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Pre-Travel Health Consultation. Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor School of Public Health and Tropical Medicine James Cook University & Visiting Professor School of Public Health University of the Witwatersrand. About the author.

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Pre-Travel Health Consultation

Dr Peter A. Leggat

MD, PhD, DrPH, FAFPHM, FACTM, FFTM

Associate Professor

School of Public Health and Tropical Medicine

James Cook University &

Visiting Professor

School of Public Health

University of the Witwatersrand


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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.


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By the end of this session

  • Briefly revisit who provides pre-travel health advice

  • Emphasize the need for resources in travel medicine

  • Overview the main functions of the pre-travel health consultation

  • Introduce the concept of documentation in travel medicine


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The Continuum of Travel Medicine

Pre-Travel

Visitors

Preventive Medicine

During Travel

Contingency Planning

Post-Travel

Treatment & Rehabilitation


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Travelers get information from various sources

  • Travel agent/travel industry

  • Books, popular press and the Internet

  • Person “next door”

  • Pharmacy

  • General practice / Travel clinics

  • Government/public health services

  • Professional and academic bodies

Ref: Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85-8


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Giving correct and consistent advice to travelers is important

  • Giving the correct health advice to travelers needs:

    • Information

    • Training

    • Experience

    • Documentation

    • Travellers


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Need to be prepared with adequate resources important

  • Need adequate staff training and continuing education

  • Need adequate time and good time management

  • Need to have access to national and international guidelines for travel medicine

  • Need to have health education resources

  • Need to have access to good geographically based epidemiological information regarding risks to health and safety of travelers (internet, computerized databases etc)


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Travel Health Advice Needs Adequate Notice important

  • Travelers need to be informed that they need travel health advice

  • Travelers need to be informed that they need to seek travel health advice early, about 6-8 weeks prior to travel

  • A risk assessment must be performed for every traveler


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PRE-TRAVEL HEALTH ADVICE important

  • Immunize travelers

  • Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel

  • Prescribe appropriate chemoprophylactic and self-treatment medications


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PRE-TRAVEL HEALTH ADVICE important

  • Immunize travelers

  • Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel

  • Prescribe appropriate chemoprophylactic and self-treatment medications


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VACCINATE important

  • Always National schedule (incl Hep B)

  • Often hepatitis A (non-immune)

  • Sometimes Japanese encephalitis meningococcal disease (Mecca) polio rabies typhoid

    yellow fever (WHO)

  • Older age gp Influenza (Others) Pneumococcal disease (adapted* from NZPHR; 1996;3(8):57-59)


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IMMUNISE AGAINST important

  • Mandatory vaccinations (WHO)

  • National schedule vaccinations-update routine immunizations

  • Vaccinations for most or all travelers

  • Vaccinations for travelers at special risk+


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“Mandatory” vaccines important

  • Travelers to/from Yellow fever endemic areas

  • Travelers going to Mecca for the Hajj


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Yellow fever important

Source: http://www.cdc.gov/travel/diseases/yellowfever.htm


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Yellow fever important

  • International regulations

  • WHO International Travel and Health

  • Specially licensed Yellow Vaccination Centers

  • Need to document on appropriate certificate of immunization card


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Meningococcal meningitis important

Source: http://www.cdc.gov/travel/diseases/menin.htm


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Meningococcal meningitis important

  • Neisseria meningitidis: At least 13 antigenically distinct serogroups

  • A,B,C,W135 & Y are most common

  • Current vaccine for A,C,W135 & Y

  • NZ is trialing a vaccine against a specific B strain

  • Mandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah

  • Recommended: Travelers “roughing it” in areas where there are recurrent outbreaks of disease


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Routine vaccinations important

  • The travel health consultation is a good opportunity to update national schedule or routine vaccinations


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Vaccinations for most travelers important

  • Diseases associated with poor hygiene & sanitation

    • ETEC?

    • Hepatitis A

    • Typhoid


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Cholera important

  • Various new vaccines

  • Some activity against ETEC in one

  • Routine use of cholera vaccine is not recommended as risk is low

  • It is indicated for travelers to cholera endemic areas, who are at high risk for infection (2-3 years protection)


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Travelers at special risk important

  • Geographical risk

  • Risk because age, pre-existing conditions, or occupation


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Geographical risk important

  • Vector borne diseases

    • Yellow fever

    • Japanese encephalitis

    • Tick borne encephalitis

  • Wilderness/remote travel

    • Rabies

    • TB

  • Current epidemics (terrorist threats?)

    • Cholera

    • Plaque


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Japanese encephalitis important

Source: http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm


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Japanese encephalitis important

  • Travelers spending one month or more in rural areas of Asia, PNG & Torres Strait (Australia), particularly if the travel is during the wet season, and/or there is considerable outdoor activity and/or the standard of accommodation is suboptimal,

  • other travelers spending a year + in Asia (except for Singapore), even if much of the stay is in urban areas


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Dengue important

  • Vaccine in development

  • Four serotypes (1-4)

  • Transmitted by certain mosquitoes, including Aedes aegypti

  • Widespread, especially common in SE Asia

  • Becoming increasingly recognized in travelers


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Estimated monthly incidence of health problems importantper 100 000 travellers to developing countries


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Tick borne encephalitis important

  • Seasonal disease in parts of Europe, Scandinavia and Russia

  • Hikers, campers and agricultural workers most at risk

  • Small mammal ticks found in the undergrowth close to forested areas

  • Vaccine available/post-exposure immune globulin


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Tuberculosis-BCG important

  • Travelers over the age of 5 years who will spend prolonged periods in countries of high TB prevalence

  • Children under 5 years who will be travelling to live in countries of high TB prevalence for > than 3 months

  • WHO: high risk countries, where annual incidence is in excess of 100 per 100,000 population


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Rabies important

  • Endemic in many countries

  • Is almost a universally fatal disease


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Plague important

  • Yesinia pestis, transmitted via fleas from animal reservoir to humans

  • Rare in most parts of the world

  • Vaccination only of those at high risk, usually those engaged in field operations, laboratory workers or others who reside in areas where plague is present


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Risk because age, pre-existing conditions, or occupation important

  • Older travelers/pre-existing disease

    • Influenza

    • Pneumococcal infection

  • Occupational risk (including electives)

    • Hepatitis B (usually part of national schedule)

    • Q fever


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Influenza important

  • Routinely on annual basis for those 65 years and older

  • Travelers with chronic disorders of the pulmonary or circulatory systems or other chronic illnesses needing regular follow-up

  • Those who wish to reduce the risk


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Estimated monthly incidence of health problems importantper 100 000 travellers to developing countries


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Pneumococcal infection important

  • Routinely on annual basis for those 65 years and older

  • Travelers with asplenia, immunocompromized travelers

  • Others


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Q Fever important

  • Bacterium (rickettsia) Coxiella burnetii

  • Recommendation: those occupationally exposed to cattle, sheep, goats or kangaroos or their products

  • Serum antibody and skin testing to exclude hypersensitivity reaction

  • Contraindications: prior exposure to Q fever or anaphylaxis induced by egg proteins


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It is important to document vaccinations important

  • Vaccination record

    • Vital for those requiring proof of yellow fever vaccination

    • Evidence of specific vaccinations and screening (e.g. HIV, HBV, Syphilis, Tuberculin) needed for entry to various countries, especially longer term travelers, such as scholars and workers


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PRE-TRAVEL HEALTH ADVICE important

  • Immunize travelers

  • Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel

  • Prescribe appropriate chemoprophylactic and self-treatment medications


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ADVISE AND DISCUSS important

  • Insects

  • Ingestions

  • Indiscretions

  • Injuries

  • Immersions

  • Insurance


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ADVISE AND DISCUSS important

  • Insects repellents, nets, permethrin

  • Ingestions care with food and water diet/teeth (including airlines/jetlag/DVT)

  • Indiscretions STI’s, HIV, drugs?

  • Injuries accident avoidance, personal

    safety

  • Immersion schistosomiasis, drowning

  • Insurance* health and travel insurance* finding medical assistance o/s* (adapted from NZPHR; 1996;3(8):57-59)


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Personal safety is on the radar screen important

Leitrim County, rural Ireland

Courtesy of Rick Speare


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Personal safety important

  • There has been heightened concern regarding personal safety and travelers

  • National foreign affairs sites should be consulted on safety and security at the travelers’ destination(s).


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Personal safety important

Source: http://www.cia.gov/cia/publications/factbook/


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SPECIAL RISK GROUPS important

  • Travelers who need special assistance or need assessment as to fitness to fly

  • Pregnant travelers/children/HIV travelers

  • Altitude/mountaineering/diving

  • Adventure/outback travelers

  • Travelers to areas of extreme climate

  • School/club/other groups

  • Occupational/students/military/aviation

  • Aid/refugee camp workers


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Travel health advice needs documentation important

  • Medialert bracelets-allergies, serious medical conditions

  • Written travel health advice (may be part of doctor’s letter)-consider using a proforma

  • Travelers health record ?

  • Other certificates, e.g. diving, airline

  • Is the traveler being escorted? (aeromedical evacuation)


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Educational Resources important

  • Books

  • Travel industry guides

  • Pharmaceutical companies

  • Videos-popular in a number of clinics in the USA


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152 pp, Small pocket book important

52 pp, passport sized booklet

192 pp, reader

730 pp, manual


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144 pp, Small pocket book important

Disease specific

Specific to special groups

428 pp, reader


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PRE-TRAVEL HEALTH ADVICE important

  • Immunize travelers

  • Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel

  • Prescribe appropriate chemoprophylactic and self-treatment medications


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PRESCRIBE important(Script/Dr’s letter/medialert bracelet)

  • Always regular medication medical kit (first aid)*

  • Sometimes antimalarial medication diarrheal self-treatment condoms/PEP Other hygiene pdts (NZPHR; 1996;3(8):57-59)


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Medication needs documentation important

  • Prescription

  • Doctor’s letter-consider using a proforma

  • Customs/quarantine approvals, if required

  • If part of a clinical trial, contact details/advice regarding adverse reactions (on a laminated card)


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We do not live in an ideal world important

Travel health advice will be moderated by

  • Availability of vaccines

  • Availability of educational resources

  • Availability of drugs for chemoprophylaxis and treatment-special authority

  • Limitations in indications, limitations in available data for use

  • Risk assessment


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Bottom line of pre-travel health advice important

  • There is probably more to pre-travel health advice than travel immunizations and malaria chemoprophylaxis

  • Travelers will have different priorities and resources

  • Need for a risk assessment and access to current epidemiological information available on a geographic basis by country/region