Advice for the Traveler

1. Advice for the Traveler February 12, 2007

2. Objectives Assess the morbidity and mortality associated with travel from the U.S. to international destinations. Discuss ways to prevent travel-associated illness and death.

3. 2002 Profile of U.S. Travelers Visiting Overseas Destinations, 2002 Total Number of Travelers 23,397,000 Main Purpose of Trip Percent Leisure/Recreation/Holidays 37 Visit Friends/Relatives 30 Business 26 Study/Teaching 2 Convention/Conference 2 Source: U.S. Department of Commerce. "In-Flight Survey," July 2003.

4. Foreign-born U.S. population, 1850–2000 Angell: Ann Intern Med, Volume 142(1).January 4, 2005.67-72

5. Travelers at High Risk for Travel-Related Illnesses Backpacking or hiking while traveling Age > than 65 years Persons living in the United States but born in another country and who travel back to country of origin Persons who are immunocompromised human immunodeficiency virus infection organ transplant on immunosuppressive medications Persons who travel on a long-term basis Low-budget travelers

6. General Advice for Travelers Carry a letter stating medical diagnosis, list of medications with doses, and needles or syringes. Carry enough essential medications to last the duration of the trip. - divide between carry-on and check-in baggage Exercise legs during long flights. Practice safe sex. Don’t get drunk. Avoid riding on scooters, motorcycles, or overcrowded buses.

7. Review and discuss • Food and water precautions • Travelers diarrhea • Altitude sickness • Jet lag • Motion sickness • DVT prevention • Swimming in strange places

8. What is the most common cause of death among U.S. travelers to international destinations? A. Malaria B. Cholera C. Terrorist attack D. Car crashes E. None of the above

9. Countrieswith the highest rates of road traffic injury mortality Cyprus India Kuwait Qatar United Arab Emirates

10. Reasons that traffic accidents are common in foreign tourists Driving on the opposite side of the road than in one's home country Poor road surfaces without shoulders Unprotected curves and cliffs, Poor visibility due to lack of adequate lighting, both on the road and on the vehicle Mixed vehicle and pedestrian roadways

11. Prevention strategies to reduce risk of injuries while traveling When renting a vehicles, choose one with seat belts . Test the vehicle to be sure that brakes and lights are functional. Bring child seats Avoid trips using local unscheduled small aircraft Don’t ride in the back of open trucks Stay on one of the lower floors of high-rise hotels Choosing lodging that has smoke detectors/sprinkler system Avoid alcohol excess, which contributes to risky behaviors Bring first-aid equipment.

12. What is the most common illness effecting international tourists? • Malaria • Travelers’ diarrhea • Deep venous thrombosis • Side effects of pre-travel vaccines

13. Impact of traveler’s diarrhea on travelers to developing countries EventPercent Travelers to developing countries Who develop diarrhea 10 – 60 Affected travelers who are bedridden 20 Change their itinerary because of diarrhea 40 NEJM 2000;342:1716-1725

14. Which of the following is NOT one of the most common causes of diarrhea among international travelers from the U.S.? A. Enterotoxigenic Escherichia coli B. Campylobacter C. Salmonella D. Shigella E. Vibrio cholerae

15. Risk factors for traveler’s diarrhea among international tourists drinking tap water, iced drinks, or fresh juices eating food in small restaurants or from vendors eating locally made ice cream or flavored ices eating fruit not personally peeled by the traveler

16. Personal precautions to prevent travelers diarrhea Eat well-cooked hot foods (self-peeled fruits or vegetables are OK). Avoid: non-bottled beverages unpasteurized dairy products food from street vendors Use bottled water to make ice cubes and brush teeth. Wash hands with soap and water frequently.

17. Recommended agents for travelers to carry in the event of traveler’s diarrhea Anti-motility agents: loperamide 4mg orally, then 2 mg after each loose stool (maximum 16 mg/day) Antimicrobial agents: levafloxacin 500 mg/day for 3 days or azithromycin 500 mg on day 1 then 250 mg on days 2 to 5

18. Malaria Prevention • Insect repellants with 20 - 30% DEET • Long sleeves, lighter colors clothing • Bed netting • Avoid perfumes, after shaves, etc. • Medications

21. Medications - Malarone • Malarone (Atovaquone/Proguanil) • 250mg/100mg 1 po QD (adult) • Start 2 days prior to entering malaria zone, every day while in zone, and 7 days after leaving the zone.

22. Medications - Malarone • Malarone (Atovaquone/Proguanil) • 62.5mg/25mg Pediatric • 11-20kg: 1 tablet • 21-30kg: 2 tablets • 31-40kg: 3 tablets • 41kg or more: 1 adult tablet

23. Medications - Larium • Larium (Mefloquine) • 250mg 1 po Q week • Start 1week prior to entering malaria zone, every week while in zone, and 4 weeks after leaving the zone • 10-19kg: ¼ tab • 20-30kg: ½ tab • 31-45kg: ¾ tab • > 46kg: 1 tab

24. Medications Larium • CANNOT take if: • Seizures disorders • Cardiac abnormalities • Any history of psychiatric illness, depression, anxiety

25. Medications - others • Doxycycline 100mg Qday • Start 3 days prior to entering malaria zone, every day while in zone, and 4 weeks after leaving the zone. • Sunburn and yeast infections • Chloroquine 500mg Q week • Start 1 week prior to entering malaria zone, every week while in zone, and 4 weeks after leaving the zone. • Used less often due to high resistance

26. Resources • Malaria Hotline 770-488-7788 M-F 8am to 4:30 EST Emergency consult after hours 770-448-7100 request to speak to a CDC Malaria branch Clinician

27. Vaccinations for Travelers

28. When to Immunize • 7 to 10 days prior to travel • Exceptions • typhoid oral • Immune globulin • Hepatitis B • Japanese Encephalitis (J.E.) • Rabies

29. Most common • Hepatitis A • Hepatitis B • Tetanus • Typhoid • Polio • Yellow Fever

30. Least Common • Meningococcal • MMR - live • J. E • Rabies • Pneumonia • Influenza • Varicella - live

31. Vaccines - Hep A • Hepatitis A • Pediatric 2-18 years • Adult ≥19 years • 2 shot series • 0, 6 – 12 months • life

32. Vaccines – Hep A • Immune Globulin • Given for Hepatitis A if departure is < 7 days • 0.02 ml/kg for less than 3 month stay • 0.06 ml/kg for 3 month or longer • Gluteal • 3-5 months

33. Vaccines – Hep B • Hepatitis B • Pediatric < 20 years • Adult ≥ 20 years • 3 shot series • 0, 1month, 6 month • life

34. Vaccines - Hep A & B • Twinrix • Combination Hepatitis A and B • 3 shot series • 0, 1 month, 6 months • Can be given 0, 1-2 months, 4-6 months • life

35. Accelerated Schedules • Hepatitis B and Twinrix • 0, 7 days, 21 days, 1 year booster • J.E. • 0, 7 days, 28 days, or • 2 doses 1 to 4 weeks apart

36. Vaccines - Typhoid • Typhoid • Injection • >2 years age • Every 2 years • Oral (live) • >6 years age • Every 5 years

37. Vaccines – Yellow Fever • Yellow Fever (live) • Greater than or equal to 9 months • Every 10 years

38. Parenteral Live Vaccines • Must be given within 24 hours of each other or 30 days apart • Exception Measles and Y.F.

39. Vaccines – Td & Polio • Tetanus (Td) • greater than or equal to 7 years age • every 10 years • Polio • greater than 18 years • One adult booster = Life

40. Resources - Books • Travel and Routine Immunizations, published by Shoreland • Health Information for International Travel (CDC Yellow Book) • A GOOD Atlas!

41. Resources - Web www.cdc.gov www.mdtravelhealth.com www.travelmedicineadvisor.com

42. http://www.cdc.gov/travel/ • Destinations • Vaccinations • Diseases • Insect and Arthropod Protection • Safe Food and Water • Illness and Injury Abroad • Travel Medicine Clinics • Yellow Book • Avian Influenza and Travel • Yellow Fever Vaccination Clinics • References and Resources

43. Destinations Choose the region that contains the destinations on your itinerary: Caribbean Mexico and Central America Eastern Europe and Northern Asia Europe, Western Middle East North America South America, Temperate (Southern) South America, Tropical (Northern) Africa, Central Africa, East Africa, North Africa, Southern Africa, West Asia, East Asia, South Asia, Southeast Australia and the South Pacific

44. Health Information for Travelers to Countries in Central Africa Vaccines for Your Protection Diseases Found in Central Africa Other Health Risks What You Need To Bring With You Staying Healthy During Your Trip After You Return Home For More Information

45. Recommended Vaccinations and Preventive Medications for Travelers to Central Africa Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling. Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11–12 years who did not receive the series as infants. Malaria: your risk of malaria may be high in all countries in Central Africa, including cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Central Africa. Meningococcal (meningitis), if you plan to visit countries in this region that experience epidemics of meningococcal disease during December through June, (see see Map 4-9 on the Meningoccocal Disease page). Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities. Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders (For country specific requirements, see Yellow Fever Vaccine Requirements and Information on Malaria Risk and Prophylaxis, by Country.). Vaccination should be given 10 days before travel and at 10 year intervals if there is on-going risk. As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

46. Required vaccinations for travelers to Central Africa A certificate of yellow fever vaccination may be required for entry into certain countries in Central Africa. For detailed information, see Yellow Fever Vaccine Requirements and Information on Malaria Risk and Prophylaxis, by Country. Also, find the nearest authorized U.S. yellow fever vaccine center.

47. Table 4-20. Dosage and schedule for typhoid fever vaccination

48. Travel Vaccine Resource Web sites American Society of Tropical Medicine and Hygiene: http://www.astmh.org Centers for Disease Control and Prevention, Travelers' Health Information: http://www.cdc.gov/travel International Association for Medical Assistance to Travelers: http://www.iamat.org International Society of Travel Medicine: http://www.istm.org MD Travel Health: http://www.mdtravelhealth.com Pan American Health Organization: http://www.paho.org Shoreland's Travel Health Online: http://www.tripprep.com U.S. Department of State, Bureau of Consular Affairs: http://www.travel.state.gov (202-647-5225) World Health Organization, International Travel and Health: http://www.who.int/ith

49. Conclusions The number of travelers from the U.S. to international destinations is increasing. Numerous measures may be taken to reduce the risk of morbidity and mortality in travelers. Useful information for health care providers and travelers is easily accessible from a variety of sites.