEAN ISLANDS, 205 CASES IMPORTED TO ITALY FROM INDIA DISEASE: MYALGIA, POLYARTHRALGIA AND ARTHRITIS (ALL JOINTS MAY BE AFFECTED MAY LAST FOR MONTHS TO YEARS DEATH IS RARE AND MOSTLY IN THE ELDERLY

  12. CHIKUNGUNYA SOURCE: EID/CDC 2007

  13. CHIKUNGUNYA SOURCE: EID/CDC 2007

  14. LEPTOSPIROSIS LEPTOSPIROSIS IS CAUSED BY LEPTOSPORA INTERROGANS (SPIROCHETES) • OCCURRENCE: WORLD-WIDE, ACQUIRED WHEN SWIMMING IN CONTAMINATED FRESH WATER BODIES (LAKES, PONDS, RIVERS) • HOST RESERVOIRS: RATS, MICE, DOGS, CATTLE, PIGS • SUBCLINICAL INFECTION IS COMMON • CLINICAL INFECTION: PULMONARY INVOLVEMENT HIGH • TREATMENT: ANTIBIOTICS (PENICILLIN, AMPICILLIN, DOXYCYCLINE) HYDRATION AND SYMPTOM RELIEF SANITATION AND PERSONAL PROTECTION

  15. LEPTOSPIROSIS WHO IS AT RISK: • HIKERS, BACKPACKERS, ADVENTURE TRAVELLERS, SWIMMERS • OCCUPATIONAL EXPOSURE: ANIMAL HANDLERS, BUTCHERS, FARMERS, CHILDREN • INCREASED RISK AFTER RAINY SEASON AND FLOODS

  16. CHAGAS’ DISEASE CHAGAS’S DISEASE (AMERICAN TRYPANOSOMIASIS)IS CAUSED BY THE PROTOZOA TRYPANOSOMA CRUZI • OCCURRENCE: MAJOR PROBLEM IN RURAL AREAS OF MEXICO, CENTRAL AND SOUTH AMERICA, WITH HIGHEST INCIDENCE RATES IN BOLIVIA AND PARAGUAY TRANSMITTED THROUGH THE BITE OF INFECTED, NOCTURNAL TRIATOMINE INSECTS HOST RESERVOIRS: DOGS, CATS, GUINEA PIGS • MOST INFECTIONS (90%) ARE ASYMPTOMATIC BUT WILL LEAD TO CHRONIC CARDIOMYOPATHY, MEGACOLON, OR MEGAESOPHAGUS • CAN BE TRANSMITTED THROUGH BLOOD TRANSFUSIONS

  17. CHAGAS’ DISEASE ADVICE TO TRAVELLERS: • IN RURAL AREAS, AVOID SLEEPING IN OR CAMPING NEAR LOW- QUALITY CONSTRUCTED ADOBE OR MUD BUILDINGS WITH PALM- FRINGE THATCHED ROOFS • USE INSECTICIDE IMPREGNATED BED NETS WHEN LIVING OR TRAVELLING IN RURAL AREAS OF SOUTH AMERICA • IN CASE OF INJURY AND IN NEED OF BLOOD TRANSFUSION, MAKE SURE THAT THE BLOOD SUPPLY HAS BEEN TESTED FOR T. CRUZI

  18. CHAGAS’ DISEASE Source: IAMAT

  19. CHAGAS’DISEASE LIFE CYCLE Source: IAMAT

  20. SCHISTOSOMIASIS SCHISTOSOMIASIS IS PARASITIC INFECTION CAUSED BY SCHISTOSOMA FLATWORMS OCCURRENCE • MANY TROPICAL AND SUBTROPICAL FRESH WATER BODIES, PARTICULARLY HIGH INFESTATION RATES IN SUB-SAHARA AFRICA RESERVOIR HOSTS: SNAIL SPECIES DISEASE PRESENTS AS KATAYAMA FEVER ADVICE TO TRAVELLERS • DO NOT SWIM IN FRESH WATER BODIES IN TROPICAL AND SUB-TROPICAL AREAS • ADVENTURE TRAVELLERS, AND PERSONS LIVING IN SUB-SAHARA AFRICA MUST BE WARNED OF THE RISK

  21. SCHISTOSOMIASIS Source: IAMAT

  22. SCHISTOSOMIASIS LIFE CYCLE Source: IAMAT

  23. MALARIA RISK AREAS Source: IAMAT

  24. MALARIA LIFE CYCLE SOURCE: IAMAT

  25. MALARIA PROPHYLAXIS ATOVAQUONE (250 mg)-PROGUANIL (100 mg) (Malarone) • One dose daily • Start 1 – 2 days before exposure • Take daily • Continue for 7 days after exposure • Not recommended under 11 kg in US • Not recommended under 40 kg in Canada • Pediatric tablet available – 1 to 4 dosed by body weight • Restrictions on duration of use by European authorities which range from 5 weeks to 3 months. • No restriction on duration of use in US • Pregnancy – no data, not recommended • Breast feeding – no data, not recommended • CONTRADINDICATION – severe renal disease

  26. MALARIA PROPHYLAXIS CHLOROQUINE (Aralen) • One tablet weekly • 300 mg of base or 500 mg salt • Start 1 to 2 weeks before exposure • Take weekly • Continue for 4 weeks after exposure • Pediatric dose 10 mg base/kg weekly • Reduces antibody response to intradermal rabies vaccine • Pregnancy – safe • Breast-feeding – safe • CONTRAINDICATION - psoriasis

  27. MALARIA PROPHYLAXIS CHLOROQUINE (100 mg)- PROGUANIL (200 mg) (SAVARINE) • One dose daily • Start 1 day before exposure • Take daily • Continue for 4 weeks after exposrue • Pediatric dose >50 kg 1 tablet daily • Pediatric dose <50 kg not recommended • Reduces antibody response to intradermal rabies vaccine • Pregnancy - safe • Breast feeding - safe • Contraindication – liver or kidney insufficiency; epilepsy; psoriasis THIS DRUG IS NOW ESSENTIALLY OBSOLETE BECAUSE OF HIGH RESISTANCE OF P. FALCIPARUM TO BOTH CHLOROQUINE AND PROGUANIL

  28. MALARIA PROPHYLAXIS DOXYCYCLINE (100 mg) (Vibramycin, Doryx, generics ) • One tablet daily • Start 1 day before exposure • Take daily • Continue for 4 weeks after exposure • Pediatric dose 1½ mg salt /kg Max dose 100 mg • Contraindicated under 8 years age • Increases risk of sunburn and vaginal infections • Pregnancy - contraindicated • Breast feeding - contraindicated • Contraindication – liver dysfunction

  29. MALARIA PROPHYLAXIS MEFLOQUINE (Lariam) • One tablet weekly • Start at least 1 week (best 2 – 3 weeks) before exposure • Take weekly • Continue for 4 weeks after exposure • Pediatric dose 5 mg/kg • Contraindicated under 5 kg • Pregnancy – not in first trimester – lack of data • Breast feeding - safe • Avoid in depression, epilepsy, concomitant treatment with halofantrine • Live vaccine use (oral typhoid, cholera) should be completed at least 3 days before first dose of mefloquine • Not recommended in persons with cardiac abnormalities

  30. MALARIA PROPHYLAXIS PRIMAQUINE (30 mg base – 52.6 mg salt) • One tablet daily • Start 1 to 2 days before exposure • Take daily • Continue for 7 days after exposure • Pediatric dose 0.6 mg base (1 mg/kg salt) up to adult dose daily • Pregnancy – contraindicated • Breast feeding – contraindicated unless infant is known to have normal G6PD levels • Contraindicated in persons with G6PD deficiency TESTING FOR G6PD DEFICIENCY ESSENTIAL

  31. MALARIA PROPHYLAXIS CAUTION Overdose of antimalarial drugs can be fatal Store in childproof containers – out of reach of infants and children

  32. MALARIA SELF-TREATMENT • WHO: An option in low risk areas • CDC: Only in situations were medical care is not immediately available (24 hrs) • Not substitute for seeking professional medical care • Possible regimens • Fansidar (pyrimethamine/sulfadoxine) 3 tabs at once (very resistant in Africa) • Malarone (atovaquone/proguanil) 4 tabs daily x 3 days • Mefloquine, maybe but severe side effects • Quinine and doxycycline • Coartem – preferred option in Europe, not available in N.America (artemether-lumefantrine (also sold as Riamet)

  33. CONSIDERATIONS ENVIRONMENTAL RISKS WHICH MAY AFFECT TRAVELLERS: • INSECT BITES • TRAFFIC ACCIDENTS • HIV AND STD’S • SWIMMING/DIVING ACCIDENTS AND DROWNING • SUN EXPOSURE • AIR POLLUTION IN URBAN AREAS • SOIL/SAND CONTAMINATION OF BEACHES AND PLAYGROUNDS • ALTITUDE • HEAT • FOOD AND WATER • MENTAL HEALTH

  34. INSECT BITES • USE INSECT REPELLENT CONTAINING “DEET” (N, N-diethylmetatoluamide) 30% - APPLY SPARINGLY TO EXPOSED PARTS OF THE BODY: ARMS, LEGS, NECK - AVOID FACE AND HANDS, AVOID INHALATION OR INGESTION • USE MOSQUITO BED NETS - TREAT BED NETS WITH INSECTICIDE (PERMETHRIN OR DELTAMETHRIN) - BED NETS OFFER PROTECTION AGAINST: MOSQUITOES, FLIES, TRIATOMINE BUGS, SPIDERS - BED NETS ARE ESSENTIAL IF TRAVELLING TO AFRICA SOUTH OF SAHARA, LONG-TERM TRAVEL TO RURAL AREAS OF THE TROPICS AND SUB- TROPICS ADVICE TO TRAVELLERS

  35. TRAFFIC ACCIDENTS ADVICE TO TRAVELLERS • USE SEATBELTS AT ALL TIMES • BACK SEATS ARE USUALLY SAFER • NEVER TRAVEL ON THE BACK OF OPEN TRUCKS (OFTEN SEEN IN POOR RURAL AREAS) • AVOID MOTORCYCLES AND NEVER RIDE MOTORCYCLES AT NIGHT (USE HELMET AND PROTECTIVE CLOTHING IF USING A MOTORCYCLE) TRAFFIC ACCIDENTS CAUSE THE HIGHEST INCIDENCE OF DEATHS AMONG TRAVELLERS

  36. HIV AND STDS SEXUALLY TRANSMITTED DISEASES ARE MORE OFTEN ACQUIRED IN URBAN SETTINGS LONG-TERM TRAVELLERS AND PERSONS ON WORKING ASSIGNMENTS ARE AT PARTICULAR RISK, LONELINESS AND HOME SICKNESS CAN CONTRIBUTE TO SEEKING COMMERCIAL SEX ADVICE TO TRAVELLERS: • NEVER HAVE UNPROTECTED SEX

  37. SWIMMING, DIVING ACCIDENTS ADVICE TO TRAVELLERS • USE SUPERVISED BEACHES AND OBSERVE RESTRICTIONS AND PROHIBITIONS • NEVER SWIM ALONE, DO NOT DIVE INTO UNKNOWN DEPTHS OF WATER • SUPERVISE SWIMMING CHILDREN AT ALL TIMES • USE LIFE JACKETS AT ALL TIMES WHEN BOATING OR WATER SKIING • KNOW WEATHER, WIND AND WATER CURRENT PATTERNS: CHANGES ARE OFTEN RAPID AND UNPREDICTABLE • AVOID JELLYFISH, STINGING FISH • AVOID CORAL CUTS (USE BEACH SANDALS) • ALWAYS DIVE WITH EXPERIENCED GUIDES AND ONLY AFTER PROPER TRAINING

  38. ALTITUDE HIGH ALTITUDE ILLNESS IS UNPREDICTABLE AND RISK IS NOT AFFECTED BY THE TRAVELLERS PHYSICIAL FITNESS OR TRAINING HIGHEST AIRPORTS: LHASA 3’749 m LA PAZ 3’444 m CUZCO 3’200 m PERSONS WITH CONGESTIVE HEART FAILURE, ANGINA OR ANY PULMONARY INSUFFICIENCY SHOULD NOT TRAVEL TO HIGH ALTITUDE AREAS UNLESS NECESSARY • ACUTE MOUNTAIN SICKNESS (AMS) CAN OCCUR AT ALTITUDES AS LOW AS 1200 m, BUT OCCURS MOST OFTEN AFTER RAPID ASCENT TO OVER 2700 m SYMPTOMS: HEADACHE, FATIGUE, NAUSEA, LOSS OF APPETITE, START: USUALLY 6-12 HOURS AFTER ARRIVAL

  39. ALTITUDE • HIGH ALTITUDE CEREBRAL EDEMA (HACE) SEVERE PROGRESSION OF AMS: CONFUSION, LETHARGY RAPID DESCENT TO LOWER ALTITUDE IS IMPERATIVE • HIGH ALTITUDE PULMONARY EDEMA (HAPE) SYMPTOMS: BREATHLESSNESS WITH EXERTION LEADING TO BREATHLESSNESS AT REST (CAN OCCUR BY ITSELF OR WITH SYMPTOMS OF HACE), CAN BE RAPIDLY FATAL, RAPID DESCENT TO LOWER ALTITUDE IMPERATIVE MEMBERS OF TREKKING AND HIGH ALTITUDE EXPEDITIONS MUST BE PREPARED FOR SUCH ILLNESS (GAMOW BAG ESSENTIAL FOR RESCUE OF ILL TRAVELLERS)

  40. ALTITUDE ADVICE TO TRAVELLERS • IF POSSIBLE ASCEND SLOWLY AND REST EVERY 1000 m • WHEN FLYING INTO HIGH ALTITUDE AREAS, REST AS MUCH AS POSSIBLE FOR THE FIRST FEW DAYS • DO NOT EXERCISE STRENUOUSLY UPON ARRIVAL • INCREASE YOUR WATER INTAKE • DESCEND TO LOWER ALTITUDE IF SYMPTOMS WORSEN WHILE RESTING • THE DRUG ACETAZOLAMIDE (DIAMOX, 125 mg/12 h or 250 mg /24 h) CAN HELP WITH ACCLIMATIZATION WHEN TAKEN BEFORE ASCENT

  41. SUN EXPOSURE EXPOSURE TO SUNLIGHT IS BENEFICIAL FOR THE BODY’S PRODUCTION OF VITAMIN D AND A FACTOR IN THE ABSORPTION OF CALCIUM - OVER EXPOSURE TO ULTRAVIOLET RAYS CAN CAUSE SERIOUS PROBLEMS ADVICE TO TRAVELLERS • USE SUN SCREEN FOR ALL OUTDOOR ACTIVITIES: VISIT TO BEACHES, SKIING, HIKING, WALKING, WORKING • USE PROTECTIVE CLOTHING: HATS , SHIRTS, PANTS • AVOID SUN BURNS, ESPECIALLY IN SMALL CHILDREN • PROTECT YOUR EYES FROM OVEREXPOSURE ESPECIALLY REFLECTIVE SURFACES SUCH AS WATER AND SNOW • DRUGS SUCH AS THIAZIDES, DIURETICS, TETRACYLINE, DOXYCYCLINE, SULFA DRUGS, NONSTEROIDAL INFLAMMATORY DRUGS (IBUPROFEN) CAN CAUSE INCREASED SENSITIVITY TO SUNLIGHT AND CAUSE SERIOUS SUNBURNS

  42. AIR POLLUTION IN URBAN AREAS MOST LARGE URBAN AREAS HAVE AIR POLLUTION PROBLEMS CAUSED BY • SUSPENDEND PARTICULATES • OZONE • SULFUR DIOXIDE (BURNED FOSSIL FUELS) • CARBON MONOXIDE (BURNING OIL, WOOD, GASOLINE) ADVICE TO TRAVELLERS WITH CARDIAC AND PULMONARY DISEASES: • AVOID TRAVEL TO SMOG PRONE CITIES, INQUIRE WHAT TIME OF THE YEAR IS LEAST POLLUTED (HOT DAYS ARE USUALLY WORSE) OR LIMIT YOUR VISIT TO AIRPORT TRANSFERS ONLY • TAKE ALL NECESSARY MEDICATIONS (INHALERS, ANTIBIOTICS, STEROID TAPER) WITH YOU FOR STANDBY TREATMENT

  43. HEAT ILLNESSES THE COMBINATION OF HEAT AND SMOG CAN CREATE AN INCREASE OF TEMPERATURE IN CITIES OF 1-6 DEGREES HIGHER THAN THE SURROUNDING AREA IN RECENT YEARS HEAT WAVES IN CITIES HAVE HAD A DISASTROUSLY HIGH TOLL ON THE ELDERLY ADVICE TO TRAVELLERS • AVOID TRAVEL TO CITIES DURING HOTTEST TIME OF YEAR • AVOID SITE-SEEING DURING THE HEAT OF THE DAY (11-4) THIS ALSO APPLIES TO RURAL AREAS AND BEACH RESORTS • REMAIN IN SHADED OR AIR-CONDITIONED AREAS • AVOID OUTDOOR ACTIVITIES DURING THE HEAT OF THE DAY OR DURING HEAT WAVES • RE-HYDRATION IS OF UTMOST IMPORTANCE (1 l/1 h) I

  44. SOIL/SAND CONTAMINATION PARASITIC INFECTIONS FROM CONTACT WITH SOIL AND BEACH SAND AFFECTS MORE CHILDREN THAN ADULTS, THE MOST COMMON ARE • HOOKWORM • CUTANEOUS LARVA MIGRANS (BEACH RESORTS) • ASCARIASIS • LEISHMANIASIS • STRONGYLOIDIASIS ADVICE TO TRAVELLERS • AVOID WALKING BARE FOOT, WASH FEET WITH SOAP AFTER RETURNING FROM THE BEACH • SIT OR PLAY ON SHEET OR TOWEL, NEVER DIRECTLY ON THE GROUND

  45. FOOD AND WATER PRECAUTIONS ADVICE TO TRAVELLERS • EAT WELL COOKED MEATS, LEGUMES AND VEGETABLES, EAT FOOD WHILE HOT • WASH FRUIT WITH PURIFIED WATER (BOILED, COOLED) AND PEEL JUST BEFORE EATING • YOGHURT, DAIRY PRODUCTS MADE FROM PASTEURIZED MILK, HARD CHEESES, BREADS AND BAKED GOODS ARE USUALLY SAFE • USE BOTTLED OR BOILED WATER FOR DRINKING AND BRUSHING TEETH, TO PURIFY WATER BRING IT TO A ROLLING BOIL AND LET IT COOL IN A CLEAN COVERED CONTAINER • IN RURAL AREAS THE WATER MUST FIRST BE FILTERED AND THEN BOILED • WHEN USING BOTTLED WATER, CHECK THAT THE CAP OR SEAL HAS NOT BEEN BROKEN, CARBONATED WATER IS SAFER • HOT TEA OR COFFEE ARE USUALLY SAFE

  46. MENTAL HEALTH • DO NOT CHANGE DRUG REGIMEN SHORTLY BEFORE TRAVEL – PATIENTS SHOULD BE WELL ADJUSTED AND FAMILIAR WITH THEIR MEDICATIONS • ENSURE THAT PATIENTS NEED TO TAKE THEIR MEDICATIONS ON A REGULAR REGIMEN EVEN WHEN CROSSING TIME ZONES • AVOID TRAVEL STRESS – ALLOW ADDITIONAL TRAVEL TIME – MAKE DIRECT FLIGHT ARRANGEMENTS FOR LONG TRIPS • IF POSSIBLE TRAVEL WITH A FAMILY MEMBER OR A FRIEND FAMILIAR WITH PATIENT’S MEDICATIONS

  47. CASE 1 BOB, AGE 75, A JOURNALIST, HAS BEEN INVITED TO A WRITERS’ CONFERENCE IN MANAUS, BRAZIL. HE WILL BE FLYING FROM NEW YORK TO MANAUS AND STAYING IN A GOOD HOTEL. AFTER THE CONFERENCE HE WILL TAKE A THREE DAY BOAT TRIP DOWN THE AMAZON. THE CABINS ARE AIR CONDITIONED. BOB IS IN GOOD HEALTH, BUT SUFFERS FROM PULMONARY CONGESTION WHICH IS AGGRAVATED BY AIR POLLUTION. HE HAS NOT HAD ANY VACCINATIONS OR BOOSTERS FOR YEARS, AND IS NOT SURE IF HE EVER HAD THE YELLOW FEVER VACCINE. WHAT VACCINES DOES HE NEED? WHAT ADDITIONAL ADVICE DOES HE NEED?

  48. CASE 1 BOB NEEDS: VACCINES • A TETANUS-DIPHTHERIA BOOSTER (OR Tdap IF HE NEVER HAD A Tdap booster before) • HEPATITIS A+B • TYPHOID FEVER • YELLOW FEVER • PNEUMOCOCCAL VACCINE • INFLUENZA VACCINE MALARIA PROPHYLAXIS ADVICE ON FOOD AND WATER PRECAUTIONS ADVICE ON PROTECTION AGAINST INSECTS

  49. CASE 2 LIU F. , 35 YEARS OLD, IS A MERCHANT SAILOR AND TRAVELS WITH HIS SHIP FROM QINGDAO TO HONGKONG, SINGAPORE, KOLKOTA - INDIA, PORT ELIZABETH- SOUTH AFRICA AND THEN TO SAO PAOLO - BRAZIL THE SHIP WILL STAY IN EACH PORT FOR AT LEAST ONE WEEK AND THE CREW WILL HAVE THREE DAYS FREE TIME IN EACH PORT. LIU F. WILL GO ON DAY-TIME EXCURSIONS IN EACH PORT, BUT WILL RETURN TO HIS SHIP TO SLEEP. LIU F. HAS RECEIVED THE FOLLOWING VACCINES AS A CHILD: HBV, BCG, TDaP, OPV, MMR MENINGITIS A, JE, THE LAST BOOSTER FOR TETANUS 12 YEARS AGO. WHAT VACCINATIONS DO YOU RECOMMEND? DOES HE NEED MALARIA PROPHYLAXIS? WHAT ADDITIONAL ADVICE TO GIVE HIM?

  50. CASE 2 VACCINES NEEDED • YELLOW FEVER • TETANUS/DIPHTHERIA OR Tdap BOOSTER • IPV BOOSTER • HEPATITIS A (IF HE IS ANTIBODY NEGATIVE) • TYPHOID FEVER MALARIA RISK: KOLKOTA INDIA ONLY – MOSQUITO PREVENTION ADVICE REGARDING RISK OF HIV AND STD’S ADVICE ON INSECT PROTECTION (DENGUE/CHIKUNGUNYA) ADVICE ON FOOD AND WATER SANITATION

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