Keeping our Traveling Students Safe and Healthy

1. Keeping our Traveling Students Safe and Healthy Jean Haulman MD March 6, 2009

2. www.kidsforsavingearth.org Risks Loss of inhibitions

4. Your favorite “exotic” disease is only an airplane ride away

5. Transportation hazards http://www.blueskyaviation.mn/medevac.html

6. Injury: Land & Water Leading cause of death in travelers is Motor Vehicle Accidents (<55 y/o)

7. Auto accidents • According to the Association for Safe International Road Travel, the risk is 20-80 times higher in developing countries than in the U.S. • Approximately 750 Americans die annually in auto accidents abroad, and approximately 25,000 are injured. • Why does this occur?

8. Modes of Transportation are Unique

9. Conditions leading to MVAs Poor road conditions Poor vehicle maintenance Lack of seatbelts 3rd world countries do not always have the same rules of the road http://www.explorenorth.com/blog/deathroad.jpg http://www.autocult.com.au/img/gallery/full/nickop196.jpg

10. Road signs may be confusing Advice for drivers in India Road signs http://2.bp.blogspot.com/...qHw5g5ewdM/s400/2Indianroadsignsmall.jpg

11. Traffic in Cairo http://www.infoforhealth.org/pr/m15/p6a.jpg

12. Donor-mobile

13. AAA Abroad:Roadside service varies

14. Rule: Pedestrians do not always have the right of way http://www.cartoonstock.com/newscartoons/cartoonists/aia/lowres/aian23l.jpg

15. Risks Drowning is second leading cause of mortality for travelers

16. What is the common denominator for MVA and drowning? ALCOHOL !

17. Risks Illness – Destination Specific

20. What are the options for prevention and treatment? First step: Pack your common sense Second Step: Schedule a pre travel consultation. Novice students need in person consultation.

21. Pre-Travel Counseling Visit • Focus is prevention • Advice given regarding ways to minimize destination specific risks • Disease and environment education • Traffic risks, drowning risks • Insect precautions • Food and water • Vaccines • Medications for travelers’ diarrhea (TD), malaria prophylaxis, altitude sickness, HIV PEP for traveling health care students

22. Travel Clinic Consultation • Itinerary • Reason for travel • Accommodations • Duration of travel • Modified by • Medical and immunization history • Allergies • Special needs

23. Itinerary and Reasons for Travel http://www.arr-the-kraken.com/images/oz_02.jpg • Itinerary • Country and region • City vs. rural • Reason for travel: backpacking, trekking, spelunking, business, study abroad • Accommodations: Hotel, tent, hostel, cave, host family http://ritz-carlton-boston-commons.visit-boston-massachusetts.com/boston-ritz-carlton-suite.jpg

24. Accommodations • Host families • Hepatitis A, Typhoid • Local water • Well water • Crowded living conditions, group travel, exposure to ill persons: • Meningococcal disease • Influenza • Tuberculosis Rule: There is so such thing as safe drinking water in a 3rd world country unless it comes from a sealed bottle.

25. Travel location(s) and duration of stay • Diseases follow geographic patterns and seasonal variations • The longer the stay the greater the risk of travel related illness • Short stays are considered <2-3 weeks • Long stays are > 1 month

26. Pre-travel Consultation VACCINES: Routine, Recommended and Required

27. Diphtheria: 9,235 Measles: 30-40 m Pertussis 20-40 m Polio: >35,000 Mumps: Unknown Tetanus >300,000 (most neonatal) 0 cases in 2005 64 cases: 2008 * 25,827 in 2004 Last wild case 1979 5,783 cases in 2006 @ 40 cases in 2006 Why insure completion and update of routine vaccines? World vs US 86% imported

28. Recommended • Hepatitis A • Typhoid • Hepatitis B • Rabies • Polio • Meningococcal • JEV • (HPV)

29. Recommended Vaccines • Hepatitis A vaccine: • 1st dose can be given on the way to the airport • Most common vaccine-preventable illness in returned travelers, next to influenza • Typhoid vaccine: recommended for all 3rd world travel unless staying in 4-5 star accommodations and never eating from the street • 1140 US cases reported 1999-2003, 74% imported

30. Hepatitis A 2 brand of vaccines available, equally effective Given 6 months apart Expected lifetime immunity Typhoid 2 types of vaccines available Injectable: good for 2 years Can cause sore arm May feel run down for 1 day Students and insurances prefer Oral: good for 5 years Live attenuated Can cause nausea Cannot take concurrent antibiotics 1 pill qod x 4 doses Should complete 4 dose schedule at least 10 days prior to departure Vaccines

31. Encouraged for all travelers at risk for MVA while traveling Recommended for sexual partner seeking travelers Recommended for travelers seeking medical procedures, tattoos, and/or piercings 3 dose vaccine given at 0, 1, and 6 months First cancer preventing vaccine Hepatitis B vaccine Courtesy of Patricia Walker MD Ramsey Clinical Assts St. Paul, MN

32. Hepatitis A/B Vaccine • Given as series of 3 • Standard schedule 0, 1, 6 months • 3 doses of standard hepatitis B • 3 doses of ½ standard dose for hepatitis A • New FDA approved accelerated dosing • Advantage for travelers • Given at day 0, 7, 21-28 days, booster at 1 year • Can fit in complete series prior to travel

33. 2003: Polio

34. Polio • Travel as a risk factor: 2003 and 2005, 25 previously polio-free countries were re-infected due to imports of the virus • As of March 2008, only four countries in the world (Afghanistan, India, Nigeria, Pakistan,) are still considered to be endemic for Polio • However new case reports appear monthly in most sub Saharan countries • Recent imported case from Indonesia to Australia

35. Rule: If it has fur and teeth do not touch it.

36. Vaccines in short supply • Rabies vaccine: current shortage, not available for pre travel use • Disease is 100% fatal • Only post exposure vaccination is available • HRIG (expensive) + 5 doses of vaccine on days 0,3,7,14,28

37. JEV: SE Asia Short supply Mosquito Dusk to dawn Rainy season 30% mortality Given as a 3 dose series 0,7,21 days Can cause allergic reaction New 2 dose vaccine close to FDA approval Vaccines for specific destinations

38. Required vaccine Can be obtained only at a yellow fever certified center Must be documented on the official CDC or WHO yellow card 50% mortality from disease Vaccine has rare serious side effects 1 vaccine q 10 years Yellow Fever: Required

39. For travelers going to Africa during the dry season Required for travelers going to the Hajj in Saudi Arabia Sporadic outbreaks in other African countries 2 vaccines Meningococcal Conjugate vaccine: age 2-55 yrs Meningococcal Polysaccharide: Approved for age 3 months and older Meningococcal Infections

40. Medications DIARRHEA PreventionA.K.A. Montezuma’s revenge Aztec two-step The trots Turkey Trots Turista

41. Distribution of TD

42. Why is diarrhea more common in the developing world?

44. Travelers’ diarrhea • Incidence highest for travelers going to a 3rd world country • Food is the vector for travelers’ diarrhea more often than water

45. Travelers’ diarrhea • Acute, self-limiting illness; resolves within about 5 days. • 3-10% of pts with TD will have symptoms lasting longer than 2 weeks. • Up to 3% of travelers have TD lasting over 30 days. • Most symptoms occur while abroad and are never reported

46. Treatment for Travelers’ Diarrhea (short term travelers) • Ciprofloxacin 500mg up to q 12 hours for 3 days (adults) OR • Azithromycin 10mg/kg up to 500mg q 24 hrs for up to 3 days (peds and adults) OR • Azithromycin 1000mg all at once (adults) • Newer option: Rifaximin 200mg tid for 3 days

47. Travelers prefer to sit here http://www.advillas.com/images/newImages/AdvillasBeachSunset.jpg

48. --not here--

49. Malaria prevention Fever is malaria until proven otherwise AND Many developing countries treat every fever with malaria medication