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THE PRE-TRAVEL CONSULTATION Gary W. Brunette, MD, MS Travelers’ Health Team Division of Global Migration and Quarantine Centers for Disease Control and Prevention Outline Travelers’ Health Epidemiology Traveler Assessment Itinerary Review Sources of Information Risks to the Traveler

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the pre travel consultation

THE PRE-TRAVEL CONSULTATION

Gary W. Brunette, MD, MS

Travelers’ Health Team

Division of Global Migration and Quarantine

Centers for Disease Control and Prevention

outline
Outline
  • Travelers’ Health Epidemiology
  • Traveler Assessment
  • Itinerary Review
  • Sources of Information
  • Risks to the Traveler
  • Travel Vaccines
  • Travel Medications
  • Counseling
u s residents traveling abroad
U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico

where do u s residents travel
Where Do U.S. Residents Travel?

Of the 17% who traveled outside the U.S. . . .

Source: HealthStyles Survey 2005

vfrs visiting friends and relatives
VFRs: Visiting Friends and Relatives
  • Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million1
  • 20% of US population are first- or second-generation immigrants
  • VFRs comprised ~46% of US international air travelers in 20043

1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States Population 2000, issues Dec 2003???

2 Angell & Cetron, 2005

32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

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

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
the patient other issues
The Patient: Other Issues
  • Reproductive
    • Pregnant
    • Breastfeeding
    • Preconception
  • Risk-taking behaviors
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
  • World Health Organization
    • www.who.int/int
  • State Department
    • travel.state.gov
  • International Society of Travel Medicine
    • www.istm.org
  • Health Information for International Travel
    • CDC “Yellow Book”
  • International Travel and Health
    • WHO “Green Book”
regional destinations
Regional Destinations
  • Region-specific pages
  • Goal to move to country-specific format
deaths related to international travel
Deaths Related to International Travel

N = 2463

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.

injury deaths and international travel
Injury Deaths and International Travel

N = 601

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

other risks to the traveler
Other Risks to the Traveler
  • Accidental injury
  • Environmental hazards
  • Crime and assault
  • Psychiatric problems
  • Animal bites, stings and envenomations
  • Dermatologic disorders
  • Altitude
  • …….

ETC.

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

Immunizations to Consider for Adult Travelers

* Td or Tdap

+ MMR

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
  • Hand washing and hygiene
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
journals
Journals
  • American Journal of Tropical Medicine and Hygiene
  • Bulletin of the World Health Organization
  • Emerging Infectious Diseases Journal
  • Eurosurveillance Weekly
  • Journal of Travel Medicine
  • Morbidity and Mortality Weekly Report
  • Tropical Medicine and International Health
  • Vaccine
books
Books
  • Textbook of Travel Medicine and Health, 2nd Ed.
    • DuPont, H.L. and Steffen R. (editors)
  • The Travel and Tropical Medicine Manual, 3rd Ed.
    • Jong, E.C., McMullen, R.
  • Travel Medicine
    • Keystone, J.S., Kozarsky, P.E., et al
websites
Websites

Eurosurveillance

www.eurosurveillance.org

Travax EnCompass

www.travax.com

GIDEON

www.gideononline.com

International SOS

www.internationalsos.com

Medical Advisory Service for Travelers Abroad (MASTA)

http://www.masta.org/

Armed Forces Medical Intelligence Center

www.afmic.detrick.army.mil/

Central Intelligence Agency

www.cia.gov/cia/publications/factbook/